Cerebrovascular Accident

Prepared by: Cellanie P. Janson

Introduction
Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke or brain attack.

Incidence
3rd Cause of death in US and Canada Statistics 2/3 in people >65 = in men and women Higher incidence and death rates among African-Americans, Hispanics, NativeAmerican, Asian Americans

ANATOMY AND PHYSIOLOGY

Neurons
Receives stimuli and transmit action potential to the other neurons or the effector organs. It consist of Dendrites Cell body Axons

Spinal cord
Provides neuron and synapse networks to produce involuntary responses to sensory stimulation. Horns It is central gray part of the spinal cord Nerve tracts White part forming nerve tracts

Meninges
The meninges is a fibrous connective tissues that cover the brain and spinal cord. The layers of the meninges are the following: Dura mater Arachnoid membrane Pia mater

Cerebrospinal Fluid &Ventricles

Cerebrospinal Fluid Acts as protective cushion; aids in the exchange of nutrients and wastes It is produced by the choroid plexuses, which are located in the ventricles. Ventricles Fluid filled cavities Consist of four; right and left lateral ventricles, third ventricles, and fourth ventricles

Cerebral Circulation
Normal blood flow through the brain of the adult person averages 50 to 65 milliliters per 100 grams of brain tissue per minute. For the entire brain, this amounts to 750 to 900 ml/min, or 15 per cent of the resting cardiac output. The brain does not store nutrients and has a high metabolic demand that requires the high blood flow.

Blood supply by arteries

Blood is supplied to the brain by two major pairs of arteries Internal carotid arteries Vertebral arteries The internal carotids arise from the bifurcation of the common carotid and supply much of the anterior circulation of the brain.

Carotid arteries branch to supply most of the Frontal, parietal, and temporal lobes Basal ganglia Part of the diencephalon
Thalamus Hypothalamus

Blood supply by arteries

The vertebral arteries branch from the subclavian arteries, flow back and upward on either side of the cervical vertebrae, and enter the cranium through the foramen magnum.

Vertebral arteries join to form the basilar artery, which supply the Middle and lower temporal lobes Occipital lobes Cerebellum Brainstem Part of the diencephalon

The circle of Willis and is

formed from the branches of the internal carotid arteries, anterior and middle cerebral arteries, and anterior and posterior communicating arteries Functionally, the posterior portion of the circulation and the anterior or carotid circulation usually remain separate. The arteries of the circle of Willis can provide collateral circulation if one or more of the four vessels supplying it become occluded or are ligated.

STROKE

Two Categories of Stroke

Intracerebral hemorrhage Subarachnoid hemorrhage
Thrombotic stroke Embolic stroke

Risk Factors
Non Modifiable Age Gender Race Heredity
Modifiable Atherosclerosis which includes the following risk factors: HTN, Smoking, Hyperlipidemia, Diabetes mellitus, Physical inactivity. Polycythemia vera Hypercoagulability Asymptomatic carotid stenosis Heart disease, atrial fibrillation Oral contraceptives Sickle cell disease

PATHOPHYSIOLOGY OF ISCHEMIC STROKE

PATHOPHYSIOLOGY OF HEMORRHAGIC STROKE

Clinical Manifestation
Stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which vessels are obstructed), the size of the area of inadequate perfusion, and the amount of collateral (secondary or accessory) blood flow.

NEUROLOGIC DEFICIT Visual Field Deficits Homonymous hemianopsia (loss of half of the visual field) Loss of peripheral vision

MANIFESTATION Unaware of persons or objects on side of visual loss Neglect of one side of the body Difficulty judging distances Difficulty seeing at night Unaware of objects or the borders of objects Double vision

Diplopia

Motor Deficits Hemiparesis

Weakness of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere) Paralysis of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere) Staggering, unsteady gait Unable to keep feet together; needs a broad base to stand Difficulty in forming words Difficulty in swallowing Numbness and tingling of Extremity Difficulty with proprioception Unable to form words that are understandable; may be able to speak in single-word responses Unable to comprehend the spoken word; can speak but may not make sense Combination of both receptive and expressive aphasia Short- and long-term memory loss Decreased attention span Impaired ability to concentrate Poor abstract reasoning Altered judgment

Hemiplegia

Ataxia

Dysarthria Dysphagia Sensory Deficits Paresthesia (occurs on the side opposite the lesion) Verbal Deficits Expressive aphasia

Receptive aphasia Global (mixed) aphasia Cognitive Deficits

Emotional Deficits Loss of self-control Emotional lability Decreased tolerance to stressful situations Depression Withdrawal Fear, hostility, and anger Feelings of isolation

LEFT HEMISPHERIC STROKE Paralysis or weakness on right side of body Right visual field deficit Aphasia (expressive, receptive, or global) Altered intellectual ability Slow, cautious behavior

Comparison of Left and Right Hemispheric Strokes

RIGHT HEMISPHERIC STROKE Paralysis or weakness on left side of body Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive behavior and poor judgment Lack of awareness of deficits

MANAGEMENT

Management
Goals of stroke prevention include Health management for the well individual Education and management of modifiable risk factors to prevent a stroke

Medical Management
Platelet-inhibiting medications(e.g., aspirin, clopidogrel, dipyridamol) Thrombolytic agents

Cholesterol-lowering statins Antihypertensive medications (diuretics, ACE inhibitors, angiotensin blockers, beta blockers, calcium channel blockers, etc.) Calcium channel blockers

Surgical Management
Carotid endarterectomy Transluminal angioplasty Stenting Cerebral bypass surgery

Nursing Management
Respiratory System Maintain patent airway and administer O2 as prescribed Neurologic System Monitor closely the patient for level of consciousness

Cardiovascular System Monitoring vital signs frequently. Maintain a BP of less than 150/100 Monitor intake and output

Musculoskeletal System Trochanter roll at hip Hand cones Arm supports with slings and lap boards PROM exercises

Integumentary System Maintain skin integrity Provide skin care Gastrointestinal System Assess gag reflex and ability to swallow Feedings must be followed by scrupulous oral hygiene

Communication Speak slowly and calmly, using simple words or sentences Use picture boards, communication boards or computer technology.

 Approach the client from the unaffected side Place the clients personal objects within the visual fields Provide eye care for visual deficits Place eye patch over the affected eye if the client has diplopia