Cerebrovascular Stroke
Dr. Abdul-Monim Batiha
Assistant Professor
Critical Care Nursing
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Cerebrovascular disease is the most frequent
neurological disorder of adults.
It is the third leading cause of morbidity and
mortality in the USA after heart disease and
cancer.
It includes any pathological process that involves
the blood vessels of the brain.
Most cerebrovascular disease is caused by
thrombosis, embolism, or hemorrhage.
The mechanism of each of these etiologies is
different, but the ultimate result is damage to a
focal area of the brain.
A “brain attack” must be viewed as a
medical emergency.
 To reverse cerebral ischemia, patients
must be evaluated promptly.
 Ischemic brain injury occurs when
arterial occlusion lasts longer than 2 to
3 hours.
 Delay in seeking medical care may
eliminate the potential for tissuesaving therapy with thrombolytic
agents.
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 A stroke may be defined as a neurological
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deficit that has a sudden onset, lasts more
than 24 hours, and results from
cerebrovascular disease.
A stroke occurs when there is a disruption
of blood flow to a region of the brain.
Blood flow is disrupted because of an
obstruction of a vessel, on account of a
thrombus or embolus, or the rupture of a
vessel.
The clinical features seen depend on the
location of the event and region of the brain
the vessel perfused.
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Approximately three-fourths of strokes are
due to vascular obstruction (thrombi or
emboli), resulting in ischemia and infarction.
About one-fourth of strokes are hemorrhagic,
resulting from hypertensive vascular disease
(which causes an intracerebral hemorrhage), a
ruptured aneurysm, or an arteriovenous
malformation.
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Approximately 750,000 strokes occur every
year in the US
The incidence in men is greater than in
women.
It is estimated that there are 3 million stroke
survivors and that stroke is a leading cause of
disability and a leading diagnosis for longterm care.
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Risk factors for stroke include smoking,
hypertension, obesity, cardiac disease,
hypercholesterolemia, diabetes, and use of
birth control pills.
Prevention efforts focus on lifestyle changes
that can modify risk factors.
In addition, the appropriate use of warfarin or
aspirin in patients at risk for cardiac sources
of emboli (e.g., atrial fibrillation) constitutes
primary prevention.
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When blood flow to any part of the brain is
impeded as a result of a thrombus or
embolus, oxygen deprivation of the cerebral
tissue begins.
Deprivation for 1 minute can lead to
reversible symptoms, such as loss of
consciousness.
Oxygen deprivation for longer periods can
produce microscopic necrosis of the neurons.
The necrotic area is then said to be infarcted.
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If the neurons are ischemic only and have not yet
necrosed, there is a chance to save them.
The ischemic cascade begins within seconds to
minutes after perfusion failure, creating a zone
of irreversible infarction and surrounding area of
potentially salvageable “ischemic penumbra.”
A stroke caused by an embolus may be a result
of blood clots, fragments of atheromatous
plaques, lipids, or air.
Emboli to the brain most often have a cardiac
source, secondary to myocardial infarction or
atrial fibrillation
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If hemorrhage is the etiology of a stroke,
hypertension often is a precipitating factor.
Vascular abnormalities, such as
arteriovenous malformations and cerebral
aneurysms, are more prone to rupture and
cause hemorrhage in the presence of
hypertension.
The most frequent neurovascular syndrome
seen in thrombotic and embolic strokes is
due to involvement of the middle cerebral
artery.
This artery mainly supplies the lateral
aspects of the cerebral hemisphere.
 Infarction to that area of the brain can
cause contralateral motor and sensory
deficits.
 If the infarcted hemisphere is
dominant, speech problems result,
and dysphasia may be present.
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Dysphasia: difficulty in speaking and
putting words into the correct order
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A stroke is usually characterized by the
sudden onset of focal neurological
impairment.
The patient may experience signs such as
weakness, numbness, visual changes,
dysarthria, dysphagia, or aphasia.
dysarthria :difficulty in speaking words clearly,
caused by damage to the central nervous system
dysphagia :difficulty in Swallowing
aphasia : a condition in which a person is unable to
speak or write, or to understand speech or writing
because of damage to the brain centres controlling
speech
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The manifestations of a stroke depend on the
anatomical location of the lesion.
If symptoms resolve in less than 24 hours,
the event is classified as a transient ischemic
attack (TIA).
Most TIAs last for only minutes to less than
an hour, which further clouds recognition and
prompt treatment.
Furthermore, the differential diagnosis of
stroke includes ruling out intracerebral
hemorrhage, SAH, subdural or epidural
hematoma, neoplasm, seizure, or migraine
headache
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The time of symptom onset to administration
of thrombolytic therapy (or “time to needle”)
should be within a 3-hour window.
patient’s history helps determine what has
happened to the individual.
It is important to obtain a description of the
neurological event; how long it lasted; and
whether the symptoms are resolving,
completely gone, or the same as at the time
of onset.
 Determination
of risk factors for
stroke, such as hypertension,
chronic atrial fibrillation, elevated
serum cholesterol, smoking, oral
contraceptive use, or a familial
history of stroke, also aids in
diagnosis
CT scan of the brain without contrast,
is obtained within 60 minutes of
arrival
 Blood studies (including complete
blood cell count, electrolytes, glucose,
and coagulation parameters, are
obtained)
 neurological examination, and a
screen performed using the National
Institutes of Health Stroke Scale
(NIHSS)
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Cerebral angiography has been the
gold standard for evaluating cerebral
vasculature.
 (ECG) should be obtained to assess for
evidence of arrhythmia or cardiac
ischemia
 Additional tests that can be done are
transesophageal echocardiography
(TEE) and Holter monitoring.
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The management of an ischemic stroke comprises
four primary goals:
1. restoration of cerebral blood flow (reperfusion),
2. prevention of recurrent thrombosis,
3. neuroprotection,
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4. supportive care.
The focus of initial treatment should be to
save as much of the ischemic area as
possible.
Three ingredients necessary to this area are
oxygen, glucose, and adequate blood flow.
The oxygen level can be monitored through
(ABGs), and oxygen can be given to the
patient if indicated.
Hypoglycemia can be evaluated with serial
checks of blood glucose.
Reperfusion may be accomplished by the use
of IV tissue plasminogen activator (t-PA).
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Cerebral perfusion pressure is a reflection of the
systemic blood pressure, ICP, functioning
autoregulation in the brain, and heart rate and
rhythm.
The parameters most easily controlled externally are
the blood pressure and cardiac rate and rhythm.
Arrhythmias usually can be corrected.
If the patient is a candidate for thrombolytic therapy,
treatment with t-PA begins in the emergency
department, and he or she is then moved to the ICU
for further monitoring.
If the individual is not a candidate for thrombolytic
therapy, the complexity of the patient’s problems
determines his or her placement in the ICU, medical
unit, or stroke specialty unit.
Thrombolytic agents: IV thrombolytic
therapy should be initiated within 3
hours or less of the onset of
neurological symptoms.
 The direct administration of a
thrombolytic into a vessel is an
alternative to IV t-PA.
 Such administration is effective in acute
ischemic stroke and can be given up to 6
hours after the onset of symptoms
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secondary treatment options for stroke include
anticoagulation with antithrombotic and
antiplatelet agents. If a patient experiences
atrial fibrillation, anticoagulation with warfarin
(Coumadin) may be necessary.
Antiplatelet drugs include dipyridamole-ER,
ticlopidine, clopidogrel, and aspirin.
These agents discourage platelets from
adhering to the wall of an injured blood vessel
or other platelets and are given to prevent a
future thrombotic or embolic event
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If the diastolic blood pressure is above
approximately 105 mm Hg, it may need to be
lowered gradually.
This may be accomplished effectively with
labetalol.
The usual methods of controlling increased
ICP can be instituted: hyperventilation; fluid
restriction; head elevation; avoidance of neck
flexion or severe head rotation that would
impede venous outflow from the head; and
the use of osmotic diuretics (mannitol) to
decrease cerebral edema
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In patients with carotid stenosis, carotid
endarterectomy may be performed to prevent
a stroke.
 Assessment
 Plan
 Emotional
and Behavioral
Modification
 Communication (Expressive
Dysphasia & Receptive Dysphasia)
 PATIENT EDUCATION AND
DISCHARGE PLANNING
Maintain adequate cerebral
perfusion pressure.
• Obtain vital signs and perform a
neurological assessment to establish
a baseline and to monitor for the
development of additional deficits.
• Position head of bed at 30 degrees to
promote venous return.
• Implement DVT precautions
• Perform a neurological assessment at a minimum
of every 2 to 4 hours.
- Verbal response, orientation.
- Eye opening, pupil size, and
reaction to light.
- Motor response.
• Monitor vital signs with neurological
checks
• Ask the physician for acceptable
limits for blood pressure.
• Perform a cardiac assessment.
• Elevate the head of the bed 30 to 45
degrees.
• Avoid activities that may increase
intracranial pressure.
- Avoid extreme hip or neck flexion.
- Avoid clustering nursing
procedures.
- Provide a quiet environment.
• Perform aneurysm/AVM precautions.
- Ensure complete bed rest in a quiet &
darkened room.
- Elevate head of bed d 30 to 45
degrees.
- Restrict TV, radio, and visitors.
- Avoid hot ,cold beverages and caffein
products.
- Avoid straining &vigorous coughing.
Prevent Sensory/ Perceptual
Alteration
1- Use frequent verbal and tactile cues to
help the client perform activities of daily
living.
2- Break tasks down into small steps when
cueing.
3- Approach the client from the non-affected
side.
4-Teach the client to scan with eyes
and turn the head side to side
(when visual impairments occur).
5- Place objects within the client’s field
of vision.
6- Place a patch over the affected eye if
diplopia is present.
7- Remove clutter from the room.
8- Orient the client to time, place, and
persons.
9- Provide a structured, repetitious, &
consistent routine or schedule.
10- Present information in a clear, simple,
concise manner.
11- Use a step-by-step approach.
12- Place pictures and other familiar objects
in the room.
Prevent complications of
immobility.
• Assess for neglect.
• Provide active or passive range of
motion to all extremities every shift.
• Establish splinting routine to affected
extremities.
• Monitor daily blood glucose.
• Instruct in mobility aids; instruct in
strategies of fall prevention.
Establish an effective method
of communication.
• Assess ability to speak and to follow simple
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commands.
Arrange for consultation with speech language
pathologist to differentiate language
disturbances.
Use communication aids such as picture cards and
pantomime to enhance communication.
Provide a calm, unrushed environment.
Listen attentively to the patient.
Speak in a normal tone.
Maintain adequate airway ,oxygen
saturation (SpO2) & prevention of
atelectasis
• Monitor breath sounds every shift.
• Check oxygen saturation every shift.
• Instruct to cough and deep breathe
and incentive spirometry every 2
hours while awake.
• Assist with removal of airway
secretions as needed. Be certain to
preoxygenate before suctioning.
Maintain nutrition & prevent
aspiration.
• Obtain admission weight.
• Perform cranial nerve assessment (including
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ability to swallow) to identify deficits.
Obtain consultation from speech–language
pathologist to see if patient is safe to eat orally.
Provide proper diet and assist with feeding as
needed.
Monitor caloric intake; implement calorie count if
necessary.
Obtain dietary consultation to obtain
recommendation for supplements.
Achieve urinary continence
• Perform assessment of usual patterns and
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habits.
Establish a toileting schedule using a
bedpan, urinal, or bedside commode.
Monitor for the development of urinary
retention or urinary tract infection.
Use bladder scanner to evaluate contents
of bladder.
Avoid use of indwelling catheter to
prevent infection.
• Establish the cause of the problem and
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type (bowel/bladder).
Determine the client’s usual voiding or
bowel movement pattern.
Implement an individualized bladder
training program.
Use an intermittent catheterization
program if urinary incontinence is due to
upper motor lesion.
Place the client on a bedpan or commode
every 2 hours.
Encourage fluids to 2000 per day unless
contraindicated
Impaired Physical Mobility
- Self-Care Deficit
• Perform active and passive range-of-motion
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exercises at least daily.
Position the client in proper body alignment
carefully.
Maintain correct use of splints and braces.
Use antiembolism stockings; Position and
mobilize the client frequently as soon as possible
to prevent deep-vein thrombosis or pneumonia.
Measure thighs and calves daily and check for
positive Homan’s sign (possible deep-vein
thrombosis).
Prevent dysrhthmias
• Monitor vital signs closely.
• Manage blood pressure carefully; avoid
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sharp drops in blood pressure that could
result in hypotension and cause an
ischemic event secondary to hypotension.
During cardiac monitoring phase, identify
dysrrhythmias.
Treat dysrrhythmias to maintain adequate
cerebral perfusion pressure and reduce
chance of neurological impairment.
Emotional & behavioral modification
• Patients who have experienced a stroke
may display emotional problems ,and their
behavior may be different from baseline.
• Emotions may be labile; for example, the
patient may cry one moment and laugh
the next, without explanation or control.
• Tolerance to stress may also be
reduced. A minor stressor in the prestroke state may be perceived as a
major problem after the stroke.
• Patients may show frustration or
agitation with the nursing staff or
their family members.
• It is the nurse’s role to help the family
understand patient's behavioral changes.
& help modify the patient’s behavior by
- Controlling stimuli in the environment,
- Providing rest periods throughout the
day to prevent the patient from
becoming overtired,
- Giving positive feedback,
- Providing repetition when the patient is
trying to relearn a skill.
Communication
• Patients can demonstrate much
frustration with their deficits. Probably
no deficit produces more frustration for
the patient and those trying to
communicate with him or her than the
one involving the production &
understanding of language.
• Dysphasia can involve motor abilities,
sensory function, or both.
• If the area of brain injury is in or
near the left Broca’s area, the
memory of motor patterns of speech
is affected. This results in an
expressive dysphasia, in which the
patient understands language but is
unable to use it appropriately.
• Receptive dysphasia usually is a
result of injury to the left Wernicke’s
area ,which is the control center for
recognition of spoken language.
• The patient therefore is unable to
understand the significance of the
spoken word.
• The presence of both expressive and
receptive dysphasia is referred to as
global dysphasia.
• It is important for the nursing staff
to inform families that having
dysphasia does not mean that a
person is intellectually impaired.
• Communication at some level should
be attempted, whether it is by
writing, using picture boards, or
gestures.
Patient education & discharge
planning
1- Modifying risk factors
2- Recognize the signs & symptoms
of a stroke.
3- Medication
4- Other lifestyle modifications to
manage blood pressure.
5- Smoking cessation programs.
6- Weight management
7- Exercise programs.
8- Compliance with medication
regimens should also be stressed.
• Hospitals need to organize community
outreach programs regarding
- stroke prevention,
- the recognition of signs & symptoms
of a stroke,
- its emergent nature,
- the need to contact 911 at the onset
of symptoms.
• There must be public awareness about the signs
and symptoms, such as
- Sudden onset of numbness or weakness of the
face, arm, or leg;
- Confusion;
- Trouble speaking or understand understanding;
- Vision problems;
- Dizziness;
- Loss of balance;
- Severe headache.
- The urgency of immediate attention must be
stressed.
• Emergency medical personnel need
to be able to identify the symptoms
of a stroke and mobilize the patient
to the nearest hospital with a full
complement of stroke services from
diagnosis to discharge.
• Family members may require education
about how to provide care for the patient
at home.
• Instruction about mobility, nutrition,
safety, sleep, and eliminative care must
occur, along with referrals for home care,
if appropriate.
• With support, the patient will be able to
achieve maximum quality of life and
reintegrate into the community.
Good Luck