PRESENTED BY:

K.MANGALESHWARI,
M.SC [N] 1st YEAR,
SACON,
KARUR.
 INTRODUCTION
“Cerebrovascular disorders” is any functional abnormality of the central
nervous system that occurs when the normal blood supply to the brain is
disturbed. Stroke is the primary cerebrovascular disorder in the united states
and in the world wide. Stroke is still the third leading cause of death.
ANATOMY AND PHYSIOLOGY

The nervous system is divided into two

parts:
 Central nervous system
 Peripheral nervous system
Arteries: two internal carotid arteries;
two vertebral arteries
This Photo by Unknown Author
is licensed under CC BY
 DEFINITION

 A stroke, or cerebrovascular accident [cva] occurs when blood supply to part

of the brain is disturbed, causing brain cells to die.

 CvA results when there is inadequate supply of blood to the brain [cerebral
ischemia] or cerebral hemorrhage within the brain. Regardless of the cause,
the damaged brain no longer performs cognitive; sensory, motor or emotional
functions. The effects of cva may vary from minor to severe disability.
 INCIDENCE
 AGE: The percentage is higher for people age 65 and older. Of those whp
survive, 50% to 70% will be functioning independent and 15% to 30% will live
with permanent disability.
 SEX: stroke is more common in men than in women.
 RACE:
 African American have a higher incidence of strokes than whites.
 This high incidence may be related to increase rate of hypertension, diabetes
mellitus and sickle cell anemia in African americans.
 African americans also have a higher incidence of smoking and obesity than
white; which are two other risk factors for stroke.
 African American are twice as likely to die from a stroke as white.
COUNTRY
 An estimated 700000 person in the united states and 500000 in Canada
suffer a stroke annually.
 Stroke is the third most common cause of death in the united states and
Canada, behind and heart disease.
 In Canada about 16000 die from stroke each year, while in united states
there are over 160000 deaths from strokes.
 ETIOLOGY
 NONMODIFIABLE RISK FACTORS:
 Age: more than 65 yr
 Gender: more in men than women
 Race: African American
 Family history: heredity
 MODIFIABLE RISK FACTORS:
 Hypertension
 Heart disease
 Smoking
 Excessive alcohol consumption
 Obesity
 Sleep apnea
Continue…..

 Metabolic syndrome
 Poor diet
 Drug abuse
 Oral contraceptive

CAUSES
VESSEL WALL EMBOLUS
 Carotid artery most often the source
 Related to thrombus formation distal to stenosis

CARDIAC SOURCE

 Mitral valve stenosis

 Mitral valve prolapsed
Continue….

 Calcified mitral annulus

 Ventricular aneurysm
 Atrial or ventricular clot
 Valvular vegetation
 Atrial septal defect

VASCULAR SOURCES

 Intracranial artery thrombus [ esp. African americans]

 Aortic arch atherosclerotic plaque
 Transient hypotension with carotid stenosis
TYPES OF STROKE

 Strokes are classified as ischemic or hemorrhagic based on the underlying pathophysiologic findings.

TYPES OF STROKE

ISCHEMIC STROKE
HEMORRHAGIC STROKE

 THROMBOTIC STROKE INTRACEREBRAL

HEMORRHAGE
 EMBOLIC STROKE INTRACRANIAL
ANEURYSM

SUBARACHNOID HEMORRHAGE
 THROMBOTIC STROKE

Thrombotic stroke occurs from injury to blood vessels wall and formation of a blood clot. The
lumen of the blood vessel becomes narrowed and if it becomes occluded, infarction occur.
Thrombosis develops readily where atherosclerotic plaques have already narrowed blood
vessels. Thrombotic stroke, which is the most common cause of stroke. Two third of
thrombotic stroke are associated with hypertension or diabetes mellitus.

This Photo by Unknown Author is licensed under CC BY-SA

 EMBOLIC STROKE

 Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque
[cholesterol and calcium deposits on the wall of the inside of the heart or artery] breaks loose,
travels through the bloodstream and lodges in an artery in the brain. When blood flow stops,
brain cells do not receive the oxygen and glucose they require to function and a stroke
occurs. This type of stroke is referred to as an embolic stroke.
 CLINICAL MANIFESTATIONS

 VISUAL FIELD DEFICITS:

Homonymous hemianopsia [loss of half of the visual field]
 Unaware of persons or objects on side of visual loss
 Neglect of one side of the body
 Difficulty judging distances
Loss of peripheral vision
 Difficulty seeing at night
 Unaware of objects or the borders of objects
Diplopia:
 Double vision
 MOTOR DEFICITS
 HEMIPARESIS
 Weakness of the face, arm; and leg non the same side [due to a lesion in the opposite
hemisphere]
 HEMIPLEGIA
 Paralysis of the face, arm, and leg on the same side [due to a lesion in the opposite
hemisphere]
 ATAXIA
 Defective muscular co-ordination, unsteady gait unable to keep feet together, needs a broad
base to stand.
 DYSARTHRIA
 Difficulty in forming words.
 DYSPHAGIA
 Difficulty in swallowing
 SENSORY DEFICITS

 PARATHESIA [occurs on the side opposite the lesion]

 Numbness and tingling of extremity

VERBAL DEFICITS
 EXPRESSIVE APHASIA
 Unable to form words that are understandable; may be able to speak in
single- word responses
 RECEPTIVE APHASIA
 Unable to comprehend the spoken word; can speak but may not make
sense
 GLOBAL[mixed] APHASIA
 Combination of both receptive and expressive aphasia
COGNITIVE DEFICITS

 Short- and long- term memory loss

 Decreased attention span
 Impaired ability to concentrate
 Poor abstract reasoning
 Altered judgement

EMOTIONAL DEFICITS

 Loss of self-control
 Emotional lability
 Decreased tolerance to stressful situations
 Withdrawal
 Fear, hostility, and anger
 Feelings of isolation
 ASSESSMENT AND DIAGNOSTIC FINDINGD

 HEALTH HISTORY
 Past health history: Hypertension, previous stroke, aneurysm, cardiac disease [including
recent myocardial infraction], dysrhythmias, heart failure, valvular disease, infective
endocarditis, hyperlipidemia, polycythemia, diabetes.
 Family history: Hypertension, diabetes, stroke, coronary artery disease.
 Medications: Use of oral contraceptives, use of anti hypertensive and anti coagulant therapy.
 Nutritional history: Anorexia, nausea, vomiting, dysphagia, altered sensation of taste and
smell.
 Cognitive perceptual history: Numbness, tingling of one side of body, loss of memory, altered
in speech, pain, headache, visual disturbance.
 PHYSICAL ASSESSMENT

GLASGOW COMA SCALE

 GLASGOW COMA SCALE

NIHSS

 The NIHSS is a 42- points scale. Patients with minor strokes usually
have a score of less than 5. an NIHSS score of greater than 10
correlates with an 80% likelihood of proximal vessel occlusions [as
identified on CT or standard angiograms
 COGNITIVE FUNCTION

 ORIENTATION:
Speech: aphasia and other problems
 fluent aphasia[motor/ wernicke’ s] – inability to understand the spoken language.
 non-fluent aphasia [sensory/ borka’s] – inability to understand the spoken language.
 other aphasia syndromes- amnesia, conduction.
Other alteration include:
 Confabulation- fluent, non sensial speech
 Preservation- continuation of thought process with inability to change rain of thought without direction or repetition.

MOTOR FUNCTION

 Voluntary movement
 Reflexive movement: biceps, triceps, patellar, achiles, planter.
DIAGNOSTIC
EVALUATION
 DIAGNOSTIC EVALUATION

 CTA- A dye is injected into a vein to make the blood vessels and blood flow easier to see
on the x-ray. CTA may be used to check for aneurysms (a bulge in the blood vessel wall),
blockages in the arteries, blood clots, and other blood vessel problems. Also
called computed tomography angiography and CT angiography.

 MRI- Magnetic resonance imaging (MRI) is increasingly being used in the diagnosis and
management of acute ischemic stroke and is sensitive and relatively specific in detecting
changes that occur after such strokes.

 SPECT- A single-photon emission computerized tomography (SPECT) scan lets your

doctor analyze the function of some of your internal organs. A SPECT scan is a type of
nuclear imaging test, which means it uses a radioactive substance and a special camera to
create 3-D pictures.
 PET- A positron emission tomography (PET) scan is an imaging test that can help
reveal the metabolic or biochemical function of your tissues and organs. The PET
scan uses a radioactive drug (tracer) to show both normal and abnormal metabolic
activity.

 MRS - Magnetic resonance spectroscopy (MRS) is a non-invasive in vivo method

that allows the investigation of biochemical changes in both animals and humans.
The application of MRS to the study of stroke has made possible dynamic studies
of intracellular metabolism of cerebral ischemia.

 XENON CT- This test reveals blood flow to regions of the brain to determine if
enough blood is reaching all areas. Patients breathe xenon (an odorless, colorless
gas), which acts as a contrast agent to show regions of low and high blood flow.
 EEG- Electroencephalography (EEG) is a method to record an electrogram of the
electrical activity on the scalp that has been shown to represent the macroscopic
activity of the surface layer of the brain underneath. It is typically non-invasive, with
the electrodes placed along the scalp.

 CEREBRAL ANGIOGRAPHY- Cerebral angiography is most often used to identify or

confirm problems with the blood vessels in the brain. Your provider may order this
test if you have symptoms or signs of: Abnormal blood vessels in the brain (vascular
malformation) Bulging blood vessel in the brain (aneurysm).

 CSF ANALYSIS- Cerebrospinal fluid (CSF) analysis is a group of laboratory tests

that measure chemicals in the cerebrospinal fluid. CSF is a clear fluid that surrounds
and protects the brain and spinal cord. The tests may look for proteins, sugar
(glucose), and other substances.
 CEREBRAL BOOD FLOW MEASURES :

 CEREBRAL ANGIOGRAPHY- Cerebral angiography is most often used to identify or

confirm problems with the blood vessels in the brain. Your provider may order this test if
you have symptoms or signs of: Abnormal blood vessels in the brain (vascular
malformation) Bulging blood vessel in the brain (aneurysm).

 DIGITAL SUSTRACTION ANGIOGRAPHY- Provides an image of the blood vessels in the

brain to detect a problem with blood flow. The procedure involves inserting a catheter (a
small, thin tube) into an artery in the leg and passing it up to the blood vessels in the
brain.

 DOPPLER ULTRASONOGRAPHY- A Doppler ultrasound is a noninvasive test that can be

used to estimate the blood flow through your blood vessels by bouncing high-frequency
sound waves (ultrasound) off circulating red blood cells. A regular ultrasound uses sound
waves to produce images, but can't show blood flow.
 TRANSCRANIAL DOPPLER- An intracranial neurovascular exam is also known as a
Transcranial Doppler (TCD) study. TCD is a non-invasive, painless ultrasound
technique that uses high-frequency sound waves to measure the rate and direction of
blood flow inside vessels.

 CAROTID DUPLEX- Carotid duplex is an ultrasound test that shows how well blood is
flowing through the carotid arteries. The carotid arteries are located in the neck. They
supply blood directly to the brain.

 CAROTID ANGIOGRAPHY- Carotid angiography, or angiogram, is a test to help diary

disease. Providers do this test to see how blood moves through the large arteries in
your neck. Carotid angiography uses X-rays to take images and a special dye to make
your arteries visible.
 CARDIAC ASSESSMENT

 Electrocardiography
 Chest x-ray
 Cardiac enzymes
 Holter monitor
 ADDITIONAL STUDIES
 Complete blood count
 Prothrombin time, activated partial thromboplastin time
 Electrolytes
 Blood glucose level
 Renal and hepatic studies
 Lipid profile
 Arterial blood gas analysis
MANAGEMENT
 PHARMACOLOGICAL MANAGEMENT OF ISCHEMIC STROKE

 TO ADMINISTER ANTIPLATELET DRUG

CYCLOOXYGENASE/TX2 SYNTHASE INHIBITORS - ASPIRIN

ADENOSINE DIPHOSPHATE RECEPTOR INHIBITOR

IRREVERSIBLE- CLOPIDOGREL,TICLOPIDINE

REVERSIBLE - PRASUGREL, TICAGRELOR, CANGRLOR, CLOPIDOGREL.

GLYCOPROTEIN INHIBITOR

ABCIXIMAB, EPTIFIBATIDE, TRIOFIBAN, DEFIBROTIDE.

PHOSPHODIESTERASE INHIBITOR

CILOSTAZOL
ADENOSINE REUPTAKE INHIBITORS

DIPYRIDAMOL

TO ADMINISTER THROMBOLYTIC AGENT

 STREPTOKINASE

 UROKINASE

 ALTOPLASE

 RETEPLASE

TO ADMINISTER ANTICOAGULANTS

 HEPARIN
 ANTI HYPERTENSIVE DRUGS

 TO administer calcium channel blocker

CLASIFICATION

DIHYDROPYRIDINE
Nifedipine
Nimodipine
Felodipine
Amlodipine
NON DIHYDROPYRDINE
Verapamil Diltizizem
Bepridil
TO ADMINISTER SYMPATHETIC DRUGS -CENTRALLY ACTING
 Clonidine
 Methyldopa
 Guanabenz and Geanfacine
AFFENERGIC RECEPTOR BLOCKERS
ALPHA BLOCKERS
 Clonidine prazosis, Terazosis
 Doxazocin phenoxybenzamine, phentolamine
BETA BLOCKERS
 Propranol
 Atenolol
 Esmolol
 Metoprolol
ALPHA & BETA BLOCKERS
 labetalol
 Carvedilol

GANGLION BLOCKERS
 Trimethaphan

ADRENERGIC NEURO BLOCKERS

 Guanithidine
 Reserpine

ACE INHIBITORS
To administerACE inhibitors
They inhibit the activity of angiotensin converting enzyme,an enzme
responsible for converting angiotensin(I) or angiotensin(II) a patent vasoconstrictor. The
drugs are
 Captopril
 enalapril
 fosinopril
 lisinopril
Maxiprep , Perindopril
Pamipril ,quinapril

ANGIOTENSIN- II ANTAGONIST
 To administer antagonist II angiotensin, The drugs are,
 Losartan , Candesartan
 Valsartan , Eprosartan
 Irbesartan , olmesartan
 RENNIN INHIBITORS
 To administer renin inhibitor, The drugs are
 Aliskiren
 VASODIALATORS
 Hydralazine
 Minoxidil
SURGICAL
MANAGEMENT
 SURGICAL MANAGEMENT

 CAROTID ADINOPLASTY AND STENTING : Carotid angioplasty and stenting are procedure that
open clogged arteries to return blood flow to the brain they are after performed to treat or prevent
stroke.

 CAROTID ENDARTERCTOMY : Carotid endarterectomy is a surgical procedure to remove a

build-up of fatty deposits(plaque) which causes narrowing of a carotid artery.

 MECHANICAL THROMBECTOMY is type of minimally-invasive procedure in which an

interventional radiologist uses specialized equipment to remove a clot from a patient's artery.
Using fluoroscopy, or continuous x-ray, the doctor guides instruments through the patient's arteries
to the clot, extracting the clot all at once.
 CEREBRAL ARTERY BYPASS SURGERY :Cerebral artery bypass surgery is performed to
restore, or “Revascularize”,blood flow to the brain. A cerebral bypass is the brain’s equivalent
of coronary bypass in the heart.The surgery connect a blood vessel from outside of the brain
to reroute blood flow around a damaged or blocked artery.
ELIGIBILITY CRITERIA FOR t-PA ADMINISTRATION

 Age 18 years or older

 Clinical diagnosis of stroke with NIH stroke scale score under22
 Time of onset of stroke known and is 3 hours or less
 Bp systolic <185; diastolic <110
 Not a minor stroke or rapidly resolving stroke
 No seizure at onset of stroke
 Not taking warfarin [coumadin]
 Prothrombin time,15 seconds or INR <1.7
 Not receiving heparin during the past 48 hours with elevated partial
thromboplastin time
 Platelet count >100000
 Blood glucose level between 50 and 400 mg/ dl
 No acute myocardial infarction
 No prior intracranial hemorrhage, neoplasm, arteriovenous, malformation, or
aneurysm.
 No major surgical procedures within 14 days
 No stroke or serious head injury within 3 months
 No gastrointestinal or urinary bleeding within last 21 days not lactating or
postpartum within last 30 days
NURSING
MANAGEMENT
 ASSESSMENT

 Assess the level of consciousness or responsiveness as evidenced by movement, resistance to

change of position, and response to stimulation, orientation to time, place, and person
 Presence or absence of voluntary or involuntary movements of the extremities ; muscle tone;
body posture ; and position of the head
 Stiffness or flaccidity of the neck
 Eye opening , comparative size of pupils and pupillary reactions to light and ocular position.
 Color of the face and extremities; temperature, and moisture of the skin
 Quality and rates of pulse and respirations; arterial blood gas values as indicated, body
temperature, and arterial pressure
 Ability to speak
 Volume of fluids ingested or administered; volume of urine excreted each 24 hours
 Presence of bleeding
 Maintenance of blood pressure within the desired parameters
 NURSING DIAGNOSIS
 Impaired physical mobility related to hemiparesis, loss of balance and co-
ordination, spasticity, and brain injury
 Acute pain related to hemiplegia and tissue of extremity
 Self-care deficits [ hygiene, toileting, grooming, and feeding] related to stroke
 Disturbed sensory perception related to altered sensory reception, transmission,
and / or integration
 Impaired swallowing
 Incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty
in communicating
 Disturbed thought processes related to brain damage, confusion, or inability to
follow instructions
 Impaired verbal communication related to brain damage
 Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or decreased
mobility
 Continue……..

 Interrupted family processes related to catastrophic illness and caregiving

burdens
 Sexual dysfunction related to neurologic deficits or fear of failure
 HEMORRHAGIC STROKE
 Hemorrhagic strokes account for 15% of cerebrovascular disorders and are
primarily caused by an intracranial or subarachnoid hemorrhage
 Hemorrhagic strokes are caused by bleeding into the brain tissue, the
ventricles, or the subarachnoid space. Primary intracerebral hemorrhagic from
a spontaneous rupture of small vessels accounts for approximately 80% of
hemorrhagic strokes and is primarily caused by uncontrolled hypertensoin
 PATHOPHYSIOLOGY

ETIOLOGICAL FACTORS

PRESSES ON NEARBY CRANIAL NERVES OR BRAIN TISSUE

CAUSING SUBARACHNOID HEMORRHAGE

INCREASE IN ICP RESULTING FROM THE SUDDEN ENTRY OF BLOOD INTO THE SUBARACHNOID SPACE

INJURES BRAIN TISSUE; OR BY SECONDARY ISCHEMIA OF THE BRAIN RESULTING FROM THE REDUCED
PERFUSION PRESSURE
 TYPES OF HEMORRHAGE

 INTRACEREBRAL HEMORRHAGE

An intracerebral hemorrhage , or bleeding into the brain substance, is most common

in patients with hypertension and cerebral atherosclerosis because degenerative
changes from these disease cause rupture of the vessel.
 INTRACRANIAL [CEREBRAL] HEMORRHAGE

 An intracranial [cerebral] aneurysm is a dilation of the walls of a

cerebral artery that develops as a result of weakness in the arterial wall
 SUBARACHNOID HEMORRHAGE

 A subarachnoid hemorrhage [ hemorrhage into the subarachnoid

hemorrhage ] may occur as a result trauma, or hypertension.
 CLINICAL MANIFESTATIONS

 Severe headache
 Loss of consciousness
 Rigidity of the back and neck [nuchal rigidity]
 Pain in spine due to meningeal irritation
 Visual disturbance [visual loss, diplopia, ptosis
 hemiparesis
 ASSESSMENT AND DIAGNOSTIC FINDING

 CT- To determine the size and location of the hematoma as well as

presence or absence of ventricular blood
 CEREBRAL ANGIOGRAPHY- To confirm the diagnosis of an
aneurysm or AVM
 LUMBAR PUNCTURE
SURGICAL MANAGEMENT

CRANIOTOMY:

 Craniotomy is a surgical procedure where an opening is made in the skull to enable

to access and expose the brain.
 Many patients with intracerebral hemorrhage are not treated surgically. However,
surgical evacuation is strongly if the diameter exceeds 3 cm. surgical evacuation is
most frequently accomplished via a craniotomy.

TYPES OF CRANIOTOMY

 Suboccipital incision
 Paraitel and frontotemporal craniotomy
 Frontal craniotomy [unilateral or bilateral]
 Temporal craniotomy
 Suboccipital craniotomy
Other types of craniotomy
 Keyhole craniotomy
 Stereotactic craniotomy
 Awake craniotomy

CRANIECTOMY

Decompressive craniectomy:

Decompressive craniectomy is a neurological procedure in part of the skull is removed

to allow brain than to expand without being squeezed. It is performed on terms of
traumatic brain injury, stroke, chiari malformation, other conditions associated with
raised intracranial pressure
MICROSURGICAL CLIPPING

 An microsurgical clipping, a small metal clip is used to stop flow into the
aneurysm. A craniotomy is performed to create an opening in the skull to reach
the aneurysm in the brain. The clip is placed on the neck[ opening ] of the
aneurysm to obstruct the flow of blood, and remains inside the brain.
 MICROSURGICAL COILING
Endovascular coiling is a minimally invasive technique, which means an
incision in the skull is not required to treat the brain aneurysm. Rather, a
catheter is used to reach the aneurysm in the brain.
NURSING DIAGNOSIS

 Ineffective cerebral tissue perfusion related to bleeding

 Disturbed sensory perception related to medically imposed restrictions
[aneurysm precautions]
 Anxiety related to illness and/ or medically imposed restrictions
aneurysm precaution]

PREVENTION

 Control hypertension
 Stop smoking
 Stop to take alcohol
 Avoid to take high cholesterol diet
CONTROL HYPERTENSION STOP SMOKING AVOID ALCHOLISM

AVOID HIGH CHOLESTERAL DIET REGULAR EXERCISE REGULAR FOLLOW-UP

REHABILITATION

 Improve motor control

 Lomb physiotherapy
 Chest physiotherapy
 Balance retraining
 Tone management
 Oedema management
 Gait re-education
 Follow up - regular
HOME CARE

 Discuss measures to prevent subsequent strokes.

 Identify signs and symptoms of specific complications
 Identify potential complications and discuss measures to prevent them
[blood clots, aspiration, pneumonia, urinary tract infection, fecal
impaction, skin breakdown, contractures]
 Identify psychosocial consequences of stroke and appropriate
interventions.
 Identify safety measures to prevent falls
 State names, doses, indications, and side effects of medications
 Demonstrate adaptive techniques for accomplishing ADLs
 Demonstrate swallowing techniques [for patients with dysphagia ]
 Demonstrate care of enteric feeding tube, if applicable.
 Demonstrate home exercise, use of splints or orthotics, proper
positioning, and need for frequent repositioning
 Describe procedures for maintaining skin integrity
 Demonstrate indwelling catheter care, if applicable
 Describe a bowel and bladder recreational or diversional activities,
support groups, and community resources.
THANK YOU
PRESENTED BY:
K.MANGALESHWARI,
M.SC [N] 1st YEAR,
SACON,
KARUR.