Management of Patients With
Cerebrovascular Disorders
Edited M. Leavitt
Cerebrovascular Disorders
 Functional abnormality of the CNS that occurs when
the blood supply to the brain is disrupted
o Ischemic stroke: inadequate blood flow
o Hemorrhagic stroke: bleeding
 Stroke (“brain attack”) is the primary cerebrovascular
disorder and the fifth leading cause of death in the
United States
 Stroke is the leading cause of serious long-term
disability in the United States
 Financial impact is profound
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Question
What is agnosia?
A. Failure to recognize familiar objects perceived by the
senses
B. Inability to express oneself or to understand language
C. Inability to perform previously learned purposeful
motor acts on a voluntary basis
D. Impaired ability to coordinate movement, often seen
as a staggering gait or postural imbalance
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Answer to Question
A. Failure to recognize familiar objects perceived by the
senses
Agnosia is failure to recognize familiar objects perceived
by the senses.
Aphasia is an inability to express oneself or to
understand language.
Apraxia is an inability to perform previously learned
purposeful motor acts on a voluntary basis.
Ataxia is an impaired ability to coordinate movement,
often seen as a staggering gait or postural imbalance
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Question
 Which of the following patients has the highest risk of
stroke?
o A. Obese 45-y/o Native American
o B. 35 y/o Asian American woman who smokes
o C. 32 y/o white woman taking oral contraceptives
o D. 65 y/o African American man with hypertension
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Prevention
 Non-modifiable risk factors
o Age (older than 55 years), male gender, African
Americans (see Health Disparities p. 1347)
 Modifiable risk factors
o Hypertension is the primary risk factor
o Cardiovascular disease
o Elevated cholesterol or
elevated hematocrit
o Obesity
o Diabetes
o Oral contraceptive use
o Smoking and drug and
alcohol abuse
o Women w/ migraine aura
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Question
Is the following statement true or false?
Ischemic stroke account for 85% to 87% of strokes, and
hemorrhagic stroke accounts for 13% to 15%
A. True
B. False
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Answer to Question
A. True
Ischemic stroke account for 85%-87% of strokes, while
hemorrhagic stroke accounts for 13%-15%
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Transient Ischemic Attack (TIA)
 Temporary neurologic deficit resulting from a
temporary impairment of blood flow
 May be due to microembolii
 Typically lasts less than 60 minutes
 “Warning of an impending stroke”
 Diagnostic workup is required to treat and prevent
irreversible deficits
 Treat as a medical emergency
 TIA
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Preventive Treatment and Secondary
Prevention
 Health maintenance measures including a healthy
lifestyle, not smoking, exercise, healthy diet and
weight
 Carotid endarterectomy for carotid stenosis
o Removes plaques that block cerebral blood flow
 Anticoagulant therapy for atrial fibrillation
 Antiplatelet therapy
 “Statins”
 Antihypertensive medications
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Carotid Endarterectomy
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Stroke
 “Brain attack” Urgent issue similar to “heart attack”
 TIME = BRAIN
 Older name CVA (cerebrovascular accident)
 Sudden loss of function resulting from a disruption of
the blood supply to a part of the brain
 Types of stroke:
o Ischemic (85% - 87%)
 Thrombotic: injury to vessel wall -> clot in lumen
 Embolic: embolism lodges in vessel wall
o Hemorrhagic (13% - 15%)
 Intracerebral vessel rupture
 Subarachnoid aneurysm rupture
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Stroke: Ischemic vs Hemorrhagic
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Ischemic Stroke
 Disruption of the blood supply caused by an obstruction,
usually a thrombus or embolism, that causes infarction
of brain tissue
 Types
o Large artery thrombosis: plaques in large vessels
o Small penetrating artery thrombosis: common type
AKA Lacunar Stroke (infarcted tissue leaves a cavity)
o Cardiogenic embolism: A fib, LV thrombus, Patent
Foramen Ovale (PFO). Most common site is Left
Middle Cerebral Artery
o Cryptogenic: no known cause, might be PFO
o Other: cocaine, coagulopathies, vasospasm,
dissection of carotid or vertebral arteries
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Left atrial appendage
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Patent foramen ovale and closure
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Pathophysiology
The Ischemic Cascade
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Manifestations of Ischemic Stroke
 Symptoms depend on which blood vessels are
obstructed and size of the affected brain area
 Numbness or weakness of face, arm, or leg, especially
on one side
 Confusion or change in mental status
 Trouble speaking or understanding speech
 Difficulty in walking, dizziness, or loss of balance or
coordination
 Sudden, severe headache (more freq hemorrhagic)
 Perceptual disturbances
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Terms
 Hemiplegia: paralysis of one side or part of the body
 Hemiparesis: weakness of one side or part of the body
 Dysarthria: difficulty formulating words due to muscle
weakness
 Aphasia: Expressive, receptive, or both (Global)
o expressive aphasia: unable to form words
o receptive aphasia: unable to comprehend words
 Hemianopsia: loss of visual field
o Homonymous hemianopsia: loss of half visual field
 Agnosia: failure to recognize familiar objects perceived by
the senses.
 Apraxia: inability to perform a previously learned action
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Visual Pathways
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Assessment
 History: When last seen well? WHY?
 Airway: loss of gag or cough? altered respiratory pattern?
o
Bedside dysphagia screening
o
Fluoroscopic swallow study
 CV: BP, heart rate & rhythm, carotid bruit?
 Assessment of stroke: NIHSS assessment tool
 Neuro deficits: Symptoms depend on which blood vessels are
obstructed and size of the affected brain area
o
o
o
o
o
o
o
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of balance or coordination
Sudden, severe headache
Perceptual disturbances
Stroke!
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National Institutes of Health Stroke
Scale (NIHSS) Table 57-10., p. 1368
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National Institutes of Health Stroke
Scale (NIHSS)
 Significance of NIHSS (start at 0.30, advance to 2:50)
 Tips on scoring the NIHSS (go to 0.55, then 7:10)
 NIHSS Demo
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Knowledge Check
 Your patient with a right-sided stroke has left
homonymous hemianopsia. Which of the following
would you do?
o A. Tell patient to look to right side to see objects
o B. Place bedside table on right side of bed
o C. Explain food on plate using clock method
o D. Place wheelchair on patient’s left side
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Diagnostic Studies
 Diagnosis: ED Diagnosis
o CT scan: non-contrast to direct treatment
 CT Scan
 Ischemic stroke
 Hemorrhagic stroke
o Cerebral angiography
o Lumbar puncture if CT is negative and ICP is not
elevated to confirm subarachnoid hemorrhage
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Question
 A patient has trouble finding words and right arm
weakness. What area of the brain is likely involved?
o A. Brainstem
o B. Vertebral artery
o C. Left middle cerebral artery
o D. Right middle cerebral artery
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Left vs. Right hemispheric stroke
Left hemisphere: language, math, analytics
Right hemisphere: visual & special awareness;
proprioception
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Medical Management: Acute Phase of
Stroke
 Prompt diagnosis and treatment
 Continued assessment of stroke: NIHSS assessment tool
 Thrombolytic therapy
o Criteria for tPA
o IV dosage and administration
o Patient monitoring
o Side effects: potential bleeding
 Elevate head of bed (HOB) unless contraindicated
 Maintain airway and ventilation
 Continuous hemodynamic monitoring and neurologic
assessment
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Ischemic Stroke Treatment
 tPA screening:
o Non-contrast CT to R/O hemorrhagic stroke
o Labs: Blood sugar & PT, PTT
o History
 GI Bleed or head trauma last 3 months
 Active internal bleeding last 3 weeks
 Major surgery last 2 weeks
 tPA infusion, systemic IV
o Dose is weight-based
o Monitor VS & neuro status
o Control systolic BP <185 mmHg
 May also give tPA IA, directly to clot, within 6 hours
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Ischemic Stroke Treatment
 tPA
o Binds to fibrin, converts plasminogen to plasmin,
digests fibrin, breaks down clot.
o Give within 3 hrs of sx (sometimes up to 4.5 hrs)
o Goal: given within 60 minutes of ED arrival
o Door to needle in 5 minutes
o Thrombectomy with stent retrievers is standard of
care for some acute ischemic strokes
o Neurovascular Stent Retriever
o Must meet criteria (>18, pre-stroke no deficits, tPA
within 4.5 hrs, proximal large vessel occlusion in the
anterior circulation (internal carotid or middle
cerebral arteries), endovascular tmt within 6 hrs)
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If tPA contraindicated…
 Oxygen
 HOB up to decrease ICP
 Hemodynamic monitoring
o If hypertensive, reduce MAP by 30%
o Balance of reducing BP but not reducing cerebral
perfusion pressure (CPP)
 Less than 220/120
o Higher BPs are desired to perfuse brain
 May need intubation for airway mgmt
 Mannitol (osmotic diuretic) is controversial. Has not
been shown to have statistically significant benefit
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Find source of embolic stroke
Carotid ultrasound
CT angiography
MRI angiography
Transthoracic echo
Transesophageal echo
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Knowledge Check
 Which of the following findings would you expect in a
patient with a left-hemispheric stroke?
o A. Poor impulse control
o B. Poor judgment
o C. Difficulty understanding language
o D. Loss of depth perception
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Hemorrhagic Stroke
 Caused by bleeding into brain tissue, the ventricles, or
subarachnoid space
 May be caused by
o spontaneous rupture of small vessels primarily related
to hypertension
o subarachnoid hemorrhage (SAH) caused by a ruptured
aneurysm:
 SAH -> SIADH -> what electrolyte problem? 30-55%
 What IV fluid order should be anticipated?
o intracerebral hemorrhage related to amyloid angiopathy
o arterial venous malformations (AVMs)
o intracranial aneurysms
o medications such as anticoagulants
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Hemorrhagic Stroke
 Brain metabolism is disrupted by exposure to blood
 ICP increases caused by blood in the subarachnoid
space
 Compression or secondary ischemia from reduced
perfusion and vasoconstriction causes injury to brain
tissue
 Intracerebral hemorrhage from HTN and cerebral
atherosclerosis
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Manifestations
 Similar to ischemic stroke
 Severe headache: may be sign of leaking aneurysm or
other brain bleed
 Early and sudden changes in LOC
 Vomiting
 Bleeding
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Aneurysms
Dilation of walls
of cerebral artery
due to weakness
in the arterial
walls
Usually occur at
bifurcations of
large arteries at
Circle of Willis
Rupture =
Hemorrhagic
stroke
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Aneurysms
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Aneurysm treatment (Fig. 57-7, p. 1356)
 Cerebral aneurysms
 3 ways to treat cerebral aneurysms
 Aneurysm coiling and stenting
 Aneurysm clipping (start at 30 sec)
 Clipping unruptured middle cerebral artery aneurysm
(clip goes on at 5 min)
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Aneurysm Precautions
 Provide a nonstimulating environment, prevent increases
in ICP, prevent further bleeding:
o Absolute bed rest with HOB 30 degrees
o Avoid all activity that may increase ICP or BP;
Valsalva maneuver, acute flexion or rotation of neck
or head
o Stool softener and mild laxatives
o Nonstimulating, nonstressful environment; dim
lighting, no reading, no TV, no radio
o Visitors are restricted
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Arteriovenous Malformations
 Tangle of arteries and veins in brain that lacks a
capillary bed
 Vessels can dilate and rupture
 AVM
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Nursing Process: The Patient With a
Hemorrhagic Stroke—Assessment
 Complete and ongoing neurologic assessment; use neurologic
flow chart
 NIHSS
 Altered LOC: earliest sign of deterioration
o Drowsy, slurred speech, sluggish pupils
 Sluggish pupillary reaction
 Motor and sensory dysfunction
 Cranial nerve deficits
 Speech difficulties and visual disturbance
 Headache and nuchal rigidity
 Other neurologic deficits
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Nursing Process: The Patient With a
Hemorrhagic Stroke—Diagnoses
 Risk for ineffective tissue perfusion (cerebral) related
to bleeding or vasospasm
 Anxiety related to illness and/or medically imposed
restrictions (aneurysm precautions)
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Collaborative Problems and Potential
Complications: Hemorrhagic Stroke
 Decreased cerebral blood flow
 Inadequate oxygen delivery to brain
 Pneumonia
 Vasospasm
 Seizures
 Hydrocephalus
 Rebleeding
 Hyponatremia
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Nursing Process: The Patient With a
Hemorrhagic Stroke—Planning
 Goals may include:
o Improved cerebral tissue perfusion
o Relief of anxiety
o The absence of complications
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Nursing Process: The Patient Recovering
From a Stroke—Assessment
 Acute phase:
o Ongoing, frequent monitoring of all systems,
including vital signs and neurologic assessment
o LOC
o Motor symptoms
o Speech
o Pupil changes
o I&O
o Blood pressure maintenance
o Bleeding
o Oxygen saturation
o Collaborative Care: Box on p. 1359
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Nursing Care Post Acute Phase
After the acute phase:
o Mental status
o Sensation/perception: Fig. 57-9, p. 1362
o Motor control: Fig. 57-10, p. 1363
o Swallowing ability
o Nutritional and hydration status
 Assistive devices Fig 57-8, p. 1361
o Skin integrity
o Activity tolerance
o Bowel and bladder function
o Neglect Parietal lobe problem
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Knowledge Check
 Which of the following findings would you expect in a
patient with a right hemispheric stroke?
o A. Left hemiplegia and poor impulse control
o B. Left hemiplegia and aphasia
o C. Right hemiplegia and poor situational awareness
o D. Right hemiplegia and poor depth perception
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Nursing Process: The Patient Recovering
From a Stroke—Diagnoses
 Impaired physical mobility
 Acute pain
 Self-care deficits
 Impaired comfort R/T disturbed sensory perception
 Impaired swallowing
 Urinary incontinence
 Constipation
 Acute confusion
 Impaired verbal communication
 Risk for impaired skin integrity
 Interrupted family processes
 Sexual dysfunction
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Nursing Process: The Patient Recovering
From a Stroke—Planning
 Major goals may include
o
Improved mobility
o
Avoidance of shoulder pain
o
Achievement of self-care
o
Relief of sensory and perceptual deprivation
o
Prevention of aspiration
o
Continence of bowel and bladder
o
Improved thought processes
o
Achieving a form of communication
o
Maintaining skin integrity
o
Restored family functioning
o
Improved sexual function
o
Absence of complications
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Interventions
 Focus on the whole person
 Provide interventions to prevent complications and
promote rehabilitation
 Provide support and encouragement
 Listen to the patient
 Therapy for aphasia: board of common words &
phrases
 Nursing Through the Years (J&J)
 2020 Podcast interview with Rebecca Koszalenski
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Improving Mobility and Preventing Joint
Deformities
 Turn and position in correct alignment every 2 hours
 Use of splints
 Passive or active ROM four or five times day
 Positioning of hands and fingers
 Prevention of flexion contractures
 Prevention of shoulder abduction
 Do not lift by flaccid shoulder
 Measures to prevent and treat shoulder problems
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Improving Mobility and Preventing Joint
Deformities
 Encourage patient to exercise unaffected side
 Establish regular exercise routine
 Quadriceps setting and gluteal exercises
 Assist patient out of bed as soon as possible; assess
and help patient achieve balance; move slowly
 Ambulation training
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Interventions
 Enhancing self-care
o Set realistic goals with the patient
o Encourage personal hygiene
o Ensure that patient does not neglect the affected side
 If visual field loss, approach from intact side
 Homonymous hemianopsia (loss of half of visual
field): may not recognize one side of body as own.
Need to see it
o Use of assistive devices and modification of clothing
 Support and encouragement
 Strategies to enhance communication
 Encourage patient to turn head, look to side with visual
field loss
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Interventions
 Nutrition
o Consult with speech therapy or nutritional services –
immediate dysphagia screen
o Have patient sit upright, preferably out of bed to eat
o Chin tuck or swallowing method
o Use of thickened liquids or pureed diet
 Bowel and bladder control
o Assessment of voiding and scheduled voiding
o Measures to prevent constipation: fiber, fluid,
toileting schedule
o Bowel and bladder retraining
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Knowledge Check
 How should you communicate with a patient who has
global (both receptive and expressive) aphasia?
o A. Speak louder
o B. Speak slower
o C. Use a letter board
o D. Provide multiple instructions at one time
 Communication with patient with aphasia: Table 57-11, p.
1361
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Interventions
 Relieving sensory deprivation and anxiety
 Keep sensory stimulation to a minimum for aneurysm
precautions
 Realty orientation
 Patient and family education
 Support and reassurance
 Seizure precautions
 Strategies to regain and promote self-care and
rehabilitation
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Home Care and Education for the Patient
Recovering from a Stroke
 Prevention of subsequent strokes, health promotion, and
follow-up care;
 Prevention of and signs and symptoms of complications
 Medication education
 Safety measures
 Adaptive strategies and use of assistive devices for ADLs
o Unexpected emotional responses -> Frustration
 Nutrition: diet, swallowing techniques, tube feeding
administration
 Elimination: bowel and bladder programs, catheter use
 Exercise and activities, recreation and diversion
 Socialization, support groups, and community resources
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Question
What intervention would NOT be included in aspiration
precautions for a patient in the acute phase of a
stroke?
A. Referral to speech therapy
B. Have patient tuck their chin toward the chest when
swallowing
C. Thickened fluids or pureed diet
D. Raise HOB to 30 degrees when feeding
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Answer to Question
D. Raise HOB to 30 degrees when feeding
Interventions to prevent aspiration include a referral to
speech therapy for swallowing evaluation; having
the patient tuck the chin toward the chest when
swallowing to close off the trachea, preventing
aspiration into the lungs; providing thickened fluids
or a pureed diet; and sitting the patient at a full
upright position (90 degrees) when feeding or
providing fluids. The patient’s HOB should be
elevated to 30 degrees at all times to prevent
aspiration of secretions but would not prevent
aspiration of food or fluids when feeding
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Questions?
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