Exam 3 Flashcards
two types of strokes:
two types of strokes:
Ischemic: inadequate blood flow to part of the brain
Hemorrhagic: bleeding into the brain that results in death of brain cells
Subarachnoid hemorrhage :
Subarachnoid hemorrhage : hemorrhage into the subarachnoid space *headache, sudden, usually head trauma incident
Impairments seen after a stroke depend on which part of the brain is either deprived of oxygen or damaged due to bleeding;
can affect things like movement, sensation, thinking, talking or emotions.
Brain requires continuous supply of blood to provide oxygen and glucose to neurons
Severity of the loss depends on location and extent of damage
Normally our brains can tolerate a bit of fluctuation in Blood pressure because of cerebral autoregulation(vessels change diameter & regulate blood flow), if the brain tissue is deprived of oxygen…autoregulation is impaired = brain is dependent on systemic blood pressure regulation mechanisms
A patient is admitted with uncontrolled atrial fibrillation. What type of stroke is this patient at MOST risk for? A. Ischemic Thrombotic Stroke B. Ischemic Embolic Stroke C. Hemorrhagic - intracerebral D. Hemorrhagic - subarachnoid
If the patient is in uncontrolled A-fib, they are at risk for clot formation within the heart chambers. Clot then leaves the heart and travels to the brain. * thrombotic forms IN the BRAIN
Add patho behind what is seen
Common long-term disabilities :
- hemiparesis (partial paralysis on one side)
- inability to walk
- stroke is a lifelong change for patients and families
Right – Sided Brain Damage
Clinical Manifestations Left sided hemiplegia and/or neglect Spatial- perceptual deficits Tends to deny or minimize problems Rapid performance, short attention span Impulsive; safety problems Impaired judgment Impaired time concepts
Left – Sided Brain Damage
Clinical Manifestations Right sided hemiplegia and/or neglect Impaired speech-language (aphasias) Impaired right-left discrimination Slow performance, cautious Aware of deficits, depression, anxiety Impaired comprehension related to language, math Visual field deficits
A patient has right sided brain damage from a stroke. Select all the signs and symptoms that occur with this type of stroke: A. right sided hemiplegia B. confusion on date, time, and place C. aphasia D. unilateral neglect E. aware of limitations F. impulsive G. short attention span
confusion on date, time, and place
unilateral neglect
impulsive
short attention span
Stroke can occur at any age-
34% or strokes occur in people younger than 65 years
Hispanics, Native Americans and Asian Americans –
higher incidence than whites
Hispanics – more prone to diabetes = big risk factor for stroke (overtime, high BG levels damage vessels & buildup of clots or fat deposits)
Why for each? Add from book
Modifiable Risk Factors
Hypertension – single most important modifiable risk factor- goal is systolic less than 140
Heart Disease – afib, myocardial infarctions, cardiomyopathy or valve abnormalities or congenital defects - potential for clots or decreased perfusion to brain
Alcohol- Women >1 , Men >2
Drugs – cocaine especially – weakens vessels
Obesity- associated with hypertension, high BG, high cholesterol … huge risk
Estrogens- acts on vascular endothelium and smooth muscle – potential for clots is higher *especially when combined with smoking
Others: metabolic syndrome (combo of central obesity, high BP, high chol., etc), sleep apnea.
Why for each?
Transient Ischemic Attack (TIA)
TIA or Mini-stroke
A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain.
Why does this happen?
Risk Factors:
Clinical symptoms typically last less than 1 hour
Always counsel patients to seek treatment if any stroke like symptoms arise- there is no way to know if they are TIA symptoms that will resolve or if they are stroke symptoms; monitor
1/3 of patients will not have another TIA, 1/3 will have another, the other 1/3 will progress to a stroke
* warning sign of progressive cerebrovascular disease
s/s depend on placement of “microembolism”- eg. If carotid, blindness
You’re educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition:
A. TIAs are caused by a temporary decrease in blood flow to the brain
B. TIAs produce signs and symptoms that can last for several weeks to months.
C. A TIA is a warning sign that an impending stroke may occur.
D. TIAs don’t require medical treatment.
Signs can last a few minutes up to hours and then resolve
Need medical treatment and monitoring
-TIA can develop into a more severe condition
Diagnostic
Diagnostics done to confirm that it is truly a stroke not another brain lesion
Why?
CT/MRI – distinguishes between ischemic and hemorrhagic, size and location
- may use multiple scans to evaluate treatments given *MRI better but CT is faster
ECG & Chest x-ray: many strokes are caused by blood clots from the heart – look for abnormalities that may be the cause (rhythm and structure)
Angiography – looks at blood flow and health of the vessels
*risk of dislodging the clot – also many need contrast – risk of allergic reaction Ultrasounds- less invasive Lumbar puncture- cerebrospinal fluid – RBC’s If yes = SAH likely Labs- looking for common conditions that contribute to stroke (oxygen deprivation from a heart abnormality, viscosity of the blood, heart rhythm changes, electrolyte changes (increased ADH may decrease urine output, fluid is retained and serum sodium decreases) Cardiac Markers – Troponin- CK-MB- Echo- transthoracic, transesophageal CBC- Coagulation: PT- activated partial thromboplastin time- Electrolytes- Blood glucose- renal and hepatic studies- lipid profile- cerebrospinal fluid analysis-
Acute Care for Ischemic Stroke?
EMS Assessment: Cincinnati Prehospital Stroke Scale; facial droop, arm drift, speech or
FAST (stroke.org);
ASK ONSET OF SYMPTOMS <3 HOURS – TPA MAY BE AN OPTION!!!
Hospital Stroke Capabilities: Can they give IV alteplase? Can they preform thrombectomy? *should transport to accredited facility w/stroke team
Does the hospital participate in data repositories?
Said to improve patient outcomes after acute strokes; promotes consistent adherence to current guidelines for stroke care
tPA (tissue plasminogen activator) – clot busting drug (works by binding to the fibrin in the clot; plasminogen changes to plasmin which digests the fibrin & breaks down the clot)** must be 0-4.5 hrs from symptom onset; some contraindications; given via IV
Thrombolysis- like a heart cath- tPA is administered directly into the clot blocking blood flow to the brain; must meet strict criteria for this option; done within 6 hrs of onset of symptoms
Thrombectomy- uses a device to retrieve the clot; can be done up to 8 hours from symptom onset; can be done if patient fails tPA or is ineligible
Telemedicine:
When should we give tPA?
Diagnosis of Ischemic Stroke causing neuro deficits
< 4.5 hours from onset of symptoms (<3hrs in most facilities – FDA approved)
*if it is 3-4.5hrs …
When should we not give tPA?
No if… >80 yrs old, NIHSS>25, hx of DM or stroke, taking anticoagulants
+ intracranial hemorrhage
+ subarachnoid hemorrhage
Active internal bleeding
Recent (w/in 3 months) head trauma or potential for head bleed
Bleeding diathesis
Current severe uncontrolled hypertension >185/110
