Megan Keiser, RN, DNP(c), CNRN, APRN
MANS/AANN-SEM Chapter Meeting
June 2011
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Define “stroke.”
Explain the historical perspective of
stroke.
Describe the epidemiology of stroke.
List the different types of stroke.
List the different causes of stroke.
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Elected officer (Secretary/Treasurer) of the
American Association of Neuroscience
Nurses (AANN).
Neurosurgery Nurse Practitioner at William
Beaumont Hospital, Royal Oak, MI
No financial conflicts of interest.
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A stroke is the sudden death of
a portion of the brain cells due
to a lack of oxygen.
The World Health Organization
(1980) defines stroke as “rapidly
developing clinical signs of focal
(at times global) disturbance of
cerebral function, lasting more
than 24 hours or leading to
death with no apparent cause
other than that of vascular
origin.”
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Hippocrates, the father of medicine, first
recognized stroke over 2,400 years ago.
At this time stroke was called apoplexy, which
means "struck down by violence" in Greek.
This was due to the fact that a person
developed sudden paralysis and change in
well-being.
Physicians had little knowledge of the
anatomy and function of the brain, the cause
of stroke, or how to treat it.
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It was not until the mid1600’s that Johann Jacob
Wepfer found that
patients who died with
apoplexy had bleeding in
the brain.
He also discovered that a
blockage in one of the
brain's blood vessels
could cause apoplexy.
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Medical science continued
to study the cause,
symptoms, and treatment
of apoplexy and, finally, in
1928, apoplexy was
divided into categories
based on the cause of the
blood vessel problem.
This led to the terms
stroke or "cerebral
vascular accident (CVA)."
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Stroke is now often referred to
as a "brain attack" to denote
the fact that it is caused by a
lack of blood supply to the
brain, very much like a heart
attack is caused by a lack of
blood supply to the heart.
The term brain attack also
conveys a more urgent call for
immediate action and
emergency treatment by the
general public.
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"Stroke" is a literal translation of
the original Greek term
"apoplexy".
“The explanation, for centuries,
was that someone had been
struck down by God.”
Because many people woke up in
the morning with symptoms, it
was said to occur at the “stroke of
midnight” and, thus, it was called
a stroke.
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Prevalence
 Among adults age 20 and older, the estimated
prevalence of stroke in 2006 was 6,400,000.
 About 2,500,000 males and 3,900,000 females.
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Incidence
 Each year about 795,000 people experience a new
or recurrent stroke.
 About 610,000 of these are first attacks, and
185,000 are recurrent attacks.
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Incidence
 On average, every 40 seconds someone in the United
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States has a stroke.
Each year, about 55,000 more women than men have a
stroke.
Men’s stroke incidence rates are greater than women’s at
younger ages but not at older ages.
The male/female incidence ratio is 1.25 at ages 55–64;
1.50 for ages 65–74; 1.07 at 75–84 and 0.76 at 85 and older.
Blacks have almost twice the risk of first-ever stroke
compared with whites.
The age-adjusted stroke incidence rates at ages 45–84 are
6.6 per 1,000 population in black males, 3.6 in white
males, 4.9 in black females and 2.3 in white females
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Mortality
 Stroke accounted for about one of every 18 deaths in the
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United States in 2006.
Stroke mortality for 2006 was 137,119 (54,524 males,
82,595 females).
When considered separately from other cardiovascular
diseases, stroke ranks No. 3 among all causes of death,
behind diseases of the heart and cancer.
On average, every four minutes someone dies of a stroke.
Among people ages 45–64, 8 to 12 percent of ischemic
strokes and 37 to 38 percent of hemorrhagic strokes result
in death within 30 days.
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Mortality
 From 1996–2006, the stroke death rate fell 33.5 percent
and the actual number of stroke deaths declined 18.4
percent.
 The 2006 final death rate for stroke was 43.6 per 100,000.
 Death rates were 41.7 for white males and 67.1 for black
males; 41.1 for white females and 57.0 for black females.
 Because women live longer than men and stroke occurs at
older ages, more women than men die of stroke each
year. Women accounted for 60.6 percent of U.S. stroke
deaths in 2006.
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Aftermath
 Stroke is a leading cause of serious, long-term disability in
the United States.
 The median survival time (in years) following a first stroke
is:
▪ at ages 60–69: 6.8 for men and 7.4 for women.
▪ at ages 70–79: 5.4 for men and 6.4 for women.
▪ at age 80 and older: 1.8 for men and 3.1 for women.
 After stroke, women have greater disability than men. In an
analysis of 108 stroke survivors from the Framingham Heart
Study, 34 percent of women were disabled six months after
their stroke compared to 16 percent of men.
 Cost
 The estimated direct and indirect cost of
stroke for 2010 is $73.7 billion.
 The mean lifetime cost of ischemic stroke in
the United States is estimated at $140,048.
 This includes inpatient care, rehabilitation
and follow-up care necessary for lasting
deficits.
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The stroke belt was first
identified in 1962 by
Centers for Disease
Control (CDC) researchers
who noted a concentration
of high stroke death rates
in the Atlantic coastal plain
counties of North Carolina,
South Carolina and
Georgia.[4] Similar high
stroke rates were later
observed in the Mississippi
Delta region as well.
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Analysis by the CDC of U.S. mortality statistics
from the period 1991 to 1998 found that for both
blacks and whites the counties with the highest
stroke death rates were in the southeastern
states and the Mississippi Delta region.
The causes of the elevated incidence of stroke in
the stroke belt region have not been
determined.
Numerous possible contributing factors have
been identified, including race, hypertension,
low socioeconomic status, diet, quality of
healthcare facilities, smoking, and infections.
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Non-modifiable
 Age (> 55)
 Gender (male>female)
 Heredity
 Race (>Hispanic,
Asian, African
American)
 Prior stroke, TIA, MI
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Modifiable
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HTN
Smoking
Obesity
High-fat Diet
High cholesterol
Diabetes
Genetic disorders
A-fib
Carotid artery disease
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A thromboembolic stroke
occurs when one of the
blood vessels in the brain is
blocked so that an area of
the brain has restricted or
absent blood flow for a
period of time long enough
to cause permanent
damage.
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Thrombus: a blood clot that obstructs flow
to a blood vessel
Embolus: something that travels through
the bloodstream, lodges in a blood vessel
and blocks it – this usually refers to a piece
of fat or atherosclerotic plaque when
discussing stroke
Surgical retraction
Vessel sacrifice
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Hemiparesis or hemiplegia
Numbness
Decrease or loss of vision
Speech difficulty
Swallowing difficulty
Headache
Vertigo or dizziness
Loss of coordination
Decreased level of
consciousness
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TIME IS BRAIN!!!!
Intravenous tPA
Intra-arterial tPA
Clot retrieval
When is it surgical???
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Thrombolytics restore cerebral blood flow in
some patients with acute ischemic stroke and
may lead to improvement or resolution of
neurologic deficits
Symptom onset clearly documented within 34.5 hours of tPA infusion
Know the exclusion criteria
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IA tPA is a faster way to
deliver clot-busters directly
to the blockage.
Requires a cerebral
arteriogram
Expands the window of
treatment to 6 hours
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Mechanical clot retrieval
device = MERCI
Opens the window to
8 hours after symptom onset
Requires cerebral arteriogram
“Corkscrew” device is forced into thrombus
and removed
Causes recanalization of blood vessel and
restoration of blood flow
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Topic of much debate
Younger patients with
non-dominant
hemisphere CVA and
intractable
intracerebral edema
may be offered a
decompressive
craniectomy
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Hemorrhagic stroke
occurs when a blood
vessel bursts inside the
brain. The brain is very
sensitive to bleeding and
damage can occur very
rapidly, either because of
the blood itself, or
because the blood
increases pressure in the
brain.
High blood pressure is leading cause
Conversion of thrombotic stroke (tPA)
Aneurysm or AVM rupture
 Amyloid angiopathy
 Hemorrhages in or around brain tumors
 Anticoagulation
 Clotting Disorders
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An aneurysm is a ballooning out of a blood
vessel which makes it weak and prone to
hemorrhage
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AVMs are an abnormal area of blood vessels
that have many weak spots prone to
hemorrhage. Cavernomas are a type of AVM
in which the vessels are very small, but they
are still prone to hemorrhage.
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Accumulation of protein called amyloid
within artery walls, particularly in the elderly.
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Either as a result of surgery or because the
tumor is eroding through blood vessels.
FIX WHATEVER CAUSED
IT!!!
 Control blood pressure
 Clip or coil the aneurysm
 Resect/embolize the AVM
 Reverse anticoagulation
 Give platelets if necessary
 When is it surgical???
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Topic of much debate
Early treatment of
ruptured aneurysm – later
for ruptured AVM
Almost never to evacuate
the clot – too deep!
Exception – cerebellar
IPH
Decompressive
craniectomy
Infratentorial vs.
supratentorial
 Decompressive
suboccipital
craniotomy and
evacuation of clot
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Used for spontaneous IPH
Sometimes used in conjunction with EVD if
clot has ruptured into the ventricle
 Know your stuff when it comes to tPA
 Know when you’re getting into
trouble – worsening or new deficits
are a red flag!
 Know what questions will be asked
when you call a physician
 Aggressive BP management is crucial
 Prevent complications
 Early rehab is a nursing function
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MKeiserRN@aol.com or
mkeiser@beaumonthospitals.com