STROKE
Cerebrovascular Accident (CVA)
&
Brain Attack
Stroke
Ischemia is inadequate blood flow
Occurs when ischemia to part of the
brain results in death of brain cells
Stroke
Movement, sensation, or emotions
controlled by affected area are lost or
impaired
Loss of function varies with location
and extent of damage
Stroke
Brain attack
– Term increasingly being used to
describe stroke and communicate
urgency of recognizing stroke
symptoms and treating their onset as
a medical emergency
National Stroke
Association
10% of stroke survivors recover almost
completely
25% recover with minimal impairment
40% experience moderate to severe impairments
that require special care
10% require care in a nursing home or other
long-term facility
15% die shortly after the stroke
Approximately 14% of stroke survivors
experience a second stroke in the first year
following a stroke
Risk Factors
Nonmodifiable
Age
Gender (women more likely to die)
Race (African Americans)
Heredity
Risk Factors
Modifiable
Asymptomatic carotid stenosis
Diabetes mellitus
Heart disease, atrial fibrillation
Heavy alcohol consumption
Hypercoagulability
Hyperlipidemia
Risk Factors
Modifiable
Hypertension
Obesity
Oral contraceptive use
Physical inactivity
Sickle cell disease
Smoking
Reduce You Stroke Risk
• Control high blood pressure
Don’t smoke
• Consume less sodium
• Lower cholesterol
• Lose excess weight
• Get physically active
Etiology and Pathophysiology
Brain requires continuous supply of O2
and glucose for neurons to function
If blood flow is interrupted
– Neurologic metabolism is altered in
30 seconds
– Metabolism stops in 2 minutes
– Cell death occurs in 5 minutes
Etiology and Pathophysiology
Atherosclerosis is a major cause of
stroke
– Can lead to thrombus formation and
contribute to emboli
Sites for Atherosclerosis
Fig. 56-2
Etiology and Pathophysiology
Around the core area of ischemia is a
border zone of reduced blood flow
where ischemia is potentially reversible
If adequate blood flow can be restored
early (<3 hours) and the ischemic
cascade can be interrupted
– less brain damage and less neurologic
function lost
Transient Ischemic Attacks
(TIA)
Temporary focal loss of neurologic
function caused by ischemia
Most resolve within 3 hours
May be due to micro-emboli that
temporarily block blood flow
A warning sign of progressive
cerebrovascular disease
Types of Stroke
Classification based on underlying
pathophysiologic findings
– Ischemic
Thrombotic
Embolic
– Hemorrhagic
Major Types of Stroke
Fig. 56-3
Ischemic Stroke
Result of inadequate blood flow to brain
due to partial or complete occlusion of
an artery
Constitute 85% of all strokes
Most patients with ischemic stroke do
not have a decreased level of
consciousness in the first 24 hours
Symptoms often worsen during first 72
hours d/t cerebral edema
Ischemic Stroke
Thrombotic stroke
– Thrombosis occurs in relation to
injury to a blood vessel wall → blood
clot
– Result of thrombosis or narrowing of
the blood vessel
– Most common cause of stroke
Ischemic Stroke
Thrombotic stroke
– Two-thirds are associated with HTN
and diabetes
– Often preceded by a TIA
Ischemic Stroke
Embolic stroke
– Embolus lodges in and occludes a
cerebral artery
– Results in infarction and edema of the
area supplied by the vessel
– Second most common cause of stroke
Ischemic Stroke
Embolic stroke
– Majority of emboli originate in heart,
with plaque breaking off from the
endocardium and entering circulation
– Associated with sudden, rapid
occurrence of severe clinical
symptoms
Ischemic Stroke
Embolic stroke
– Patient usually remains conscious
although may have a headache
– Recurrence is common unless the
underlying cause is aggressively
treated
Hemorrhagic Stroke
Account for approximately 15% of all
strokes
Result from bleeding into the brain
tissue itself or into the subarachnoid
space or ventricles
Hemorrhagic Stroke
Intracerebral hemorrhage
– Bleeding within the brain caused by a
rupture of a vessel
– Hypertension is the most important
cause
– Commonly occurs during activity
Hemorrhagic Stroke
Intracerebral hemorrhage
– Often a sudden onset of symptoms
that progress over minutes to
hours b/c of ongoing bleeding
– Manifestations include neurologic
deficits, headache, decreased levels of
consciousness
Hemorrhagic Stroke
Subarachnoid hemorrhage
– Bleeding into cerebrospinal space
between the arachnoid and pia mater
– Commonly caused by rupture of a
cerebral aneurysm
Clinical Manifestations of Stroke
Affects many body functions
Motor activity
Intellectual function
Spatial-perceptual alterations
Personality
Sensation
Communication
Clinical Manifestations
Motor Function
Most obvious effect of stroke
Can include impairment of
– Mobility
– Respiratory function
– Swallowing and speech
– Gag reflex
– Self-care abilities
Clinical Manifestations
Motor Function
Characteristic motor deficits (contra-
lateral)
– Loss of skilled voluntary movement
– Impairment of integration of
movements
– Alterations in muscle tone (flaccid →
spastic)
– Alterations in reflexes (hypo → hyper)
Clinical Manifestations
Communication
Patient may experience aphasia when
stroke damages the dominant
hemisphere of the brain
– Aphasia: total loss of comprehension
and use of language
– Dysphasia: difficulty with
comprehension and use of language
Classified as nonfluent or fluent
Clinical Manifestations
Communication
Dysarthria
– Disturbance in the muscular control
of speech
– Impairments in pronunciation,
articulation, and phonation; NOT
meaning or comprehension
Clinical Manifestations
May have difficulty controlling their
emotions
Emotional responses may be
exaggerated or unpredictable
Depression , impaired body image and
loss of function can make this worse
May be frustrated by mobility and
communication problems
Clinical Manifestations
Intellectual Function
Memory and judgment may be
impaired
Left-brain stroke: more likely to result
in memory problems related to
language
Manifestations of Right and Left-Brain Stroke
Fig. 56-6
Clinical Manifestations
Spatial-Perceptual Alterations
Stroke on the right side of the brain is
more likely to cause problems in spatial-
perceptual orientation
However, this may occur with left-
brain stroke
Clinical Manifestations
Spatial-Perceptual Alterations
Spatial-perceptual problems may be
divided into four categories
1. Incorrect perception of self and
illness (may deny illness or body
parts)
2. Erroneous perception of self in
space (e.g., neglect all input from
affected side; distance judgement)
Clinical Manifestations
Spatial-Perceptual Alterations
3. Inability to recognize an object by
sight, touch, or hearing
4. Inability to carry out learned
sequential movements on
command
Homonymous Hemianopsia (food on left side
is not seen)
Fig. 56-8
Diagnostic Studies
When symptoms of a stroke occur,
diagnostic studies are done to
– Confirm that it is a stroke
– Identify the likely cause of the stroke
CT is the primary diagnostic test used
after a stroke
F.A.S.T. IS
Face Drooping-Does one side of the face droop or is it
numb? Ask the person to smile.
• Arm Weakness-Is one arm weak or numb? Ask the
person to raise both arms. Does one arm drift
downward?
• Speech Difficulty- are they unable to speak, or are they
hard to understand? Ask the person to repeat a simple
sentence. Is the sentence repeated correctly?
• Time-to call for ambulance to go hospital immediately.
Collaborative Care
Prevention
Education and management of
modifiable risk factors to prevent a
stroke
Close management of patients with
known risk factors
Collaborative Care
Prevention
Antiplatelet drugs (usually Aspirin) to
prevent stroke in those with history of
TIA
Coping
– A stroke is often a family disease,
affecting the family emotionally,
socially, and financially
– Changing roles and responsibilities
occur
– Clear explanations about what has
happened, diagnostic and therapeutic
procedures
