Cerebrovascular Accident (CVA = Stroke)

Question 1

Incidence and prevalence

Answer 1

• 2nd most leading common cause of death in the world
  
  • heart disease is the first
• 5th in the US
• leading cause of disability among older adults
• book states:
  
  • 795,000 strokes a year
  • someone in the U.S. experience a stroke in every 40 seconds
  • someone in the U.S. dies of a stroke in every 4 minutes

Question 2

Description and definitions

Answer 2

• results from an interruption in the blood flow to the brain from a blocked or ruptured blood vessel
• the inadequate supply of oxygen and nutrients to the brain leads to brain damage
• can occur in the brain, cerebral hemispheres, cerebellum, or brain stem
• the functional loss depends on the site and the severity and extension of the stroke
• CVAs are divided into 2 main categories:
  
  • ischemic = a clot
  • hemorrhagic = an opening in the artery

Question 3

Transient ischemic attacks (TIA)

Answer 3

• also known as “mini strokes”
• occur when the blood supply to your brain is briefly blocked by a clot or narrowed artery
  
  • narrowed arteries are usually caused by plaque = a buildup of fat, cholesterol, calcium, and other substances
• the symptoms of a TIA are the same as in a stroke, the difference is that in a TIA, the blockage is temporary and the blood flow returns on its own
• since blood flow is interrupted only for a short time, symptoms of a TIA usually go away within an hour
• because the symptoms go away, many people ignore them = BIG MISTAKE because they can be a red flag warning you that a major stroke could happen and often within the next 48 hours

Question 4

CVA (characteristics from the table)

Answer 4

• cerebrovascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that can cause permanent damage
• duration of symptoms = permanent
• severity of symptoms = can be severe
• risk of recurrence = high
• prognosis = can be poor

Question 5

TIA (characteristics from the table)

Answer 5

• transient ischemic attack (TIA) is also known as a mini stroke, a temporary interruption of blood flow to the brain that causes stroke-like symptoms, but the symptoms typically lasts only few minutes or hours (TIAs are a warning sign of a more serious stroke)
• duration of symptoms = minutes to hours
• severity of symptoms = mild to moderate
• risk of recurrence = high
• prognosis = usually good

Question 6

Classification of CVA

Answer 6

• stroke = ischemic (85%) and hemorrhagic (15%)
• ischemic = thrombotic and embolic (MC)
• hemorrhagic = intracerebral hemorrhage and subarachnoid hemorrhage

Question 7

Thrombosis ischemic CVA

Answer 7

• blood clot forms within one of the arteries of the brain, causing obstruction where it is formed
• typically these arteries have already been damaged by atherosclerosis
• most common cause of CVA
• symptoms = stuttering, progressive symptoms over several hours or days, onset during sleep is common, and TIAs prior to an actual stroke

Question 8

Atherosclerosis

Answer 8

• rough irregular fatty deposits from in the arteries
• clots occur when 66% of the vessel is blocked

Question 9

Lacunar strokes

Answer 9

• small infarcts (clots) located usually in the deep brain structures such as basal ganglia, thalamus, pons, internal capsule, and deep white matter
• 20-25% of ischemic strokes
• the strokes are very small
• minimal neurological symptoms are often present and may go undetected

Question 10

Embolism

Answer 10

• occurs when a clot that has formed elsewhere (thrombus) breaks off (embolus), and travels to the brain, reaches an artery too small to pass through and blocks that artery
• effects are like a thrombosis, just in a different origin
• typically occur during daytime activities
• can be precipitated by sudden movements which raised blood pressure and dislodges a clot
• symptoms maximal at onset but they can break through, move and then get stuck again
• no real history of TIA

Question 11

Hemorrhagic CVA

Answer 11

• 15-20% of CVAs
• caused by a rupture in a blood vessel with resultant bleeding into or around the cerebral tissue
• can also be caused by an aneurysm
• intracerebral (ICH)
• subarachnoid (SAH)

Question 12

Aneurysm

Answer 12

• an artery in a weak area that fills with blood in or around the brain bulges

Question 13

Intracerebral hemorrhage (ICH)

Answer 13

• bleeding into the brain substance
• higher percentage of death than ischemic stroke
• disruption of brain function of that region
• blood irritates the brain causing swelling
• blood forms a mass called hematoma
• increased pressure destroys these areas
• oxygen deprivation
• when the bleeding stops, a clot will form = may recede, break down, and be reabsorbed

Question 14

Subarachnoid hemorrhage (SAH)

Answer 14

• bleeding within the brains surround membranes and cerebrospinal fluid (CSF)
• 2-5% of all CVAs
• 85% of these SAH are caused by leakage of blood for an aneurysm
• “worst headache ever”

Question 15

Modifiable risk factors

Answer 15

• high blood pressure (HTN) = “silent disease”
  
  • most significant controllable risk factor
  • the higher the pressure, the faster the blood flows through the system and wears down the arterial walls, making them thinner
  • 110/70 = normal blood pressure (used to be 120/80)
• atherosclerosis
• lack of physical activity
• waist-to-hip ratio = increased abdominal adiposity
• apolipoprotein
• smoking = causes one of every 3 deaths
• cardiac causes
• alcohol consumption
• high blood sugar levels (diabetes)
• psychosocial factors

Question 16

Atherosclerosis

Answer 16

• thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery

Question 17

Apolipoprotein

Answer 17

• buildup of high amounts of certain fats and cholesterol in the blood

Question 18

Non-modifiable risk factors

Answer 18

• ethnicity/race = Mexican Americans and African Americans are more prone to strokes
• age = single most important risk (risk doubles every decade of life after age 55)
• genetics/heredity play a factor

Question 19

Pediatric stroke

Answer 19

• effects one in every 4,000 newborns
• effects 2,000 children each year
• among one of the 10 causes of death in children
• ischemic CVA = 10.5% mortality rate
• hemorrhagic CVA = 26.1% mortality rate
  typically a congenital issue with the blood vessel in the brain that caused the stroke

Question 20

Signs and symptoms

Answer 20

• even in individuals with the same neurological deficits, the impact of disability is different, depending on the individual’s life situation

Question 21

Know the signs of a stroke

Answer 21

• when it comes to stroke care, time is of the essence
• BE FAST
• balance = sudden loss of balance
• eyes = sudden loss of vision in one or both eyes
• face = uneven face (facial droop) or uneven smile
• arm - sudden arm weakness
• speech = sudden slurred speech or trouble speaking, confusion
• time = time is critical (call 911 immediately)

Question 22

Right-sided cerebral injury (middle cerebral artery)

Answer 22

• MCA = an artery that runs down in the middle of the brain, almost right above the ear (hits the temporal and parietal lobes)
• MCAs = most common
• hemiplegia/hemiparesis on left side of face, trunk, and extremities = loss of voluntary movement and coordination on left side
• hemianesthesia left side = impaired sensation, temp, pain, and proprioception on left side
• spatial and perceptual deficits
• unilateral inattention (neglect) = patient neglects the left side of the body and/or the left side of the environment
• apraxia:
  
  • ideomotor apraxia = inability to perform motor tasks, even though the patient understands the concept
  • ideational apraxia = patients have trouble understanding the purpose of a task
• homonymous hemianopsia on left side
• IMPULSIVE, quick and imprecise movements, errors of judgement
• visual neglect
• dressing apraxia

Question 23

Left-sided cerebral injury (middle cerebral artery)

Answer 23

• hemiplegia/hemiparesis on right side of face, trunk, and extremities = loss of voluntary movement and coordination on right side
• hemianesthesia right side = impaired sensation, temp, pain, and proprioception on right side
• aphasia = inability to speak or understand speech, writing or gestures
• dysarthria = problems with articulation of speech, disturbance in muscle control of lips, mouth, tongue, and vocal cords
• homonymous hemianopsia on right
• memory deficits for recent and past events

Question 24

Apraxia

Answer 24

• on right side injury of the brain
• doesn’t have the motor connection to speak

Question 25

Aphasia

Answer 25

- on left side injury of the brain - cannot understand

Question 26

Posterior (vertebrobasilar) cerebral artery stroke (PCA)

Answer 26

- visual disturbances including impaired coordination of the eyes - impaired temp sensation or localized numbness - impaired ability to read and/or name objects - vertigo - ataxia - paralysis of the face, limbs, or tongue - clumsy movement of the hands - dysmetria - dysphagia - loss of memory

Question 27

Lateral medullary syndrome

Answer 27

- Wallenberg syndrome - brainstem stroke - vertebral or cerebella’s artery occlusion - contra lateral pain and temp loss - ipsilateral horner syndrome - ataxia - facial sensory loss - palatal paralysis, hoarseness, dysphagia, vertigo - often results in coma, damage to central involved with alertness and wakefulness - hemorrhage is usually fatal - if survived it, recovery is good

Question 28

Anterior cerebral artery (ACA)

Answer 28

- rare CVA - contralateral paralysis of lower extremities, more so than upper extremities - loss of sensation in contralateral toes - loss of control of bowel and bladder movement - balance problems in standing, sitting, and walking - lack of spontaneity of emotion, whispered speech, loss of all communication - memory impairment

Question 29

Secondary complications of a stroke

Answer 29

- brain edema - seizures - aspiration pneumonia = impaired swallowing ability - pneumonia - UTI - bedsores - clinical depression - DVT = deep vein thrombosis

Question 30

How to get diagnosed with a stroke

Answer 30

- CT = hemorrhagic vs ischemic - MRI = can provide more info about affected parts and if new or chronic CVA - Dopplar = determines the lesion size

Question 31

Interventions for thrombotic stroke

Answer 31

- blood thinners (medication to reduce clots) - tPA (medicine) can be administered within 3 hours of symptoms to dissolve the clot - catheter to remove clot (through the groin)

Question 32

Interventions for aneurysm

Answer 32

- microsurgical clipping - endovascular coiling

Question 33

ADLs implications from a stroke

Answer 33

- dysfunction of motor systems - decreased sense of touch, temperature, proprioception, and pain - decreased stereognosis - difficulty completing 2 handed tasks - ex: tying shoes and washing hands - decreased balance

Question 34

Stereognosis

Answer 34

- ability to identify items based on feel

Question 35

IADLs implications from a stroke

Answer 35

- difficulty meal preparation - difficulty taking care of pets - impact on visual field - impact on language - impact on functional cognition

Question 36

Occupational implications

Answer 36

- “new normal” - new routines - takes longer to do things - issues with rest and sleep = insomnia - change in roles - 30-50% will develop a psychological or emotional disorder - may need a caregiver - difficulty with play and leisure - decreased social participation