INTRODUCTION

Stroke (cerebral vascular accident or brain attack) is an emergency condition in

which neurologic deficits result from a sudden decrease in blood flow to a localized area
of the brain. Strokes may be ischemic (when blood supply to a part of the brain is
suddenly interrupted by a thrombus, embolus, or blood vessel stenosis), or hemorrhagic
(when blood vessel ruptures, spilling blood into spaces surrounding neurons).
A stroke is caused by the interruption of the blood supply to the brain, usually
because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen
and nutrients, causing damage to the brain tissue
There are types of stroke: the ischemic stroke; [transient ischemic attack, large vessel
(thrombotic) stroke, small vessel stroke (lacunar infarct), cardiogenic embolic stroke]
and hemorrhagic stroke, [intracerebral hemorrhage and subarachnoid hemorrhage].
Infarct is when there is death of tissue with surrounding inflammation due to a sudden
and complete loss of arterial blood supply. It is often preceded by ischemic injury but if it
is gradual and there is only partial ischemia, the body can quickly develop collateral
blood supply to the target area.
Ischemia and an infarct can occur in any tissue or organ in the body but is the
most life threatening when it affects the heart (heart attack) or brain (cerebrovascular
accident or stroke). Although ischemia and infarct are often discussed in the context of a
blockage in the artery, like plaques in atherosclerosis or a blood clot (thrombus or
embolus), it can also arise from a rupture in the artery thereby preventing oxygenated
blood from reaching the target tissue.
Causes of Cerebrovascular accident:
Intracerebral hemorrhage (rupture of a blood vessel in the pia mater or brain
Emboli (blood clots)
Atherosclerosis (formation of plaque) of the cerebral arteries.
Types of Stroke by Etiology:

1. Hemorrhage stroke (intracranial hemorrhage)

5% of all strokes
Two division:
a. Intracerebral (10%) due to rupture of weakened vessels within brain
parenchyma as result of Hypertension, arteriovenous malformation or tumor
b. Subarachnoid (5%) result from aneurismal rupture of a cerebral artery with
blood loss into space surrounding the brain; evolve over 1 2 hours.
2. Ischemic Strokes (remaining 85%)
Large (40%) or small (20%) vessel thrombosis
- Most commonly occur in presence of atherosclerotic cerebrovascular disease
- Vascular changes or lipohyalinosis found in small deep penetrating arteries as
associated with chronic hypertension can lead to small vessel thrombosis.
-rapid or prolonged interval of onset and may lead last many hours
Cerebral embolism (20%)
- Usually a cardiac origin
- Frequently result of chronic ischemic cardiovascular disease with secondary
ventricular wall hypokinessis or atrial arrhythmia both conditions increase risk of
intracardiac thrombus formation
- Quick onset and fully develop in a matter of minutes
Temporal Classification of Stroke
1. Transient ischemic attack (TIA)
neurologic symptoms develop and disappear over several minutes and completely
resolve in 24 hours
most frequently associated with atherosclerotic carotid artery disease

2. Reversible Ischemic Neurologic Deficit

- Etiology unknown
- Likely the result from small infarctions (Lacunes) of the deep subcortical gray and
white matter resulting in only temporary impairment
3. Stroke in Evolution
describe an unstable ischemic event characterized by the progressive development of
more severe neurologic impairment
often associated with active occlusive thrombosis of a major cerebral artery.
Once stable called Complete Stroke
Most important sign Intellectual Regression

STATISTICS
CVD is the most disabling of all neurologic diseases. Approximately 50% of survivors
have a residual neurologic deficit and greater than 25% require chronic care.
Cardiovascular disease mortality in the Philippines was studied from the existing vital
statistics for 2000-2008. Death rates from cerebrovascular diseases increased
enormously both in men and women. This increase in mortality was seen in all age
groups. The age-standardized mortality rate in men rose from 33.3 in 2000 to 78.0 in
2005, and that of women from 15.4 to 34.5. The male to female ratios in the agestandardized death rates increased during this 9-year period. Age-standardized
mortality increased clearly in the male population but decreased in the female
population of the Philippines. This excess mortality in males is mostly due to the
increased cardiovascular disease death rate. This is a clear example of how chronic
non-communicable diseases are becoming major health problems in countries where
they previously have not been prevalent. Immediate preventive measures are needed in

order to control cardiovascular diseases in countries, such as ours, where disease rates
are rapidly increasing.

SIGNS AND SYMPTOMS

Symptoms of cerebral infarction are determined by the part/s of the brain affected. If the
infarct is located in primary motor cortex- contralateral hemiparesis is said to occur. With
brainstem localization, brainstem syndromes are typical: Wallenberg's syndrome,
Weber's syndrome, Millard-Gubler syndrome, Benedikt syndrome or others. Infarctions
will result in weakness and loss of sensation on the opposite side of the body. Physical
examination of the head area will reveal abnormal pupil dilation, light reaction and lack
of eye movement on opposite side. If the infarction occurs on the left side brain, speech
will be slurred. Reflexes may be aggravated as well.

COMPLICATIONS

Altered LOC
Aspiration
Cerebral Edema
Cognitive impairment
Contractures
Fluid Imbalances
Infections (pneumonia)
Paralysis
Pulmonary Embolism
Sensory Impairment
Unstable blood pressure( from loss of vasomotor control)
Death

RISK FACTORS

Alcohol or cocaine use

Cardiac disease including atrial fibrillation and vulvar disease
Cigarette smoking Diabetes
Familial hyperlipidemia

Family history of stroke

History of transient ischemic attacks
Hypercholesterolemia
Hypertension
Increased alcohol intake
Obesity, sedentary lifestyle
Sickle cell disease
Use of hormonal contraceptives

TOP 5 RISK FACTORS

Advanced age
Hypertension
Smoking
Cardiac disease
Hypercholesterolemia

ANATOMY AND PHYSIOLOGY

Brain
The brain is composed of the cerebrum, cerebellum, and brainstem

The brain is composed of three parts: the brainstem, cerebellum, and cerebrum.
The cerebrum is divided into four lobes: frontal, parietal, temporal, and occipital.

A Brainstem - includes the midbrain, pons, and medulla. It acts as a relay center
connecting the cerebrum and cerebellum to the spinal cord. It performs many
automatic functions such as breathing, heart rate, body temperature, wake and
sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the
twelve cranial nerves originate in the brainstem. The brainstem is the lower
extension of the brain, located in front of the cerebellum and connected to the
spinal cord. It consists of three structures: the midbrain, pons and medulla
oblongata. It serves as a relay station, passing messages back and forth
between various parts of the body and the cerebral cortex. Many simple or
primitive functions that are essential for survival are located here.
1 Midbrain - is an important center for ocular motion

2 Pons - is involved with coordinating eye and facial movements, facial sensation,
hearing and balance.
3 Medulla oblongata - controls breathing, blood pressure, heart rhythms and
swallowing. Messages from the cortex to the spinal cord and nerves that branch
from the spinal cord are sent through the pons and the brainstem. Destruction of
these regions of the brain will cause "brain death." Without these key functions,
humans cannot survive.
The reticular activating system is found in the midbrain, pons, medulla and part of the
thalamus. It controls levels of wakefulness, enables people to pay attention to their
environments, and is involved in sleep patterns. Originating in the brainstem are 10 of
the 12 cranial nerves that control hearing, eye movement, facial sensations, taste,
swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial
nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves
originate from the pons: nerves 5 through 8.

B Cerebrum - the largest part of the brain and is composed of right and left
hemispheres. It is separated from the cerebrum by the tentorium (fold of dura).
The cerebrum, which forms the major portion of the brain, is divided into two
major parts: the right and left cerebral hemispheres. The cerebrum is a term
often used to describe the entire brain. A fissure or groove that separates the two
hemispheres is called the great longitudinal fissure. The two sides of the brain
are joined at the bottom by the corpus callosum. The corpus callosum connects
the two halves of the brain and delivers messages from one half of the brain to
the other. The surface of the cerebrum contains billions of neurons and glia that
together form the cerebral cortex

C Cerebellum - located under the cerebrum. Its function is to coordinate muscle

movements, maintain posture, and balance. The cerebellum fine tunes motor
activity or movement, e.g. the fine movements of fingers as they perform surgery

or paint a picture. It helps one maintain posture, sense of balance or equilibrium,

by controlling the tone of muscles and the position of limbs. The cerebellum is
important in one's ability to perform rapid and repetitive actions such as playing a
video game. It performs higher functions like interpreting touch, vision and
hearing, as well as speech, reasoning, emotions, learning, and fine control of
movement.

The cerebral cortex appears grayish brown in color and is called the "gray matter."
The surface of the brain appears wrinkled. The cerebral cortex has sulci (small
grooves), fissures (larger grooves) and bulges between the grooves called gyri.
Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons
form a white-colored area called the "white matter."

The cerebral hemispheres have several distinct fissures. By locating these landmarks
on the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are
simply broad regions of the brain. The cerebrum or brain can be divided into pairs of
frontal, temporal, parietal and occipital lobes. Each hemisphere has a frontal,
temporal, parietal and occipital lobe. Each lobe may be divided, once again, into areas
that serve very specific functions. The lobes of the brain do not function alone they
function through very complex relationships with one another.

Lobes of the brain

Frontal lobe

Personality, behavior, emotions

Judgment, planning, problem solving

Speech: speaking and writing (Brocas area)

Body movement (motor strip)

Intelligence, concentration, self-awareness

Parietal lobe

Interprets language, words

Sense of touch, pain, temperature (sensory strip)

Interprets signals from vision, hearing, motor, sensory and memory

Spatial and visual perception

Occipital lobe

Interprets vision (color, light, movement)

Temporal lobe

Understanding language (Wernickes area)

Memory

Hearing

Sequencing and organization

Messages within the brain are delivered in many ways. The signals are transported
along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the
communication between different parts of the brain. The result will be a loss of function
such as speech, the ability to read, or the ability to follow simple spoken commands.
Messages can travel from one bulge on the brain to another (gyri to gyri), from one lobe
to another, from one side of the brain to the other, from one lobe of the brain to
structures that are found deep in the brain, e.g. thalamus, or from the deep structures of
the brain to another region in the central nervous system.
Deep structures

Hypothalamus - The hypothalamus is located in the floor of the third ventricle and is
the master control of the autonomic system. It plays a role in controlling behaviors such
as hunger, thirst, sleep, and sexual response. It also regulates body temperature, blood
pressure, emotions, and secretion of hormones.

Thalamus - The thalamus serves as a relay station for almost all information that
comes and goes to the cortex. It plays a role in pain sensation, attention, alertness and
memory.
Basal ganglia - The basal ganglia include the caudate, putamen and globus pallidus.
These nuclei work with the cerebellum to coordinate fine motions, such as fingertip
movements.
Limbic system - The limbic system is the center of our emotions, learning, and
memory. Included in this system are the cingulate gyri, hypothalamus, amygdala
(emotional reactions) and hippocampus (memory).
Cranial nerves
The brain communicates with the body through the spinal cord and twelve pairs
of cranial nerves ten of the twelve pairs of cranial nerves that control hearing, eye
movement, facial sensations, taste, swallowing and movement of the face, neck,
shoulder and tongue muscles originate in the brainstem. The cranial nerves for smell
and vision originate in the cerebrum.
Number

Name

Function

Olfactory

Smell

II

Optic

sight

III

Oculomotor

moves eye, pupil

IV

Trochlear

moves eye

Trigeminal

face sensation

VI

Abducens

moves eye

VII

Facial

moves face, salivate

VIII

Vestibulocochlear

hearing, balance

IX

Glossopharyngeal

taste, swallow

Vagus

heart rate, digestion

XI

Accessory

moves head

XII

Hypoglossal

moves tongue

Blood supply

Blood is carried to the brain by two paired arteries, the internal carotid arteries
and the vertebral arteries. The internal carotid arteries supply most of the cerebrum. The
vertebral arteries supply the cerebellum, brainstem, and the underside of the cerebrum.
After passing through the skull, the two vertebral arteries join together to form a single
basilar artery. The basilar artery and the internal carotid arteries communicate with
each other at the base of the brain called the Circle of Willis. The communication

between the internal carotid and vertebral-basilar systems is an important safety feature
of the brain. If one of the major vessels becomes blocked, it is possible for collateral
blood flow to come across the Circle of Willis and prevent brain damage.
The Circle of Willis
The Circle of Willis or the Circulus Arteriosus is an arterial polygon where the
blood carried by the two internal carotid arteries and the basilar system comes together
and then is redistributed by the anterior, middle, and posterior cerebral arteries. The
posterior cerebral artery is connected to the internal carotid artery by the posterior
communicating artery.
Internal Carotid System
The internal carotid artery divides into two main branches called the middle
cerebral artery and the anterior cerebral artery. The middle cerebral artery supplies
blood to the frontoparietal somatosensory cortex. The anterior cerebral artery supplies
blood to the frontal lobes and medial aspects of the parietal and occipital lobes. Before
this divide, the internal carotid artery gives rise to the anterior communicating artery and
the posterior communicating artery.
Vertebral Artery
The two vertebral arteries run along the medulla and fuse at the pontomedullary
junction to form the midline basilar artery, also called the vertebro-basilar artery. Before
forming the basilar artery, each vertebral artery gives rise to the posterior spinal artery,
the anterior spinal artery, the posterior inferior cerebellar artery (PICA) and branches to
the medulla.
Basilar Artery
At the ponto-midbrain junction, the basilar artery divides into the two posterior cerebral
arteries. Before this divide, it gives rise to numerous paramedian, short and long

circumferential penetrators and two other branches known as the anterior inferior
cerebellar artery and the superior cerebellar artery.

MEDICAL-SURGICAL INTERVENTIONS
Anticoagulants
Whether anticoagulation therapy should be given to a patient with completed infarction
has not been resolved after 25 years of discussion. If it is used, should treatment affect
the platelet phase of the coagulative process, in the "cascade" proper, or in the
thrombolytic phase? "Full anticoagulation" is desirable and is initiated with heparin and
followed by maintenance coumarin drugs.
Platelet Antiaggregants
During hemostasis, platelets undergo adhesion, release reaction, aggregation, and
consolidation. Drugs affect different steps in this sequence, but most of the "antiplatelet"
agents employed interfere with adhesion or aggregation. Antiaggregant effects have
been demonstrated for non-steroidal anti-inflammatory agents (aspirin, phenoprofen,
phenylbutazone, sudoxicam, sulfinpyrazone) and for the pyrimidopyrimidine compounds
(dipyridamole, papaverine, pyridinolcarbamate); similar actions have been reported for
numerous other compounds (antihistamines, barbiturates, clofibrate, cyproheptadine,
halofenate, propranolol, prostaglandin PGE, tricyclic antidepressants, and antipsychotic
drugs).7
Thrombolytic therapy
Vasodilators
Patients Medications:

Aspilet 80mg
Atorvastatin 40mg - 10 mg
Perindopril 5mg tab if BP 180mmHg
Lactulose (Lilac) 20cc

Citicholine 1gm IV
Ampicillin 750mg IV

Possible surgery:
Surgery may be performed to prevent the occurrence of a stroke, to restore blood flow
when a stroke has already occurred or to repair vascular damage or malformations.
-

Carotid angioplasty for cerebral stenosis

Extracranial-intracranial bypass reestablishes blood flow to the affected area of

the brain
Endarterectomy to remove atherosclerotic plaque

DISCHARGE PLAN
MEDICATIONS
Name
ASA
Atorvastatin
Citicoline

Dosage
80mg
10mg
1gm

Frequency/Time
Once a day @ 1pm
Once a day/HS @ 8pm
2x a day @ 8am 6pm for 6

Perindopril
Ampicillin Sulbactam

5mg tab
750mg

weeks
Once a day for BP >160/90
2x a day 8am 6pm for 7

30cc

days
Once a day/HS PRN for

Lactulose

constipation (hold for BM

2x day)
Strictly adhere to medication regimen especially to prescribed medications

EXERCISE

Have frequent short periods of exercise

Safely engage in active and passive range of motion exercises on the affected

extremity
Speech therapy to help the patient improve swallowing as well as how to relearn

language and communication skills

Occupational therapy provides assistive devices and a plan for regaining lost
motor skills that greatly improve quality of life after a stroke

TREATMENT

Encourage to have enough rest and comply to the physician whenever health

problems occur
Consult with speech therapist to improve ability to communicate.
Make sure that follow-up care is adhered to religiously.

HEALTH TEACHINGS

Given positive reinforcement and emotional support from his family.

Be informed about the expected outcome of stroke, and his family should be
counseled to avoid doing things for him that he can do.

Have at least one family member who will be taught how to take blood pressure
to enable the family to monitor the patients blood pressure at home.

OUT PATIENT/REFERRALS

Instruct patient to come back for follow up check up on the date ordered
report, with the help of his family, exacerbation of present signs and symptoms
and seek prompt medical attention when deterioration of neurological status is
apparent such as loss of consciousness

DIET

Adhere to a low-sodium, low-fat diet such as avoidance of canned and processed

foods
Advise to eat nutritional foods like fruits and vegetables
Eat well balanced diet
Instruct to limit eating foods high in fats and with cholesterol

SPIRITUAL

Advise patient not to be discouraged and to have strong faith in Allah

REFERENCES
BOOKS
Medical-Surgical Nursing LeMone 5th edition
Straight As in Pathophysiology Lippincott Williams & Wilkins

INTERNET
http://www.healthhype.com/medical-terminology-ischemia-and-infarct.html
http://stroke.ahajournals.org/content/12/1/7.full.pdf
scribd.com