CNS 1.medical surgical nursingcentralppt

This power point is very important for both learners and teachers

1. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Alterations of Neurologic Alterations of Neurologic
FunctionFunction
Part 1Part 1
Chapter 15Chapter 15

2. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Brain TraumaBrain Trauma

Major head trauma Major head trauma – A traumatic insult to – A traumatic insult to
the brain possibly producing physical, the brain possibly producing physical,
intellectual, emotional, social, and intellectual, emotional, social, and
vocational changes.vocational changes.

CausesCauses – most common are motor vehicle – most common are motor vehicle
crashes, falls, sports-related events, and crashes, falls, sports-related events, and
violence.violence.

The most common types of traumatic brain The most common types of traumatic brain
injury (75% to 90%) are mild concussion injury (75% to 90%) are mild concussion
and classical cerebral concussionand classical cerebral concussion

3. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Brain TraumaBrain Trauma
ClassificationsClassifications::

Closed trauma (blunt, nonmissile)Closed trauma (blunt, nonmissile)

Head strikes hard surface or a rapidly Head strikes hard surface or a rapidly
moving object strikes the head.moving object strikes the head.

The dura remains intact and brain tissues The dura remains intact and brain tissues
are not exposed to the environment.are not exposed to the environment.

Causes focal (local) or diffuse (general) Causes focal (local) or diffuse (general)
brain injuries.brain injuries.

4. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Brain TraumaBrain Trauma

Open trauma (penetrating, missile)Open trauma (penetrating, missile)

Injury involves a skull fracture that breaks the Injury involves a skull fracture that breaks the
dura and exposes the cranial contents to the dura and exposes the cranial contents to the
environment.environment.

Causes primarily focal injuries.Causes primarily focal injuries.

5. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Brain TraumaBrain Trauma

Focal brain injuryFocal brain injury

Specific, observable brain lesions.Specific, observable brain lesions.

Diffuse brain injury (diffuse axonal injury) Diffuse brain injury (diffuse axonal injury)

Injury to neuronal axons in many areas of the Injury to neuronal axons in many areas of the
brain caused by stretching and shearing brain caused by stretching and shearing
forces received during brain injury.forces received during brain injury.

6. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Focal Brain InjuryFocal Brain Injury

Force of impact typically produces Force of impact typically produces
contusions.contusions.

Contusions can cause: Contusions can cause:

Extradural (epidural) hemorrhages or Extradural (epidural) hemorrhages or
hematomashematomas

Subdural hematomasSubdural hematomas

Intracerebral hematomas Intracerebral hematomas

7. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebral ContusionsCerebral Contusions

8. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.

9. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Focal Brain InjuryFocal Brain Injury

Coup injuryCoup injury - injury directly below the point - injury directly below the point
of impact.of impact.

ContrecoupContrecoup - injury on the pole opposite the - injury on the pole opposite the
site of impact.site of impact.

Contusion results in brain edema and Contusion results in brain edema and
increased intracranial pressure.increased intracranial pressure.

Infarction, necrosis, and multiple hemorrhages Infarction, necrosis, and multiple hemorrhages
may occur.may occur.

10. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Brain TraumaBrain Trauma

11. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Extradural Hematomas Extradural Hematomas
(Epidural Hematomas)(Epidural Hematomas)

Accumulation of blood above the dura Accumulation of blood above the dura
mater next to the cranium.mater next to the cranium.

Arise in 1% to 2% of persons with Arise in 1% to 2% of persons with
traumatic brain injury.traumatic brain injury.

Bleeding is usually from an artery (85%) Bleeding is usually from an artery (85%)
and less often from injury to the meningeal and less often from injury to the meningeal
vein or dural sinus (15%). vein or dural sinus (15%).

12. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Extradural Hematomas Extradural Hematomas
(Epidural Hematomas(Epidural Hematomas

13. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Extradural Hematomas Extradural Hematomas

Most common site - temporal fossa. The Most common site - temporal fossa. The
temporal lobe shifts medially, causing temporal lobe shifts medially, causing
hippocampal and uncal herniation through hippocampal and uncal herniation through
the tentorial notch, compressing the brain the tentorial notch, compressing the brain
stem (usually fatal). stem (usually fatal).

Individuals with classic temporal extradural Individuals with classic temporal extradural
hematomas lose consciousness at injury, hematomas lose consciousness at injury,
and then one third become lucid for a few and then one third become lucid for a few
minutes (arterial bleeding) to a few days (if minutes (arterial bleeding) to a few days (if
a vein is bleeding).a vein is bleeding).

14. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subdural HematomasSubdural Hematomas

Accumulation of blood between the dura Accumulation of blood between the dura
mater and arachnoid.mater and arachnoid.

Arise in 10% to 20% of persons with Arise in 10% to 20% of persons with
traumatic brain injury. traumatic brain injury.

Bleeding is usually from bridging veins that Bleeding is usually from bridging veins that
tear, causing both rapidly and subacutely tear, causing both rapidly and subacutely
developing subdural hematomas. developing subdural hematomas.

Act like expanding masses that increase Act like expanding masses that increase
intracranial pressure.intracranial pressure.

15. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subdural HematomasSubdural Hematomas

16. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subdural HematomasSubdural Hematomas

Acute subdural hematomasAcute subdural hematomas - develop - develop
rapidly (hours); usually located at the top of rapidly (hours); usually located at the top of
the skull. the skull.

Subacute subdural hematomasSubacute subdural hematomas - develop - develop
more slowly (48 hours to 2 weeks). more slowly (48 hours to 2 weeks).

17. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subdural HematomasSubdural Hematomas

Chronic subdural hematomasChronic subdural hematomas - develop - develop
over weeks to months; commonly found in over weeks to months; commonly found in
elderly persons and persons who abuse elderly persons and persons who abuse
alcohol (brain atrophy causes increase in alcohol (brain atrophy causes increase in
extradural space). extradural space).

Subdural space gradually fills with blood.Subdural space gradually fills with blood.

18. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Chronic Subdural HematomaChronic Subdural Hematoma

19. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Intracerebral HematomasIntracerebral Hematomas

Bleeding into the brain.Bleeding into the brain.

Arise in 2% to 3% of persons with traumatic Arise in 2% to 3% of persons with traumatic
brain injury.brain injury.

May be single or multiple, and are associated May be single or multiple, and are associated
with contusions. with contusions.

Most commonly located in frontal and Most commonly located in frontal and
temporal lobes, but may occur in deep white temporal lobes, but may occur in deep white
matter. matter.

20. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Intracerebral HematomasIntracerebral Hematomas

21. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Intracerebral HematomasIntracerebral Hematomas

Penetrating injury or shearing forces damage Penetrating injury or shearing forces damage
small blood vessels. small blood vessels.

The intracerebral hematoma then acts as an The intracerebral hematoma then acts as an
expanding mass, increasing intracranial pressure, expanding mass, increasing intracranial pressure,
compressing brain tissues, and causing edema. compressing brain tissues, and causing edema.

Delayed intracerebral hematomas may appear 3 Delayed intracerebral hematomas may appear 3
to 10 days after the head injury.to 10 days after the head injury.

Intracerebral hematomas cause a progressively Intracerebral hematomas cause a progressively
decreasing level of consciousness. decreasing level of consciousness.

22. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.

23. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ACTIVITYACTIVITY
Choices:Choices:
a. Contusiona. Contusion
b. Extradural hematomab. Extradural hematoma
c. Subdural hematomac. Subdural hematoma
d. Intracerebral hematomad. Intracerebral hematoma

24. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ACTIVITYACTIVITY
1. Bleeding into the brain tissue.1. Bleeding into the brain tissue.
2. Bruising of part of the brain.2. Bruising of part of the brain.
3. Usually due to arterial bleeding.3. Usually due to arterial bleeding.
4. Usually due to venous bleeding.4. Usually due to venous bleeding.

25. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Diffuse Brain InjuryDiffuse Brain Injury

Diffuse axonal injury (DAI)Diffuse axonal injury (DAI)

Rotational acceleration (twisting Rotational acceleration (twisting
movement) is the primary mechanism of movement) is the primary mechanism of
injury, producing shearing forces within the injury, producing shearing forces within the
brain and tearing or stretching of nerve brain and tearing or stretching of nerve
fibers.fibers.

The most severe axonal injuries are The most severe axonal injuries are
located more peripheral to the brain stem, located more peripheral to the brain stem,
causing extensive cognitive and affective causing extensive cognitive and affective
impairments.impairments.

26. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Diffuse Axonal InjuryDiffuse Axonal Injury

27. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Diffuse Brain InjuryDiffuse Brain Injury

DAI is not associated with intracranial DAI is not associated with intracranial
hypertension immediately after injury so hypertension immediately after injury so
initially they often do not suffer headache initially they often do not suffer headache
(unlike most other brain traumas).(unlike most other brain traumas).

Over time brain edema often occurs Over time brain edema often occurs
causing increased intracranial pressure causing increased intracranial pressure
and coma.and coma.

Symptoms include loss of consciousness, Symptoms include loss of consciousness,
changes in respiration, and altered pupil changes in respiration, and altered pupil
reflexes.reflexes.

28. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Mild ConcussionMild Concussion

Temporary axonal disturbance causing Temporary axonal disturbance causing
attention and memory deficits but no loss attention and memory deficits but no loss
of consciousnessof consciousness

Grade I: confusion, disorientation, and Grade I: confusion, disorientation, and
momentary amnesiamomentary amnesia

Grade II: momentary confusion and Grade II: momentary confusion and
retrograde amnesiaretrograde amnesia

Grade III: confusion with retrograde and Grade III: confusion with retrograde and
anterograde amnesiaanterograde amnesia

29. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Classic Cerebral ConcussionClassic Cerebral Concussion

Grade IVGrade IV

Involves loss of consciousnessInvolves loss of consciousness

Disconnection of cerebral systems from the Disconnection of cerebral systems from the
brain stem and reticular activating systembrain stem and reticular activating system

Physiologic and neurologic dysfunction without Physiologic and neurologic dysfunction without
substantial anatomic disruption substantial anatomic disruption

Loss of consciousness (<6 hours)Loss of consciousness (<6 hours)

Anterograde and retrograde amnesiaAnterograde and retrograde amnesia

30. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Diffuse Axonal InjuryDiffuse Axonal Injury

Produces a traumatic coma lasting more Produces a traumatic coma lasting more
than 6 hours because of axonal disruptionthan 6 hours because of axonal disruption

Mild Mild

Moderate Moderate

SevereSevere

31. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Mild DAIMild DAI

Posttraumatic coma lasts 6–24hrPosttraumatic coma lasts 6–24hr

Death uncommonDeath uncommon

Persistent residual cognitive, psychologic, Persistent residual cognitive, psychologic,
and sensorimotor deficitsand sensorimotor deficits

Rare—only 8% of severe head injuries. Rare—only 8% of severe head injuries.

32. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Moderate DAIModerate DAI

Widespread physiologic impairment Widespread physiologic impairment
throughout the cerebral cortex and throughout the cerebral cortex and
diencephalondiencephalon

Actual tearing of axons in both hemispheresActual tearing of axons in both hemispheres

Prolonged coma (longer than 24hr)Prolonged coma (longer than 24hr)

Incomplete recovery among survivorsIncomplete recovery among survivors

Common—20% of severe head injuries.Common—20% of severe head injuries.

33. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Severe DAISevere DAI

Formerly called primary brain stem injury or Formerly called primary brain stem injury or
brain stem contusionbrain stem contusion

Severe mechanical disruption of axons in Severe mechanical disruption of axons in
both hemispheres, diencephalon, and both hemispheres, diencephalon, and brain brain
stemstem

May exhibit reduced consciousness for a May exhibit reduced consciousness for a
prolonged period of timeprolonged period of time

16% of severe head injuries16% of severe head injuries

34. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ACTIVITYACTIVITY
Choices:Choices:
a. Classic concussion (Grade IV) a. Classic concussion (Grade IV)
b. Mild DAI b. Mild DAI
c. Moderate DAI c. Moderate DAI
d. Severe DAId. Severe DAI

35. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ACTIVITYACTIVITY
1. Disruption of many axons in both 1. Disruption of many axons in both
hemispheres, diencephalon and brain stem which hemispheres, diencephalon and brain stem which
causes prolonged unconsciousness.causes prolonged unconsciousness.
2. Involves posttraumatic coma of 6-24 2. Involves posttraumatic coma of 6-24
hours, with residual cognitive, psychologic, and hours, with residual cognitive, psychologic, and
sensorimotor deficits.sensorimotor deficits.
3. Damage to axons causes loss of 3. Damage to axons causes loss of
consciousness lasting less than 6 hours with both consciousness lasting less than 6 hours with both
retrograde and anterograde amnesia.retrograde and anterograde amnesia.
4. Involves posttraumatic coma of more than 4. Involves posttraumatic coma of more than
24 hours, with axonal damage to the cerebral 24 hours, with axonal damage to the cerebral
hemispheres and diencephalon.hemispheres and diencephalon.

36. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord Trauma Spinal Cord Trauma
OverviewOverview

Most commonly occurs due to vertebral Most commonly occurs due to vertebral
injuries.injuries.

Elderly are most at risk because of Elderly are most at risk because of
preexisting degenerative conditions of preexisting degenerative conditions of
vertebrae.vertebrae.

Traumatic injury of vertebral and neural Traumatic injury of vertebral and neural
tissues occurs as a result of compressing, tissues occurs as a result of compressing,
pulling, or shearing forces.pulling, or shearing forces.

37. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord Trauma Spinal Cord Trauma

Most common locations: cervical (1, 2, 4-Most common locations: cervical (1, 2, 4-
7), and T10-L2 lumbar vertebrae.7), and T10-L2 lumbar vertebrae.

Locations reflect most mobile portions of Locations reflect most mobile portions of
vertebral column and the locations where vertebral column and the locations where
the spinal cord occupies most of the the spinal cord occupies most of the
vertebral canal.vertebral canal.

Injury to the cervical spinal region is life-Injury to the cervical spinal region is life-
threatening because it interferes with the threatening because it interferes with the
phrenic nerve which controls the phrenic nerve which controls the
diaphragm.diaphragm.

38. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord Trauma Spinal Cord Trauma

39. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord Trauma Spinal Cord Trauma

40. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord Trauma Spinal Cord Trauma

41. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord Trauma Spinal Cord Trauma

42. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal ShockSpinal Shock

Normal activity of the spinal cord ceases at Normal activity of the spinal cord ceases at
and below the level of injury. Sites lack and below the level of injury. Sites lack
continuous nervous discharges from the continuous nervous discharges from the
brain.brain.

Damage to the sympathetic nervous Damage to the sympathetic nervous
system interferes with normal thermal system interferes with normal thermal
control causing body temperature to drop.control causing body temperature to drop.

43. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal ShockSpinal Shock

Spinal shock generally lasts 7 to 20 days, Spinal shock generally lasts 7 to 20 days,
with a range of a few days to 3 months. with a range of a few days to 3 months.

Edema of spinal tissue contributes to the Edema of spinal tissue contributes to the
loss of function. loss of function.

As edema resolves, the spinal shock As edema resolves, the spinal shock
terminates with the reappearance of reflex terminates with the reappearance of reflex
activity, hyperreflexia, spasticity, and reflex activity, hyperreflexia, spasticity, and reflex
emptying of the bladder.emptying of the bladder.

44. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Autonomic Hyperreflexia Autonomic Hyperreflexia

May occur after spinal shock resolves.May occur after spinal shock resolves.

Most likely with lesions at the T6 level or Most likely with lesions at the T6 level or
above.above.

Caused by massive, uncompensated Caused by massive, uncompensated
cardiovascular response to stimulation of cardiovascular response to stimulation of
the sympathetic nervous system, including the sympathetic nervous system, including
hypertension, sweating, and flushing.hypertension, sweating, and flushing.

45. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Autonomic Hyperreflexia Autonomic Hyperreflexia

It can be stimulated by pain, touch, or It can be stimulated by pain, touch, or
often a full bladder or boweloften a full bladder or bowel

Relieved by parasympathetic stimulation Relieved by parasympathetic stimulation
such as bowel- or bladder-emptying.such as bowel- or bladder-emptying.

Symptoms include headache, blurred Symptoms include headache, blurred
vision, hypertension, sweating, and vision, hypertension, sweating, and
flushing.flushing.

Life threatening condition.Life threatening condition.

46. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Autonomic Hyperreflexia Autonomic Hyperreflexia

47. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Spinal Cord TransectionSpinal Cord Transection
Complete loss of reflex function (skeletal, Complete loss of reflex function (skeletal,
bladder, bowel, sexual function, thermal control, bladder, bowel, sexual function, thermal control,
and autonomic control) occurs below any and autonomic control) occurs below any
transected area.transected area.
Loss of motor and sensory function depends on Loss of motor and sensory function depends on
the level of injury. the level of injury.
Paraplegia - paralysis of the lower half of the Paraplegia - paralysis of the lower half of the
body with both legs involved; occurs with body with both legs involved; occurs with
injuries of thoracic spinal cord.injuries of thoracic spinal cord.
Quadriplegia - paralysis involving all four Quadriplegia - paralysis involving all four
extremities; occurs with injuries of cervical extremities; occurs with injuries of cervical
spinal cord. spinal cord.

48. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Degenerative Disorders of the Degenerative Disorders of the
SpineSpine

Degenerative disk disease (DDD)Degenerative disk disease (DDD)

An alteration in intervertebral disk tissue and An alteration in intervertebral disk tissue and
can be related to normal aging. can be related to normal aging.

SpondylolysisSpondylolysis

A structural defect of the spine with A structural defect of the spine with
displacement of the vertebra. displacement of the vertebra.

49. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Degenerative Disorders of the Degenerative Disorders of the
SpineSpine

SpondylolisthesisSpondylolisthesis

Involves forward slippage of the vertebraInvolves forward slippage of the vertebra

Can involve a crack or fracture of the lamina Can involve a crack or fracture of the lamina
between the superior and inferior articular facetsbetween the superior and inferior articular facets

Usually at the L5-S1 vertebra. Usually at the L5-S1 vertebra.

Spinal stenosisSpinal stenosis

Narrowing of the spinal canal that causes Narrowing of the spinal canal that causes
pressure on the spinal nerves or cord.pressure on the spinal nerves or cord.

50. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Degenerative Disorders of the Degenerative Disorders of the
SpineSpine

Low back painLow back pain

Pain between the lower rib cage and gluteal Pain between the lower rib cage and gluteal
muscles and often radiates into the thigh. muscles and often radiates into the thigh.

Most causes of low back pain are unknown; Most causes of low back pain are unknown;
however, some secondary causes are:however, some secondary causes are:
•disk prolapse, tumors, bursitis, synovitis, disk prolapse, tumors, bursitis, synovitis,
degenerative joint disease, osteoporosis, fracture, degenerative joint disease, osteoporosis, fracture,
inflammation, and sprain. inflammation, and sprain.

51. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Degenerative Disorders of the Degenerative Disorders of the
SpineSpine

Herniated intervertebral diskHerniated intervertebral disk

A protrusion of part of the nucleus pulposus. A protrusion of part of the nucleus pulposus.

Herniation most commonly affects the Herniation most commonly affects the
lumbosacral disks (L4-5 and L5-S1). lumbosacral disks (L4-5 and L5-S1).

The extruded pulposus compresses the nerve The extruded pulposus compresses the nerve
root, causing pain that radiates along the sciatic root, causing pain that radiates along the sciatic
nerve coursenerve course, , a condition called a condition called sciaticasciatica..

52. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.

53. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.

54. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular DisordersCerebrovascular Disorders

Cerebrovascular diseaseCerebrovascular disease - any abnormality - any abnormality
of the blood vessels of the brain.of the blood vessels of the brain.

Most frequently occurring neurologic disorder. Most frequently occurring neurologic disorder.

Associated with two types of brain Associated with two types of brain
abnormalities: abnormalities:
1.1.ischemia with or without infarction ischemia with or without infarction
2.2.hemorrhagehemorrhage

55. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular Accidents (CVA) Cerebrovascular Accidents (CVA)

Also known as Also known as strokestroke..

A localized brain infarction that may result A localized brain infarction that may result
in facial, arm, or leg numbness and in facial, arm, or leg numbness and
weakness, confusion, difficulty speaking or weakness, confusion, difficulty speaking or
understanding, visual disturbances, understanding, visual disturbances,
dizziness, loss of balance, difficulty dizziness, loss of balance, difficulty
walking, and headache.walking, and headache.

Leading cause of disability and third Leading cause of disability and third
leading cause of death in United States.leading cause of death in United States.

56. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular Accidents (CVA) Cerebrovascular Accidents (CVA)

Classifications:Classifications:

Global hypoperfusion (as in shock)Global hypoperfusion (as in shock)

Ischemia (thrombotic, embolic)Ischemia (thrombotic, embolic)

HemorrhagicHemorrhagic

57. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular Accidents (CVA) Cerebrovascular Accidents (CVA)

Risk factors Risk factors (very similar to those for (very similar to those for
myocardial infarction):myocardial infarction):

Arterial hypertension Arterial hypertension (both elevated systolic (both elevated systolic
and diastolic blood pressures)and diastolic blood pressures)

SmokingSmoking - increases the risk of stroke by 50% - increases the risk of stroke by 50%

DiabetesDiabetes - increases the risk of ischemic - increases the risk of ischemic
stroke between 2½ and 3½ timesstroke between 2½ and 3½ times

Insulin resistance Insulin resistance - increases risk for - increases risk for
ischemic strokeischemic stroke

58. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular Accidents (CVA) Cerebrovascular Accidents (CVA)

Risk factors Risk factors (cont.):(cont.):

Polycythemia and thrombocythemia Polycythemia and thrombocythemia - place - place
the person at risk for ischemic strokethe person at risk for ischemic stroke

Impaired cardiac function Impaired cardiac function - increases risk for - increases risk for
ischemic strokeischemic stroke

Nonrheumatic atrial fibrillation Nonrheumatic atrial fibrillation - associated - associated
with a 5-fold increase in the incidence of with a 5-fold increase in the incidence of
ischemic strokeischemic stroke

Chlamydia pneumoniaeChlamydia pneumoniae - can increase the - can increase the
risk of stroke by infiltrating and inflaming the risk of stroke by infiltrating and inflaming the
vascular endothelium vascular endothelium

59. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular Accidents (CVA) Cerebrovascular Accidents (CVA)

Risk factors Risk factors (cont.):(cont.):

Obstructive sleep apnea Obstructive sleep apnea - increases risk for - increases risk for
stroke independent of other risk factorsstroke independent of other risk factors

Increased levels of homocysteine; lipoprotein-Increased levels of homocysteine; lipoprotein-
a; lipoprotein-associated phospholipase A2 a; lipoprotein-associated phospholipase A2
(Lp-PLa2) and C-reactive protein (indicators of (Lp-PLa2) and C-reactive protein (indicators of
inflammation) - risk factors for ischemic stroke.inflammation) - risk factors for ischemic stroke.

CVAs occur most frequently in those over 65, CVAs occur most frequently in those over 65,
in males, and in the black populationin males, and in the black population

60. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Cerebrovascular Accidents (CVA) Cerebrovascular Accidents (CVA)

Cerebral infarctionCerebral infarction - results when an area of - results when an area of
the brain loses its blood supply because of the brain loses its blood supply because of
vascular occlusion.vascular occlusion.

Cerebral hemorrhageCerebral hemorrhage - bleeding into brain - bleeding into brain
tissue, usually due to hypertension.tissue, usually due to hypertension.

61. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Thrombotic StrokeThrombotic Stroke

Arterial occlusions caused by thrombi formed in Arterial occlusions caused by thrombi formed in
arteries supplying the brain or in the intracranial arteries supplying the brain or in the intracranial
vessels.vessels.

Cerebral thrombi often develop due to Cerebral thrombi often develop due to
atherosclerosis, inflammation (arteritis), or atherosclerosis, inflammation (arteritis), or
increased coagulation disorders. increased coagulation disorders.

Risk is increased by conditions causing Risk is increased by conditions causing
inadequate cerebral perfusion (e.g., dehydration, inadequate cerebral perfusion (e.g., dehydration,
hypotension, prolonged vasoconstriction from hypotension, prolonged vasoconstriction from
malignant hypertension).malignant hypertension).

62. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Transient Ischemic Attacks (TIAs) Transient Ischemic Attacks (TIAs)

Temporary decreases in brain blood flow Temporary decreases in brain blood flow
resulting in brief changes in brain function.resulting in brief changes in brain function.

Symptoms - changes in vision, speech, motor Symptoms - changes in vision, speech, motor
function, or symptoms of dizziness or loss of function, or symptoms of dizziness or loss of
consciousness. consciousness.

Most often occur when small thrombi cause a Most often occur when small thrombi cause a
temporary blockage of circulation. temporary blockage of circulation.

63. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Transient Ischemic Attacks (TIAs) Transient Ischemic Attacks (TIAs)

All neurologic deficits clear completely All neurologic deficits clear completely
within 24 hours.within 24 hours.

No residual dysfunction and no permanent No residual dysfunction and no permanent
brain injury. brain injury.

Without treatment, 80% of persons have a Without treatment, 80% of persons have a
recurrence of symptoms by 1 year.recurrence of symptoms by 1 year.

64. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Embolic StrokeEmbolic Stroke

Caused by fragments that break from a Caused by fragments that break from a
thrombus formed outside the brain.thrombus formed outside the brain.

These frequently are from the heart, aorta, or These frequently are from the heart, aorta, or
common carotid artery. common carotid artery.

Embolus usually obstructs small brain Embolus usually obstructs small brain
vessels (often branches of the middle vessels (often branches of the middle
cerebral artery), causing ischemia. cerebral artery), causing ischemia.

65. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Embolic StrokeEmbolic Stroke

66. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Embolic StrokeEmbolic Stroke

Risk factors Risk factors - atrial fibrillation, myocardial - atrial fibrillation, myocardial
infarction, endocarditis, rheumatic heart infarction, endocarditis, rheumatic heart
disease, valvular prostheses, atrial-septal disease, valvular prostheses, atrial-septal
defects, and disorders of the aorta, carotids, defects, and disorders of the aorta, carotids,
or vertebral-basilar circulation. or vertebral-basilar circulation.

Often a second stroke follows because the Often a second stroke follows because the
source of emboli continues to exist.source of emboli continues to exist.

67. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Hemorrhagic StrokeHemorrhagic Stroke

Occurs when cerebral vessels rupture, Occurs when cerebral vessels rupture,
causing bleeding into the brain tissue.causing bleeding into the brain tissue.

Caused by hypertension, ruptured aneurysms Caused by hypertension, ruptured aneurysms
or vascular malformation, bleeding into a or vascular malformation, bleeding into a
tumor, hemorrhage associated with bleeding tumor, hemorrhage associated with bleeding
disorders, anticoagulation, head trauma, and disorders, anticoagulation, head trauma, and
illicit drug use.illicit drug use.

Hypertensive hemorrhage - associated with Hypertensive hemorrhage - associated with
significantly increased systolic and diastolic significantly increased systolic and diastolic
pressure over several years. pressure over several years.

68. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Hemorrhagic StrokeHemorrhagic Stroke

A mass of blood is formed and grows, A mass of blood is formed and grows,
displacing and compressing adjacent brain displacing and compressing adjacent brain
tissue. tissue.

Rupture or seepage into the ventricular Rupture or seepage into the ventricular
system occurs in many cases. system occurs in many cases.

69. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Hemorrhagic StrokeHemorrhagic Stroke

70. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Lacunar Stroke Lacunar Stroke

Infarcts smaller than 1 cm in diameter. Infarcts smaller than 1 cm in diameter.

Involve the small perforating arteries, Involve the small perforating arteries,
predominantly in the basal ganglia, internal predominantly in the basal ganglia, internal
capsules, and pons. capsules, and pons.

Associated with smoking, hypertension, and Associated with smoking, hypertension, and
diabetes mellitus.diabetes mellitus.

Because of the subcortical location and small Because of the subcortical location and small
area of infarction, these strokes may have area of infarction, these strokes may have
pure motor and sensory deficits.pure motor and sensory deficits.

71. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ACTIVITYACTIVITY
Choices:Choices:
a. Thrombotica. Thrombotic
b. Embolicb. Embolic
c. Hemorrhagicc. Hemorrhagic
d. Lacunard. Lacunar

72. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ACTIVITYACTIVITY
1. Due to rupture of blood vessels and 1. Due to rupture of blood vessels and
bleeding into brain.bleeding into brain.
2. Due to narrowing of cerebral or 2. Due to narrowing of cerebral or
carotid vessels.carotid vessels.
3. Due to blockage of small perforating 3. Due to blockage of small perforating
arteries.arteries.
4. Due to blockage of a cerebral 4. Due to blockage of a cerebral
vessel by fragments from elsewhere.vessel by fragments from elsewhere.

73. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Intracranial AneurysmIntracranial Aneurysm

Result from defects in the vascular wall.Result from defects in the vascular wall.

Most aneurysms are located at bifurcations in Most aneurysms are located at bifurcations in
or near the circle of Willis, in the vertebral or or near the circle of Willis, in the vertebral or
basilar arteries, or within the carotid system.basilar arteries, or within the carotid system.

Classified on the basis of form and shape. Classified on the basis of form and shape.

SaccularSaccular (berry) aneurysms - result from (berry) aneurysms - result from
congenital abnormalities and degenerative congenital abnormalities and degenerative
changes.changes.

FusiformFusiform (giant) aneurysms - result from (giant) aneurysms - result from
diffuse arteriosclerotic changes.diffuse arteriosclerotic changes.

74. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Intracranial AneurysmIntracranial Aneurysm

75. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Berry AneurysmBerry Aneurysm

76. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Intracranial AneurysmIntracranial Aneurysm

They are often asymptomatic, but signs vary They are often asymptomatic, but signs vary
depending on the location and size of the depending on the location and size of the
aneurysm. aneurysm.

Rupture results in cerebral hemorrhage, Rupture results in cerebral hemorrhage,
hemorrhagic stroke, and/or subarachnoid hemorrhagic stroke, and/or subarachnoid
hemorrhage.hemorrhage.

77. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Arteriovenous Malformation Arteriovenous Malformation
(AVM)(AVM)

A tangled mass of dilated blood vessels. A tangled mass of dilated blood vessels.

Although sometimes present at birth, AVM Although sometimes present at birth, AVM
exhibits a delayed age of onset. exhibits a delayed age of onset.

With moderate to large AVMs, sufficient blood With moderate to large AVMs, sufficient blood
is shunted into the malformation to deprive is shunted into the malformation to deprive
surrounding tissue of adequate blood surrounding tissue of adequate blood
perfusion, causing headache.perfusion, causing headache.

78. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Arteriovenous Malformation Arteriovenous Malformation
(AVM)(AVM)

79. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Arteriovenous Malformation Arteriovenous Malformation
(AVM)(AVM)

AVMs have abnormally thin walls which may AVMs have abnormally thin walls which may
rupture, causing intracerebral, subarachnoid, rupture, causing intracerebral, subarachnoid,
or subdural hemorrhage. or subdural hemorrhage.

Bleeding from an AVM into the subarachnoid Bleeding from an AVM into the subarachnoid
space causes symptoms identical to those space causes symptoms identical to those
associated with a ruptured aneurysm. associated with a ruptured aneurysm.

80. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subarachnoid HemorrhageSubarachnoid Hemorrhage

Occurs when blood escapes from defective or Occurs when blood escapes from defective or
injured vasculature into the subarachnoid injured vasculature into the subarachnoid
space. space.

Caused by head injuries, intracranial Caused by head injuries, intracranial
aneurysm, intracranial AVM, or hypertension.aneurysm, intracranial AVM, or hypertension.

Blood in the cerebrospinal fluid causes Blood in the cerebrospinal fluid causes
meningeal irritation and inflammation.meningeal irritation and inflammation.

81. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subarachnoid HemorrhageSubarachnoid Hemorrhage

82. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subarachnoid HemorrhageSubarachnoid Hemorrhage

Acute manifestations:Acute manifestations:

Ruptured vessel causes a sudden, throbbing, Ruptured vessel causes a sudden, throbbing,
“explosive” headache, accompanied by “explosive” headache, accompanied by
nausea and vomiting, visual disturbances, nausea and vomiting, visual disturbances,
motor deficits, and loss of consciousness motor deficits, and loss of consciousness
related to a dramatic rise in intracranial related to a dramatic rise in intracranial
pressure.pressure.

Meningeal irritation causes neck stiffness Meningeal irritation causes neck stiffness
(nuchal rigidity), photophobia, blurred vision, (nuchal rigidity), photophobia, blurred vision,
irritability, restlessness, and low-grade fever.irritability, restlessness, and low-grade fever.

83. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subarachnoid HemorrhageSubarachnoid Hemorrhage

Acute manifestations:Acute manifestations:

Kernig sign (straightening the knee with the Kernig sign (straightening the knee with the
hip and knee in a flexed position produces hip and knee in a flexed position produces
pain in the back and neck regions).pain in the back and neck regions).

Brudzinski sign (passive flexion of the neck Brudzinski sign (passive flexion of the neck
produces neck pain and increased rigidity).produces neck pain and increased rigidity).

84. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subarachnoid HemorrhageSubarachnoid Hemorrhage

As hemorrhage progresses, vasospasms As hemorrhage progresses, vasospasms
often occurs in adjacent vessels.often occurs in adjacent vessels.

Vasospasms cause cerebral ischemia, edema, Vasospasms cause cerebral ischemia, edema,
infarcts, and often seizures.infarcts, and often seizures.

Rebleeding often occurs within the first Rebleeding often occurs within the first
month.month.

Mortality in subarachnoid hemorrhage is 50% Mortality in subarachnoid hemorrhage is 50%
at 1 month.at 1 month.

85. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Subarachnoid Hemorrhage Subarachnoid Hemorrhage
Classification Scale Classification Scale
CategoryDescription
Grade I
Neurologic status intact; mild headache, slight nuchal
rigidity
Grade II
Neurologic deficit evidenced by cranial nerve
involvement; moderate to severe headache with more
pronounced meningeal signs (e.g., photophobia, nuchal
rigidity)
Grade III
Drowsiness and confusion with or without focal
neurologic deficits; pronounced meningeal signs
Grade IV
Stuporous with pronounced neurologic deficits (e.g.,
hemiparesis, dysphasia); nuchal rigidity
Grade V
Deep coma state with decerebrate posturing and other
brain stem functioning