stroke. cardiovascular accident and stroke

RAJKUMARI AMRIT KAUR COLLEGE OF NURSING
Lajpat Nagar, New Delhi-110024
A Medical-Surgical Nursing Presentation

CVD or CVA is a term that refers to a
functional abnormality of the central
nervous system that occurs when the
normal blood supply to the brain is
disrupted.
Brain & cerebral nerve cells are
extremely sensitive to a lack of oxygen;
if the brain is deprived of oxygenated
blood for 2-3 mins, both the brain &
nerve cells begin to die with irreversible
outcome.

Related anatomy of brain and its blood supply
Four vessels supply the brain:
• Two internal carotid arteries
(anterior circulation: most of the
frontal, parietal &temporal lobes,
basal ganglia, part of diencephalon.)
• Two vertebral arteries (posterior
circulation: middle & lower part of
temporal lobes, occipital lobes,
cerebellum, brain stem and part of
diencephalon.) The Circle of Willis is the joining area of several arteries at the
bottom (inferior) side of the brain. At the Circle of Willis, the
internal carotid arteries branch into smaller arteries that supply
oxygenated blood to over 80% of the cerebrum.

Related anatomy of brain and its blood supply
Cerebral circulation-
• Anterior circulation-
MCA, ACA, and Anterior
choroidal artery
• Posterior circulation-
Vertebral artery, Basilar
artery and Posterior
cerebral artery

Clinical stroke syndrome
Cluster of signs and symptoms produced due to the occlusion of an
artery (due to an atherothrombotic lesion or an emboli or dissection)
supplying a particular region of the brain.
Classification-
 Large vessel stroke within the anterior circulation
 Large vessel stroke within the posterior circulation
 Small vessel disease of either vascular bed

STROKE WITHIN THE
ANTERIOR CIRCULATION

Which arteries occlusion results in
the stroke within the anterior
circulation?
Question number- 01

Cerebral hemisphere in coronal section

PARTIAL SYNDROME-
Lacunar stroke within the
internal capsule produces
pure motor or sensory
motor stroke contralateral to
the side of lesion.
Lacunar infarct of putamen,
Globus pallidus-
predominantly parkinsonian
features
Brachial syndrome-
weakness of hand and arm
Frontal opercular syndrome-
Broca’s aphasia with facial
weakness with or without
arm weakness
Proximal part of the
superior division involved-
clinical features of motor
weakness, sensory
disturbances and Broca's
aphasia.
If dominant hemisphere-
Wernicke’s aphasia without
weakness with contralateral
homonymous superior
quadrantanopia
If non dominant
hemisphere- Hemineglect,
spatial agnosia without
weakness.
Occlusion of lenticulostriate
branches
If superior division of M1
involved
If inferior division of M2
involved

ANTERIOR CEREBRAL ARTERY-
•A1 segment- from internal carotid to
anterior communicating artery branches
to anterior limb of internal capsule,
inferior part of caudate, anterior
hypothalamus A2 segment- distal to
anterior communicating artery- supplies
frontal pole, entire medial part of cerebral
hemispheres.
A1 segment occlusion rarely produces clinical syndrome because collateral
flow through anterior communicating artery and collaterals from MCA and
PCA.

ANTERIOR CEREBRAL ARTERY-
A2 SEGMENT-
• c/l paralysis of foot and leg, paresis of arm
• c/l cortical sensory loss of foot and leg -urinary
incontinence.
• c/l grasp and suckling reflex -abulia, slowness,
delay -gait apraxia
• If both A2 segments arise from a single anterior
cerebral stem, it may affect both hemispheres,
b/l pyramidal signs, paraparesis or
quadriparesis and urinary incontinence

ANTERIOR CHOROIDAL ARTERY SYNDROME-
• Supplies posterior limb of internal
capsule, white matter posterolateral.
• Complete syndrome rare due to
collaterals from MCA, PCA, and ICA.
• Syndrome comprises-
c/l hemiplegia
c/l hemianesthesia
c/l homonymous hemianopia
• Anterior choroidal strokes are usually
due to in-situ thrombosis of the vessel.

INTERNAL CAROTID ARTERY
SYNDROME-

STROKE WITHIN THE
POSTERIOR CIRCULATION

DEFINITION
CVA or stroke may be defined as the abrupt development of a focal
neurological deficit as a consequence of disturbance in cerebral circulation,
or irreversible brain injury resulting from cerebral ischemia.

Episodes of stroke and familial stroke have been reported
from the 2nd millennium BC onward in ancient
Mesopotamia and Persia.
Hippocrates (460 to 370 BC) was first to describe the
phenomenon of sudden paralysis that is often associated
with ischemia.
The word stroke was used as a synonym for apoplectic
seizure as early as 1599.
In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–
1695) identified the cause of hemorrhagic stroke when he
suggested that people who had died of apoplexy had
bleeding in their brains.
The term cerebrovascular accident was introduced in 1927,
reflecting a "growing awareness and acceptance of
vascular theories and recognition of the consequences of a
sudden disruption in the vascular supply of the brain“.
HISTORY

Stroke is a major public health concern.
The prevalence of stroke in the general population varies
from 40 to 270 per 100,000 in India.
Approximately 12% of all strokes occur in those aged <40
years.
It is the third biggest killer in India after heart attacks and
cancers.
The percentage is higher for people aged 65 and older.
Family members may have a genetic tendency for stroke or
share a lifestyle that contributes to stroke. Higher levels of
Von Willebrand factor are more common amongst people
who have had ischemic stroke for the first time
Men are 25% more likely to suffer strokes than women, yet
60% of deaths from stroke occur in women.
INCIDENCE

RISK FACTORS
MODIFIABLE RISK FACTOR NON-MODIFIABLE RISK
FACTORS
Hypertension
Smoking
Atrial fibrillation
Hyperlipidemia
History of Transient
Ischemic Attack or CVA
Thrombogenic substances
Valvular disease
Drug abuse
Obesity
Diabetes
Diet
Cardiac diseases
Emotional stress
Age
Gender
Race
Genetics

CAUSES
Ischemia
Thrombosis
Cerebral embolism
Cerebral hemorrhage
Compression

WHAT ARE THE WARNING SIGNS
OF CVA?
Question number- 02

WARNING SIGNS OF CVA

Transient hemiparesis

loss of speech

hemi-sensory loss.

severe occipital or nuchal headaches

vertigo or syncope

Paresthesia

transient paralysis, epistaxis and retinal hemorrhages.

Manifestations of deficit must persist longer than 24 hours to be
diagnostic of stroke.

TIAs are focal neurologic deficits lasting less than 24 hours.

TEMPORAL CLASSIFICATION OF STROKE
1. Transient ischemic attack
2. Stroke in evolution / progressive stroke
3. Completed stroke/ established stroke

WHAT IS TRANSIENT ISCHEMIC
ATTACK?
Question number- 03

1. Transient ischemic attack
These are brief, transient and focal disturbances of neurological function that clear
with little or no residual deficit within 24 hrs. Most of them last for only 7 to 10 minutes.
Also called as “little strokes”.40% of the client develop stroke in 5 yrs.
Causes
Emboli
Carotid artery stenosis
Polycythemia
Subclavian steal syndrome
Hypertensive crisis
Migraine
Sign and symptoms of TIA
Depend on type of vessel:
Carotid: transient dysphasia, hemi paresis or
monocular vision disturbances.
Vertebrobasilar: brief unconsciousness,
vertigo, alternating hemiplegia and visual
hallucination or Diplopia, etc.
Treatment
Primary interventions: Lowering high BP, cholesterol levels and weight
Secondary interventions: Medications (anti coagulants, antiplatelets)and Surgery

When neurologic deficit occurs in
stepwise manner. If the problem
involves carotid artery distribution, the
progression does not usually extend
beyond 24 hours but if it involves the
vertebrobasilar distribution, it can
progress up to 72 hours. The symptoms
may resolve or may worsen.
When neurologic deficit appear to have
ceased escalating. This may occur
within minutes or may take 24 to 72
hrs.
2. Progressive stroke 3.Established stroke

TYPES OF STROKE
Based on the causes it is basically of two
types:
A) Ischemic stroke
B) Hemorrhagic stroke
Ischemic strokes are further divided into:
1.Thrombotic stroke (61% cases)
2.Embolic stroke (24% cases)
3. Systemic hypoperfusion (Watershed stroke)

WHAT IS ISCHEMIC STROKE?
Question number- 03

An ischemic stroke occurs when an
artery in the brain becomes blocked.
Ischemic (“is-skeem-ic”) stroke
occurs when an artery to the brain is
blocked.

THROMBOTIC STROKE
Thrombus — a built-up clot — gradually narrows the lumen
of the artery and impedes blood flow to distal tissue.
Depending upon the type of vessels involved, it is divided
into two types:
Large vessel disease
Small vessel disease
Symptoms develop gradually
 Large vessel disease
 Common are internal carotid, middle cerebral, anterior & posterior
cerebral, vertebral, and basilar arteries.
 Small vessel disease:
 Intra cerebral arteries, branches of the Circle of Willis, middle cerebral
artery, and arteries arising from the distal vertebral and basilar artery.
 Micro-atheromas.

EMBOLIC STROKE
Blockage of arterial access to a part of the brain by an
embolus :-
A traveling particle or debris in the arterial
bloodstream originating from elsewhere.
Most commonly, a clot but may be air, broken fragment of
atherosclerotic plaque, cancerous cell or bacterial particle.
Blockage is sudden in onset; symptoms usually are
maximal at start.
Embolic stroke can be divided into further categories: -
those with known cardiac source
those with an arterial source
those with unknown source

Systemic hypoperfusion (Watershed stroke)
The reduction of blood flow to all parts of the body due to:-
Cardiac pump failure
Reduced cardiac output
Bleeding

Pathophysiology of Ischemic stroke
Ischemia
Acidosis- ion imbalance
Intracellular calcium increased and release of neurotoxins.
Cell membrane & protein breakdown & Formation of free radical.
Cell injury & cell death.
Warning signs of ischemic stroke.

FAST
It is an acronym used as a mnemonic to help detect and enhance
responsiveness to stroke victim needs. The acronym stands for Facial
drooping, Arm weakness, Speech difficulties and Time.
1. Facial drooping
2. Arm weakness
3. Speech difficulties
4. Time

HEMORRHAGIC STROKE
Accounts for 15% of strokes. It results from bleeding into
brain tissues itself (intracerebral or intraparenchymal
hemorrhage) or into the sub-arachnoid space or
intraventricular hemorrhage.
Hemorrhage means escape of blood from a ruptured blood
vessel in the brain.
Sites for
hemorrhage: -
 Subdural
 Subarachnoid
 Intraventricular
 Intracerebral
Causes of Hemorrhagic stroke
 Hypertension
 Bleeding disorders
 Angiopathy
 Trauma
 Drugs (cocaine, methamphetamines)
 Aneurysm
 Inflammatory diseases of arteries

WHAT DO YOU MEAN BY
ANEURYSM?
Question number- 04

Aneurysm
Ballooning out of the wall
Rupture of the dome of the aneurysm
Stimulation of SNS & release of vasoactive substances
Loss of auto-regulation
HTN HYPOTENSION RAISED ICP
Risk of re-bleed reduced CBF decreased CBF
ischemia
vasospasm
infarction
ANEURYSM

WHAT ARE THE SYMPTOMS OF
CEREBRAL HAEMORRHAGE?
Question number- 05

Symptoms of a cerebral Hemorrhage
 Sudden onset of symptoms
 Weakness
 Numbness or pins and needles of the face, arm or leg, usually on one side of the body
 Paralysis on one side of the body
 Slurring speech or difficulty finding words
 Severe headache
 Nausea & Vomiting
 Drowsiness
 Unconsciousness
 Dizziness
 Difficulty walking or loss of balance
 Confusion.
 Flat affect, lack of spontaneity, slowness and lack of interest in surroundings
 Cognitive impairment such as perseveration and amnesia
 Urinary incontinence
 Vertebrobasilar region:
 Dizziness
 Nystagmus

DIAGNOSTIC TESTS
CT scan
LUMBAR PUNCTURE

APPROACH TO THE PATIENT
Emergency Management
• Oxygenation @ 2-4 l/mt
• Cardiac and pulse oximetry monitoring
• Vital sign monitoring
• GCS
• IV lines
• Medications
• Radiology
• NPO
Medical Management
IDENTIFY THE STROKE EARLY
• CAB, Neurological assessment, GCS
• History: history of warning signs
• Risk factors for atherosclerotic and cardiac disease, including hypertension, diabetes mellitus, tobacco use.
• Physical examination
• Standardized assessment tools can be used e.g. NIHSS (National institute of health stroke scale)
• Vital signs
• Hunt Hess scale if haemorrhagic stroke

NATIONAL INSTITUTE OF HEALTH STROKE SCALE

Tissue plasminogen activator (t-PA):-
Thrombolytic agents are used to treat ischemic
stroke by dissolving the blood clot that is blocking
the normal blood flow to the brain.
Dosage and administration: -
• Within 4½ hr tPA is given (0.9 mg/kg
over 1 hour)
Side effects: -
• Bleeding is the most common side effect of t- PA
administration. The patient should be closely
monitored for any sign of bleeding.
THROMBOLYTIC THERAPY

Therapy for patients with ischemic stroke nor receiving t-PA
• Intra-arterial thrombolytics: e.g. Heparin
• Antihypertensive: Are given rarely to reduce the BP in acute phase, as it acts as a
compensatory mech. to perfuse the brain.
• Anticoagulation: Anti platelets and Anti Thrombotic e.g. Heparin, low dose aspirin × 4 to 10
days.
• Long term anticoagulants e.g. warfarin, aspirin
• Osmotic diuretics e.g. Mannitol
• Analgesic: -If headache e.g. codeine,stronger narcotics are avoided.
• Vasodilators
• Anticonvulsants: Phenytoin (dilantin), phenobarbital, barbiturates, sedatives.
• Elevate the head end of the bed to promote venous drainage and to lower increased ICP.
• Intubation with an endotracheal tube to establish patent airway if necessary
• Continuous hemodynamic monitoring.
Other pharmacological management-

WHICH OF THE FOLLOWING IS CONTRAINDICATED IN HAEMORRHAGIC STROKE?
QUESTION NUMBER- 06
CHOOSE AMONG THE OPTIONS GIVEN BELOW-
1) ASPIRIN
2) HARTMAN SOLUTION
3) Tranexamic acid (TXA)

Surgical mx
• Craniotomy for evacuation of hematoma.
• Carotid endarterectomy
• Carotid stenting
SURGICAL MANAGEMENT

Surgical mx
•Decompressive craniotomy
• Aneurysm treatment
Coil embolization
Cliping
SURGICAL MANAGEMENT

SPECIFIC DEFICIT AFTER CVA
Pain
DECREASE STAMINA

SPECIFIC DEFICIT AFTER CVA
CONTRACTURE
Changes in sensation
•Feeling less sensitive – this is called hypoesthesia.
•Feeling less sensitive to temperature.
•Feeling more sensitive- this is called hyperesthesia and
can affect a range of your senses such as your taste,
hearing or touch.
•Feeling unaware of your position and movement in your
limbs.
•Experiencing altered sensations – this is sometimes
called dysesthesia or paraesthesia.

Assessment:
•Neurological assessment
•Vital signs
•Careful history
•CAB
•Ongoing Monitoring
Nursing Process

The major nursing care planning goals for the
patient and family may include:
 Improve mobility.
 Avoidance of shoulder pain.
 Achievement of self-care.
 Relief of sensory and perceptual deprivation.
 Prevention of aspiration.
 Continence of bowel and bladder.
 Improved thought processes.
 Achieving a form of communication.
 Maintaining skin integrity.
 Restore family functioning.
 Improve sexual function.
 Absence of complications.

NURSING DIAGNOSIS
1. Altered tissue perfusion r/t increased ICP, infarcted brain
area.
• ICP monitoring
• Neurological assessment
• Avoid causes of restlessness, e.g. full bladder
• Temperature regulation
• Activities like Straining at stool should be avoided
• Proper positioning

NURSING DIAGNOSIS
2. Altered Physical mobility r/t paralysis
• Change the position 2 hourly & position him in prone position for
10-15 mins.
• Do not place a pillow under the affected knee & avoid acute hip
flexion.
• Prevent foot drop by using footboard & ROM exercises
• At night use night splints.
• Exercises in bed
• Sitting up:
Raise the head end of the bed slowly
Help him to sit up by supporting the affected side
 Wheel chair

NURSING DIAGNOSIS
3. Self-care deficit r/t paralysis
• Help them in using paralyzed arm as much as
possible but avoid a tendency to do everything
with affected arm.
• When they can sit up, encourage them to use
the affected limb
• Assist them in carrying out ADL
• Involve the family members actively in their
care.
• Promote psychological and social support.

NURSING DIAGNOSIS
4. High risk for injury r/t paralysis
• Keep bed side rails up
• Frequent skin inspection
• Safe environment
• Eye care
• Mouth care
• Supervise their activities
.

NURSING DIAGNOSIS
5.High risk for aspiration r/t loss of
swallowing reflex
• Assess for breath sounds every 2-4 hourly
• Do tracheo-bronchial suctioning
• While giving mouth care, place the patient with
the head turned to one side.
• Place in lateral position to allow the drainage of
secretions
• Monitor ABG and other parameters.
.

NURSING DIAGNOSIS
6. Altered nutrition less than body
requirement r/t inability to swallow
• Monitor intake output of the patient
• Needs patience and care to prevent
choking and aspiration
• Small and frequent feeds should be
administer to the patient.
• High fiber diet is to be provided to
prevent constipation.

NURSING DIAGNOSIS
7.Altered elimination pattern r/t incontinence
dehydration, immobility and deterioration in LOC.
• Observe the patient to identify characteristics of voiding pattern
(e.g. freq., amount, constant dribbling)
• Maintain intake/output
• Whenever possible try to keep him catheter free by:
• Offering bedpan or urinal frequently
• Take patient to commode frequently.
• Develop a bowel training program
• Give foods known to stimulate defecation
• Initiate a suppository and laxative regimen
• Institute a bowel program.
• Enemas are avoided in presence of increased ICP.

NURSING DIAGNOSIS
9. Impaired communication r/t aphasia secondary to
CVA.
• Explain all the procedures before carrying out them.
• Do not whisper at the bed side.
• Never shout or blame the patient
• Don’t discuss about the patient’s condition with the
relative at the bed side
• Be calm, gentle and patient
• Help the family members to communicate with the
patient and encourage them to talk effectively.

Rehabilitation
Stroke rehabilitation may include some
or all of the following activities: -
1. Therapy for communication
disorders
2. Strengthening motor function
3. Mobility training
4. Range of motion therapy
5. Constraint-induced therapy
6. Electrical stimulation
7. Robotic technology
Inpatient rehabilitation units.
 Outpatient units.
 Skilled nursing facilities.
 Home-based programs.

RESEARCH INPUTS-
Optimal delay time to initiate anticoagulation after ischemic stroke in atrial fibrillation (START):
Methodology of a pragmatic, response-adaptive, prospective randomized clinical trial.
Epub 2019 Aug 18.
Aims: To determine if there is an optimal delay time to initiate
anticoagulation after atrial fibrillation-related stroke that
optimizes the composite outcome of haemorrhagic conversion
and recurrent ischemic stroke.
Sample size estimates: The study will enroll 1500 total
subjects split between a mild to moderate stroke cohort (1000)
and a severe stroke cohort (500).
Methods and design: This study is a multi-center, prospective,
randomized, pragmatic, adaptive trial that randomizes subjects
to four arms of time to start of anticoagulation. The four arms
for mild to moderate stroke are: Day 3, Day 6, Day 10, and Day
14. The time intervals for severe stroke are: Day 6, Day 10, Day
14, and Day 21. Allocation involves a response adaptive
randomization via interim analyses to favor the arms that have
a better risk-benefit profile.
Study outcomes: The primary outcome event is the composite
occurrence of an ischemic or hemorrhagic event within 30
days of the index stroke. Secondary outcomes are also
collected at 30 and 90 days.
Discussion: The optimal timing of direct oral anticoagulants
post-ischemic stroke requires prospective randomized testing.
A pragmatically designed trial with adaptive allocation and
randomization to multiple time intervals such as the START
trial is best suited to answer this question in order to directly
inform current practice on this question.

RESEARCH INPUTS-
MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset
Epub 2018 May 16.
Abstract
Background: Under current guidelines, intravenous thrombolysis is used to treat acute stroke only if it can be ascertained that
the time since the onset of symptoms was less than 4.5 hours. We sought to determine whether patients with stroke with an
unknown time of onset and features suggesting recent cerebral infarction on magnetic resonance imaging (MRI) would benefit
from thrombolysis with the use of intravenous alteplase.
Methods: In a multicenter trial, we randomly assigned patients who had an unknown time of onset of stroke to receive either
intravenous alteplase or placebo. All the patients had an ischemic lesion that was visible on MRI diffusion-weighted imaging but
no parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR), which indicated that the stroke had occurred
approximately within the previous 4.5 hours. We excluded patients for whom thrombectomy was planned.
Conclusions: In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch
between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome
and numerically more intracranial haemorrhages than placebo at 90 days. (Funded by the European Union Seventh Framework
Program; WAKE-UP ClinicalTrials.gov number, NCT01525290; and EudraCT number, 2011-005906-32 .).

CONCLUSION
The onset of stroke is a dramatic and discouraging event both for the
person having the stroke and their family. A person may go from
complete independence to complete dependence in a matter of minutes.
All nursing staff have important roles and responsibilities when caring
for people with a stroke. These include: Physiological monitoring and
maintenance of homeostasis. Reduce morbidity and prevent mortality.

BIBLIOGRAPHY-
 Black M Joyce, Hawks Jane Hokanson. Medical-surgical
nursing: clinical management for positive outcomes. 7th
ed. Elsevier publishers:2005; 2107-36.
 Harrison’s Principles Of Internal Medicine.20th
ed. Page no-
3069-78.
 Smeltzer Suzanne C, Bare Brenda G. Brunner & Suddarth’s
Textbook of medical-surgical nursing. 11th ed. lippincott
williams & wilkins:2009; 2206-25.
 Monahan, Sands. et al. Phipp’s medical surgical nursing:
health and illness perspective. 8th ed. Elsevier
publishers:2007; 1861-72.
 Chintamani; textbook of medical-surgical nursing;
published by: Elsevier; 7th
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