- Approximately 87% - Vascular occlusion (blockage in the blood vessels) and significant hypoperfusion (reduced amount of blood flow) occur

- Approximately 13% - There is extravasation (leakage) of blood into the brain or subarachnoid space

CHAPTER 15: MANAGEMENT OF PATIENTS WITH CEREBROVASCULAR DISORDERS Flashcards by Raquel Hatulan

an umbrella term that refers to a
functional abnormality of the central nervous system (CNS) that
occurs when the blood supply to the brain is disrupted.

Cerebrovascular disorders

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2 Major Categories of Stroke

Ischemic & Hemorrhagic

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Ischemic Stroke

Approximately 87%
Vascular occlusion (blockage in the blood vessels) and significant hypoperfusion (reduced amount of blood flow) occur

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Hemorrhagic Stroke

Approximately 13%
There is extravasation (leakage) of blood into the brain or subarachnoid space

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The causes of ischemic stroke

Large artery thrombosis
Small penetrating artery thrombosis
Cardiogenic embolic
Cryptogenic (no known cause)
Others

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The causes of hemorrhagic stroke

Intracerebral hemorrhage
Subarachnoid hemorrhage
Cerebral aneurysm
Arteriovenous malformation

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Main presenting symptom of ischemic stroke

Numbness or weakness of the face, arm, or leg, especially on one side of the body

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Main presenting symptom of hemorrhagic stroke

Exploding headache
Decreased level of consciousness

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Functional recovery of ischemic stroke

Usually plateaus at 6 months

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Functional recovery of hemorrhagic stroke

Slower, usually plateaus at about 18 months

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It is also known as cerebrovascular accident (CVA) or “brain attack”

Ischemic Stroke

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It is an ischemic stroke that are caused by atherosclerotic plaques in
the large blood vessels of the brain.

Large artery thrombotic strokes

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What results to ischemia and infarction (death of tissue resulting from a failure of blood supply)?

Thrombus (blood clot) formation and occlusion (blockage) at the site of the atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery.)

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There is disruption of the cerebral blood flow due to obstruction of a blood vessel.

Ischemic Brain Attack

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Clinical Manifestations of Ischemic Brain Attack

Numbness or weakness of the face, arm, or leg, especially on one side of the body
Confusion or change in mental status
Trouble speaking or understanding speech
Visual disturbances
Difficulty walking, dizziness, or loss of balance or coordination
Sudden severe headache

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VISUAL FIELD DEFICIT: Homonymous Hemianopsia (loss of half of the visual field)

Unaware of persons or objects on side of visual loss
Neglect of one side of the body
Difficulty judging distances

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VISUAL FIELD DEFICIT: Loss of peripheral vision

Difficulty seeing at night
Unaware of objects or the borders of objects

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VISUAL FIELD DEFICIT: Diplopia

Double Vision

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MOTOR DEFICITS: Hemiparesis

Weakness of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere)

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MOTOR DEFICITS: Hemiplegia

Paralysis of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere)

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MOTOR DEFICITS: Ataxia

Staggering, unsteady gait
Unable to keep feet together; need a broad base to stand

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MOTOR DEFICITS: Dysarthria

Difficulty in forming words

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MOTOR DEFICITS: Dysphagia

Difficulty in swallowing

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SENSORY DEFICIT: Paresthesia (occurs on the side opposite the lesion)

Sensation of numbness, tingling, or a “pins and needles” sensation
Difficulty with proprioception

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VERBAL DEFICIT: Expressive Aphasia

Unable to form words that are understandable; may be able to speak in single-word responses

VERBAL DEFICIT: Receptive Aphasia

Unable to comprehend the spoken word; can speak but may not make sense

VERBAL DEFICIT: Global (mixed) aphasia

Combination of both receptive and expression

Cognitive Deficits of Stroke

Short- and long-term memory loss Decreased attention span Impaired ability to concentrate Poor abstract reasoning Altered judgment

Emotional Deficits of Stroke

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 the body Right visual field deficit Aphasia (expressive, receptive, or global) Altered intellectual ability Slow, cautious behavior

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

What is the most common motor dysfunction in stroke?

Hemiplegia (paralysis of one side of the body, or part of it) - caused by a lesion of the opposite side of the brain.

What is the most common effect of stroke in terms of communication loss?

Aphasia (inability to express oneself or to understand language).

It is caused by paralysis of the muscles responsible for producing speech.

Dysarthria (difficulty in speaking)

It can be expressive aphasia (inability to express oneself), receptive aphasia (inability to understand language), or global (mixed) aphasia.

Dysphasia (impaired speech)

It may be seen when a patient makes verbal substitutions for desired syllables or words

Apraxia (inability to perform a previously learned action)

It may occur from stroke and may be temporary or permanent.

Homonymous hemianopsia (blindness in half of the visual field)

are deficits in the ability to recognize previously familiar objects perceived by one or more of the senses.

Agnosias

Damage in this lobe may impair learning capacity, memory, or other higher cortical intellectual functions

Frontal Lobe

What is the initial diagnostic test for a stroke patient?

a non-contrast computed tomography (CT) scan

Other diagnostic tests for stroke

CT angiography or CT perfusion magnetic resonance imaging (MRI) magnetic resonance angiography of the brain and neck vessels

MEDICAL MANAGEMENT: For atrial fibrillation (or cardioembolic strokes)

Dose-adjusted WARFARIN (Coumadin)

MEDICAL MANAGEMENT: Anticoagulants that may be prescribed as alternative drugs

Dabigatran (Pradaxa) Rivaroxaban (Xarelto)

MEDICAL MANAGEMENT: Platelet-inhibiting medications

Aspirin Extended-release dipyridamole plus aspirn (Aggrenox) Clopidogrel (Plavix)

The main surgical procedure for selected patients with TIAs and mild stroke

CAROTID ENDARTERECTOMY (which currently is the most frequently performed noncardiac vascular procedure)

the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries

CAROTID ENDARTERECTOMY

How many days does an acute ischemic stroke last?

1 to 3 days

The patient who has had a stroke is at risk for multiple complications including:

deconditioning and other musculoskeletal problems swallowing difficulties bowel and bladder dysfunction inability to perform self-care skin breakdown

It accounts for 15% to 20% of cerebrovascular disorders and are primarily caused by intracranial or subarachnoid hemorrhage.

Hemorrhagic Stroke

Caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space.

Hemorrhagic Stroke

The most common in patients with hypertension and cerebral atherosclerosis, because degenerative changes from these diseases cause rupture of the blood vessel.

Intracerebral Hemorrhage (bleeding into the brain tissue)

a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall

Intracranial (cerebral) aneurysm

caused by an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed. The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture

Arteriovenous Malformations

It may occur as a result of an AVM, intracranial aneurysm, trauma, or hypertension.

Subarachnoid Hemorrhage (hemorrhage into the subarachnoid space)

What does a conscious patient with hemorrhagic stroke commonly report?

Severe headache

Other symptoms that may be observed more frequently in patients with acute intracerebral hemorrhage (compared with ischemic stroke)

vomiting early sudden change in level of consciousness possibly focal seizures due to frequent brain stem involvement

Other symptoms that may be observed more frequently in patients with acute intracerebral hemorrhage (compared with ischemic stroke)

vomiting early sudden change in level of consciousness possibly focal seizures due to frequent brain stem involvement

Assessment and Diagnostic Findings for Hemorrhagic Stroke

CT scan MRI Cerebral angiography Lumbar puncture is performed if there is no evidence of increased ICP

Complications of Hemorrhagic Stroke

Cerebral Hypoxia and Decreased Blood Flow - Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Vasospasm - The development of cerebral vasospasm (narrowing of the lumen of the involved cranial blood vessel) is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial subarachnoid hemorrhage. Increased Intracranial Pressure - An increase in ICP can occur after either an ischemic or a hemorrhagic stroke but almost always follows a subarachnoid hemorrhage, usually because of disturbed circulation of CSF caused by blood in the basal cisterns. Hypertension - Hypertension is the most common cause of intracerebral hemorrhage, and its treatment is critical.

MEDICAL MANAGEMENT: The goals of medical treatment for hemorrhagic stroke

- To allow the brain to recover from the initial insult (bleeding) - To prevent or minimize the risk of rebleeding - To prevent or treat complications

MEDICAL MANAGEMENT: What to do if bleeding is caused by anticoagulation with warfarin?

Fresh-frozen plasma and Vitamin K

MEDICAL MANAGEMENT: When seizure occurs in hemorrhagic strokes

Treat with antiseizure drugs such phenytoin (Dilantin)