Tanta University

Faculty of Nursing
Critical Care and Emergency Nursing
Department

Under Supervision :
Sundus Muhammad

Prapered by :
Afaf Ibrahim Abdul Jalil Ali Abdelaziz Ali Elsadany

Ola Sadek Mohamed Elgamal Ali Mohamed Ali Ghonem

Ola Abdul Wahab Al -Khouly Ali Khalid Ali Mohammed

Alaa Mohamed Abdelfatah Ali Khalid Mohammed Ali

Alyaa Ayman Ibrahim Shaheen Ali Mahmoud Ahmed Dargham

Alyaa Mahmoud Alsayed Elnagar Ali Mohamed Alsayed Alsayed

Alyaa Wageeh Abd-Elhamed Mariam Ahmed Mostafa

Marwa Mahmoud Abdelghany Mariam Ahmed Al-Sayed Badr

Ammar Mostafa Sadek esmail Mariam gamal Mohamed

About :
Stroke
Group : 12
 Introduction
Stroke is a cerebrovascular disorder characterized by the sudden loss of neurological function due to an
interruption in cerebral blood flow or depriving brain tissue of oxygen and essential nutrients.

Stroke is a major global health concern and It is a leading cause of disability and mortality
.worldwide, posing a significant public health challenge

Stroke occurs due to either ischemia, resulting from arterial occlusion, or hemorrhage, caused by the
rupture of a blood vessel. These pathological mechanisms can lead to the rapid death of brain cells,
resulting in cognitive impairments, or even death neuronal injury and dysfunction, often with long-term
neurological consequences.

Definition of Stroke
A stroke is a medical emergency that occurs when blood flow to a part of the brain is interrupted or
reduced, preventing brain tissue from getting oxygen and nutrients. This can cause brain cells to die within
minutes, potentially leading to permanent damage or disability.

Pathophysiology of Stroke
A stroke occurs due to a disruption in cerebral blood flow, leading to brain tissue injury. The two main types
of stroke—ischemic stroke and hemorrhagic stroke—have different pathophysiological mechanisms:

1. Ischemic Stroke (≈ 85% of strokes)

Caused by a blockage in a cerebral artery, leading to reduced blood flow and oxygen deprivation (ischemia).

1. Thrombosis or Embolism → Blood clot or embolus blocks a brain artery.

2. Hypoxia & Ischemia → Lack of oxygen and glucose leads to cellular dysfunction.

3. Energy Failure → ATP depletion impairs Na+/K+ pumps, causing cell swelling (cytotoxic edema).

4. Excitotoxicity → Excess glutamate release leads to calcium influx, activating enzymes that damage
neurons.

5. Oxidative Stress & Inflammation → Free radicals and inflammatory mediators cause further neuronal
death.

6. Ischemic Core & Penumbra → The core undergoes infarction, while the surrounding area (penumbra)
may be salvageable with rapid treatment.

2. Hemorrhagic Stroke (≈ 15% of strokes)

Occurs due to rupture of a blood vessel, leading to bleeding into the brain.

1. Vessel Rupture → Common causes include hypertension, aneurysm, or trauma.

2. Hematoma Formation → Blood accumulates, increasing intracranial pressure (ICP).

3. Brain Tissue Compression → Leads to decreased perfusion and secondary ischemia.

4. Toxic Effects of Blood Products → Hemoglobin breakdown releases iron and inflammatory cytokines,
worsening injury.

5. Cerebral Edema & Herniation Risk → Severe cases may cause brain herniation, leading to fatal outcomes.

Conclusion
Regardless of the type, stroke leads to neuronal injury through ischemia, oxidative stress, excitotoxicity,
and inflammation. Early medical intervention (e.g., thrombolysis in ischemic stroke or blood pressure
control in hemorrhagic stroke) is crucial to prevent permanent brain damage.

Types Of Stroke
There are four main types of stroke, each with different causes and effects:

1. Ischemic Stroke (Most Common – ~87% of Cases)

Cause: A blood clot blocks or narrows a blood vessel, reducing blood flow to the brain.

the main types of ischemic stroke include:

1. Thrombotic Stroke

Cause: A blood clot (thrombus) forms in one of the arteries supplying blood to the brain, usually due to
atherosclerosis.

.Typically affects major arteries like the carotid or vertebral arteries

Small vessel disease (Lacunar stroke): Affects smaller, deeper arteries.

2. Embolic Stroke

Cause: A blood clot form in the body (commonly the heart) and travels to the brain, causing a blockage.

Common source: Often associated with atrial fibrillation, heart valve disease, or myocardial infarction.

2. Hemorrhagic Stroke (~13% of Cases)

Cause: A blood vessel in the brain bursts, leading to bleeding in or around the brain.

Types of Hemorrhage (bleeding) can be classified in several ways depending on source, location, duration,
or severity.

1. Subarachnoid Hemorrhage

Location: Between arachnoid and pia mater, within the subarachnoid space.

Cause: Commonly due to ruptured aneurysm (e.g., Berry aneurysm) or trauma.

Symptoms: Sudden severe headache ("worst headache of life"), neck stiffness, photophobia.

Diagnosis: CT scan or lumbar puncture (shows blood in CSF).

2. Intracerebral (Intraparenchymal) Hemorrhage

Location: Within the brain tissue itself.

Cause: Hypertension, trauma, vascular malformations, or bleeding disorders.

Common sites: Basal ganglia, thalamus, cerebellum, brainstem.

Symptoms: Depend on location—can include hemiparesis, coma, or focal neurological deficits

3. Transient Ischemic Attack (TIA) – "Mini-Stroke"

Cause: A temporary blockage of blood flow to the brain, usually lasting minutes to hours.

Key Feature: No permanent brain damage, but it’s a warning sign of a future stroke.

Causes of stroke
1.Ischemic Stroke
:Causes include

Atherosclerosis (narrowing of arteries due to plaque buildup)

Blood clots from the heart (e.g., in atrial fibrillation) or large arteries

Embolism (a clot or debris traveling from another part of the body)

Small vessel disease (blockage of tiny brain arteries)

2. Hemorrhagic Stroke (Bleeding in the Brain)

:Causes include

High blood pressure (hypertension)

Aneurysm rupture (a bulging weak spot in a blood vessel)

Arteriovenous malformation (AVM) (abnormal blood vessel connections)

Head trauma or injury

Overuse of blood thinners

Signs & Symptoms (FAST Method)

The FAST mnemonic is a quick way to recognize stroke symptoms:
F – Face Drooping: One side of the face may droop or feel numb. Ask the person to smile and check if it's
uneven.

A – Arm Weakness: Sudden weakness or numbness in one arm. Ask the person to raise both arms and see if
one drifts downward.

S – Speech Difficulty: Slurred speech or difficulty speaking/understanding words. Ask the person to repeat a
simple sentence.
T – Time to Call Emergency Services: If you notice any of these symptoms, call emergency services
immediately (e.g., 911).

Other Possible Stroke Symptoms

Sudden confusion or trouble understanding speech

Sudden vision problems in one or both eyes (blurriness, double vision, or loss of vision)

Sudden severe headache with no known cause

Dizziness, loss of balance, or coordination issues

Numbness or weakness in the face, arms, or legs, especially on one side of the body

Risk Factors for Stroke :

Stroke is one of the leading causes of death and disability worldwide. There are several risk factors that
increase the likelihood of having a stroke, and some of these factors can be modified to reduce the risk.

Modifiable Risk Factors:

1. *High Blood Pressure*: High blood pressure is a major risk factor for stroke. Blood pressure can be
controlled through medication and lifestyle changes.

2. *Diabetes*: Diabetes increases the risk of stroke. Diabetes can be managed through medication and
lifestyle changes.

3. *Overweight and Obesity*: Being overweight or obese increases the risk of stroke. Weight can be
reduced through lifestyle changes.

4. *Physical Inactivity*: A lack of physical activity increases the risk of stroke. Physical activity can be
increased through exercise.

5. *Smoking*: Smoking increases the risk of stroke. Smoking can be quit.

6. *Alcohol Consumption*: Excessive alcohol consumption increases the risk of stroke. Alcohol
consumption can be reduced.

7. *Diet*: Diet can affect the risk of stroke. Consuming a diet low in saturated fats and sodium can help
reduce the risk.

8. *Stress*: Stress can increase the risk of stroke. Stress can be managed through relaxation techniques
such as meditation and yoga.

Non modifiable risk factors :

1. Increasing age (stroke rate more than doubles for each 10 years above age 55)

2. Gender (female slightly more common than male)

3. Family history of vascular disease

4. Previous Stroke or TIA

 Complications :
Stroke can lead to a variety of complications, which can be categorized as neurological, systemic, or long-
term disabilities. Some common complications include:

Neurological Complications:
1. Hemorrhagic transformation – Conversion of an ischemic stroke into a hemorrhagic stroke.

2. Seizures – Due to cortical irritation or brain injury.

3. Brain edema and increased intracranial pressure (ICP) – Can lead to brain herniation.

4. Recurrent stroke – Higher risk of another stroke in the future.

5. Post-stroke cognitive impairment and dementia – Due to brain damage.

Systemic Complications:
6. Deep vein thrombosis (DVT) and pulmonary embolism (PE) – Due to immobility.

7. Aspiration pneumonia – Due to impaired swallowing (dysphagia).

8. Urinary tract infections (UTIs) – Common due to catheterization or incontinence.

9. Pressure ulcers (bedsores) – Due to prolonged immobility.

10. Cardiac complications – Including arrhythmias, heart failure, and myocardial infarction.

11. Malnutrition and dehydration – Due to difficulty swallowing.

Long-Term Disabilities:
12. Paralysis and muscle weakness – Commonly hemiparesis or hemiplegia.

13. Speech and language disorders (aphasia, dysarthria) – Depending on the area affected.

14. Cognitive and memory problems – Affecting daily function and independence.

15. Depression and emotional instability – Due to the psychological impact of stroke.

16. Spasticity and contractures – Muscle stiffness limiting movement.

17. Chronic pain (central post-stroke pain syndrome) – Neuropathic pain due to nerve damage.

Diagnosis for stroke

1. Clinical Assessment
A doctor will assess symptoms and medical history, looking for common stroke signs using the FAST
acronym:

Face drooping

Arm weakness
Speech difficulty

2. Imaging Tests
These are crucial for confirming a stroke and determining its type (ischemic or hemorrhagic):

CT scan (Computed Tomography): Quickly detects bleeding in the brain (hemorrhagic stroke).

MRI (Magnetic Resonance Imaging): Provides a detailed view of brain tissue damage, often used for
ischemic strokes.

CT Angiography (CTA) or MR Angiography (MRA): Helps visualize blood vessel blockages.

3. Blood Tests
Clotting tests (PT, INR, aPTT): To check for blood clotting disorders.

Blood sugar levels: Low or high glucose levels can mimic stroke symptoms.

Complete blood count (CBC): To assess infection or anemia.

4. Heart and Vascular Tests

Since strokes often result from cardiovascular issues, doctors may also perform:

Electrocardiogram (ECG/EKG): Detects heart rhythm abnormalities (like atrial fibrillation).

Echocardiogram: Looks for blood clots in the heart that may have traveled to the brain.

Carotid Ultrasound: Checks for narrowing or blockages in the carotid arteries.

5. Additional Tests (if needed)

Lumbar puncture (spinal tap): If an infection or rare condition is suspected.

EEG (Electroencephalogram): If seizures are suspected instead of stroke.

Nursing Management of stroke

1.Assess mental status and level of consciousness

2.Observe for neurological deficits with frequent and serial neurological assessments

3.Measure and monitor pupil size

4.Assess breathing

5.Monitor vital signs

6.Assess higher functions like speech, memory, and cognition

7.Provide a quiet environment with the head of the bed elevated

8.Elevate bed rails to prevent falls

9.Leave the nurse bell button at the side of the bed in case the patient needs to go to the bathroom
10.Prevent constipation and straining with stool softeners

11.Watch for seizures

12.Observe for changes in mood

13.Provide deep vein thrombosis (DVT) prophylaxis

Medical management
Medical management of ischemic stroke?
1. Acute Management (First Hours to Days)

a. Thrombolysis

Alteplase (tPA): Administered within 4.5 hours of symptom onset (ideally within 3 hours).

b. Mechanical Thrombectomy

For large vessel occlusions (e.g., internal carotid, M1), it’s recommended within 6–24 hours of symptom
onset.

c. Antiplatelet Therapy

Aspirin is typically given within 24-48 hours of stroke onset if tPA is not used.

d. Anticoagulation

Not initiated immediately, especially after tPA administration, due to risk of hemorrhage.

e. Blood Pressure Management

In acute ischemic stroke, aggressive lowering is usually not recommended.

Target BP for tPA candidates: <185/110 mmHg.

If BP >220/120 mmHg, treatment is needed.

f. Blood Glucose & Temperature Control

Blood glucose: Maintain within 80–180 mg/dL.

2. Secondary Prevention (Post-Stroke)

a. Antiplatelet Therapy

Aspirin, Clopidogrel, or Combination Therapy to reduce recurrence.

b. Anticoagulation

For patients with atrial fibrillation or cardioembolic sources, warfarin or DOACs (e.g., Apixaban,
Rivaroxaban).

c. Statin Therapy
Initiate high-intensity statin therapy (e.g., Atorvastatin 40–80 mg).

d. Blood Pressure & Diabetes Management

BP target: <140/90 mmHg (individualized based on risk).

e. Lifestyle Modifications

Smoking cessation, healthy diet (e.g., Mediterranean diet), regular physical activity, and weight
management.

The medical management of hemorrhage

involves several key steps to control bleeding, prevent shock, and address the underlying cause. The
approach can be broken down into the following stages:

1. Assessment and Stabilization

Primary Survey (ABC): The first priority is assessing and securing the airway, breathing, and circulation.

Airway: Ensure the airway is clear and manage any obstruction.

Breathing: Monitor respiratory status and provide oxygen if needed.

Circulation: Assess for signs of shock (tachycardia, hypotension) and establish intravenous (IV) access for
fluid resuscitation.

Stop Bleeding: Apply direct pressure, dressings, or tourniquets to control external bleeding. If internal
bleeding is suspected, consider imaging and other interventions.

2. Hemorrhage Control

External Hemorrhage:

Direct pressure is the most effective method.

Use dressings or hemostatic agents (such as gauze with clotting agents) to promote clot formation.

For extremity wounds, tourniquets can be applied as a last resort if direct pressure is ineffective.

Internal Hemorrhage:

Surgical or Interventional Radiology: May be required for bleeding from internal organs, such as the liver or
spleen, or for vascular injuries.

Endovascular Techniques: Embolization may be used in some cases to control bleeding from arteries.

Pharmacological Therapy: Agents like tranexamic acid may be used to prevent fibrinolysis (the breakdown
of clots).

3. Resuscitation and Fluid Replacement

IV Fluids: Crystalloids (e.g., normal saline or lactated Ringer's solution) are initially used to restore
circulating volume.

Blood Products:
If hemorrhage is severe or ongoing, transfusions of packed red blood cells (PRBCs) are often necessary.

Platelets and fresh frozen plasma (FFP) are used if coagulopathy is present or there is significant blood loss.

4. Monitoring and Support

Vital Signs Monitoring: Continuous monitoring of blood pressure, heart rate, and oxygen saturation is
essential to assess the response to treatment.

Lab Tests: Hemoglobin/hematocrit levels, coagulation profile, and lactate levels help guide management
decisions.

Temperature Control: Hypothermia can worsen coagulopathy, so efforts to maintain normothermia are
important (e.g., warm fluids, blankets).

5. Addressing Coagulopathy

Clotting Factor Replacement: If bleeding is due to a clotting disorder, administering fresh frozen plasma
(FFP) or clotting factor concentrates may be required.

Tranexamic Acid: This antifibrinolytic drug may be used to reduce bleeding in cases of trauma-induced
coagulopathy.

Factor VII or recombinant activated factor VII: Sometimes used in patients with severe bleeding and
coagulopathy.

6. Surgical and Interventional Interventions

Exploratory Surgery: In cases of internal bleeding where the source cannot be controlled conservatively or
via endovascular techniques, surgical intervention may be necessary.

Laparotomy or Thoracotomy: For major trauma to the abdomen or chest.

Endoscopic or Angiographic Techniques: These can be used to control bleeding from vascular structures or
the gastrointestinal tract.

7. Post-Resuscitation Care

Intensive Care Unit (ICU) Admission: Patients with massive hemorrhage or those requiring multiple
transfusions may need ICU-level care.

Rehabilitation and Monitoring: Long-term care may be necessary, especially in the case of major blood loss
or organ damage.

Each patient may require a different management approach depending on the severity and location of the
hemorrhage, as well as other factors such as comorbidities or the patient's response to initial treatment.