STROKE Flashcards
risk factors of a stroke for barry and in general
In general:
modifiable
- excessive alcohol consumption
- certain drugs
- high blood pressure
- high cholesterol
- obesity
- smoking
- diabetes
- atherosclerosis
non-modifiable
- arterial abnormalities
- ethnic origin
- family history of stroke
- male sex
- previous stroke
- patent foramen ovale
- certain blood disorders
- atrial fibrillation
- TIA- transient ischemic attack: temporary decrease in blood flow with subsequent recovery (within 24 hours)- big warning sign
For Barry:
- advanced age
- hypertension
- type 2 diabetes
- previous stroke
- male sex
signs and symptoms of a stroke for barry and in general
For Barry;
- difficulty walking/ moving around or uncoordinated movement (bumping into things)
- difficulty hearing
- collapse
- slurred speech
- facial droop
- difficulty moving his arm
In general: symptoms are likely to occur in combination
- numbness of face, arm or leg
- difficulty seeing with one or both eyes
- difficulty with walking
- dizziness, imbalance, or uncoordinated movement
- facial droop or uneven appearance to the face
- uneven muscle strength in limbs
F.A.S.T acronym is used to identify symptoms of stroke in a timely manner
F- Face- is it drooping, does the face or eye look crooked
A- Arms- do they have difficulty lifting one of both arms, do one or both arms drift
S- Speech- are words slurred, do they have difficulty speaking, do they have a problem understanding you
T- Time- establish the time at which the patient was last without stroke symptoms
pathophysiology of a stroke- brain injury lesson
There are two main types of stroke: Ischemic (what Barry had) and hemorrhagic stroke
Ischemic: Barry’s type
A blockage in the blood vessel (atherosclerotic plaque formed somewhere else and a piece of that comes off to form an emboli and gets stuck in the artery) so there is a lack of blood flow to the neurons in that area of the brain
Atherosclerosis is the thickening/ hardening of arterial walls due to plaque formation. When it ruptures, a thrombus forms which further restricts the artery. It is the most common cause for either of these;
Thrombotic: insitu thrombus
Embolic: dislodged/ broken piece of thrombus from elsewhere
lacunar infarcts: small thrombi in small cerebral vessels causing small infarcts (tissue death) in various regions
- blockage of cerebral vessels leads to ischemia which means a decrease in oxygen and glucose which leads to neuronal starvation and hypoxia and eventually neuronal death with inflammation and oedema in surrounding area. When neurons die you lose function in whatever pathway those neurons are involved in (motor, sensory, higher cognitive)
Barry experienced an ischemic stroke, caused by a shower of emboli obstructing blood supply to different regions of the brain. His left middle and left posterior cerebral artery and the posterior inferior cerebellar arteries were involved. This resulted in infarction occurring within portions of the left temporal and occipital lobes and the cerebellum and brainstem with involvement of the right cranial nerves 5, 6 and 7 and cranial nerve 10. This impacted on Barrys sensation and movement of muscles, his eye and eyelid movement, his facial expression and taste on front 2/3 of the tongue and movement of throat muscles and vocalisation, motor output to heart, lungs and abdominal organs and pain sensation associated with viscera.
Hemorrhagic:
Damage to the blood vessel wall (bursting, aneurysm) so blood spills through the surrounding damaged tissue and not enough blood is getting to the neurons in that part of the brain. There are two types
1.intracerebral: due to hypertension or aneurysm (blood vessel wall swells)
2. subarachnoid: due to injury
- blood loss leads to damages surrounding tissues (irritates neurons) and ischemia beyond vessel damage point. Both of these lead to neuronal death
complications of a stroke
They are highly varied, depending on the regions of the brain impacted. Some of the complications are;
- speech disorders
- occur in relation to problems with language planning, processing or motor control of speech
- aphasia can occurs which can be expressive (inability to put words together) or receptive (inability to understand the spoken word)
- apraxia which is the inability to properly plan and sequence the movements required for speech
- dysarthria is the disturbance of the muscular control of speech- Barry experienced this - Dysphagia
- the difficulty to swallow which can mean abnormal eating behaviour, difficulty chewing, coughing or choking, wet gurgling voice. Barry experienced dysphagia - Hemiparesis
- a weakness of an inability to move one side of the body. this affects everyday activities such as eating, dressing, using the bathroom and grabbing objects. Barry has right side hemiparesis due to infarction in his left cerebral hemisphere, cerebellum, brainstem and the affected cranial nerves involved in facial movement - visual disturbances
- vision loss- blind spots in the field of vision
- vision preceptrion problems- damage to the brainstem or cerebellum makes it difficult to process what the eye sees, to coordinate movement, to focus and to blink
- Barry exhibits right side homonymous hemianopia which affects his visual field on the right in both eyes which related to the infarcts in Barry’s left occipital lobe. He also experiences some visual coordination and balance problems which relate to the infarcts in his cerebellum. - fatigue
- can make patients feel unwell and constantly weary or tired, but it does not improve with rest and is not necessarily related to recent activity.
- Barry had been experiencing fatigue both prior to and since he collapsed and hospital admission - depression
- can happen at any time following a stroke. It can cause symptoms such as loss of energy, suicidal feelings, self harming, loss of sex drive and avoiding people
-Barry’s wife reported a history of increasing frustration, anger, low mood and isolation in the four years prior to his recent stroke. When he was transferred to the stroke unit it was also noted that he had a low mood but it improved with medication
Barry had:
depression
fatigue
visual disturbances
hemiparesis
dysphagia
speech disorders
comparison of other conditions- TBI
- TBI can be caused by blunt (no break in skull) or penetrating (break in skull) injury
- can be focal which is localised points of injury that can be due to blunt or penetrating trauma and causes brain tissue damage
- can be diffuse which is widespread neuronal injury which alters AP transmission and exitotoxicity which leads to further damage and neuronal death
- TBI’s can be a risk factor for the development of stroke
management of a stroke for Barry and in general
you do not treat both strokes the same.
- for ischemic stroke
anticoagulation through rtPA- why is used and how its used
clot removal
- for hemmohragic stroke
stop bleeding
monitoring ICP (inter cranial pressure)
assessment of a stroke- GCS
When this was done on Barry, he scored 10/15 upon admission and then 13/15 later on.
Glascow Coma Scale is used to assess someones level of consciousness. Each category is rated on a scale and they add up to a score of 3-15 overall. 3 meaning they are not conscious and 15 meaning they have full consciousness and are orientated. the three different categories are;
- verbal response
ask the patient a closed question such as ‘what is your name and date of birth’ or ‘what month are we in’ the scores are;
1. none
2. no words, only sounds
3. words, but disorganised or not coherent
4. conversant but confused/ incorrect responses
5. conversant with correct responses - eye opening
check if the patient opens their eyes without needing to speak or to touch them. If the patient does not open their eyes, talk to them- start with a normal volume and then get louder. If still no response, apply a pressure stimulus to their body by squeezing their finger. The scores are;
1- no eye opening
2. to pressure
3. to sound
4. spontaneous - motor response
ask the patient to squeeze your fingers and then release. Ask the patient to pull down on your fingers and then release. If the patient is unable to complete the previous tasks, apply a pressure stimulus to their finger or trapezius and check the upper limb movement in relation to the location of stimulus. The scores are;
1. none
2. elbow extension, straightening limb
3. abnormal elbow flexion (across body)
4. normal flexion response to pressure stimulus
5. localised to pressure stimulus (attempt to remove stimulus)
6. normal, obeys command
Before doing this assessment make sure their hearing is fine, that they know what is happening, ensure they speak english and check if they have a medical condition that may affect the accuracy of the GCS
assessment of a stroke- CT and MRI scans
Scans are important to identify both the affected areas of the brain and the type of stroke
CT scans
CT scans show tumors, strokes or lesions in the brain as altered densities. The speed and convenience of CT often allows for early detection of hemorrhage or ischemia. For Barry it showed infractions in regions of the brain supplied by portions of the middle cerebral srtery, the left posterior cerebral artery and the posterior inferior cerebellar arteries, some of which were likely weeks old.
MRI scans appear lighter in colour where the infarction occurred. For barry these scans confirmed acute bilateral cerebellar infarcts with brainstem involvement as well as a mature infarcts in the left occipital lobe and portions of the temporal lobe.
assessment of stroke- Neurological exam
To asses the impact of a stroke on neurological function, various neurological examinations may be performed to evaluate the effect on sensory, motor and cognitive functions.
For Barry;
1. visual field (peripheral vision)- Barry had very limited peripheral vision on his right side in both eyes
2. facial movement- Barry had limited movement on the right side of his face
3. facial sensation- Barry had limited sensation in the right side of his face
4. corneal reflex- Barry did NOT exhibit a corneal reflex with his right eye
5. leg movement (leg lift)- Barry could lift both his right and left legs, though there was apparent weakness in his right leg
6. Arm movement (arm lift)- Barry had significant weakness is his right arm and was unable to lift it
Barrys neurological impacts mostly affect Barry’s right side because he experienced infarction in his LEFT cerebral hemisphere (which controls the right side of the body) and some of his RIGHT cranial nerves were affected
management of stroke- rtPA and anticoagulation used for an ischemic stroke
This should be administered within three hours of the stroke
- immediate treatment of ischemic strokes most commonly involves using rtPA. This is done intravenously by an injection or infusion. Tissue plasminogen activator (tPA) is a naturally occurring human protease enzyme that activates plasmin. Plasmin is fibrinolytic which breaks down the fibrin holding blood clots together.
- the main goal of treatment with rtPA is reperfusion of the cerebral vessels.
- eligible patients should not have any risk factors for significant bleeding events e.g they cant have had any recent major surgery, myocardial infarction and must have normal clotting functions and a sufficient number of platelets. They should also not have hypertension
Anticoagulation is another common treatment for ischemic stroke. This can be used in addition, or instead of rtPA treatment. commonly used anticoagulants include;
- aspirin- blocks prostaglandin synthetase action
- clopidogrel- inhibits receptor P2Y12, a chemoreceptor on platelet cell membranes
- heparin- inhibits antithrombin III, which inactivates blood clotting factor Xa and inhibits blood clotting
- warfarin- inhibits vitamin K-epoxide reductase
another treatment for ischemic strokes is clot removal
management- Barry’s medications upon discharge
When Barry was discharged from the rehabilitation unit he was taking several medications related to his stroke and associated complications, as well as his pre-existing conditions (i.e. hypertension, type 2 diabetes) and various other complications that arose while in hospital (e.g. pruritis, rashes). Below is a list of some of the medications Barry was on at his discharge
1. paracetamol
2. cilazapril- ACE inhibitor which inhibits an enzyme in the body from producing angiotensin 2 which narrows blood vessels, therefore helping relax the veins and arteries to lower BP
3. diltiazem- calcium channel blocker which prevents calcium from entering the cells of the heart and arteries which causes them to squeeze, therefore they relax and it lowers BP
4. citalopram- for low mood/ depression
5. metacloprimide- enhances movement for the upper GI tract
6. ciprofloxacine- eye drops for corneal ulceration
7. omeprazole- proton pump inhibitors block gastric acid secretion by irreversibly binding to and inhibiting the ATP pump to help with gastroesophageal reflux
8. aspirin
management of stroke- speech language therapy, physical therapy and home care
In addition to medications, many stroke patients will undertake rehabilitation and require support services. Barry was initially transferred to an in-hospital rehabilitation center where his condition continued to be monitored and he underwent physical therapy and speech language therapy.
Speech language therapy
- helps with Barrys dysarthria (muscles for speech are weak) and dysphagia (swallowing difficulties)
Physical therapy
- Due to Barry’s hemiparesis and truncal ataxia, physical therapy was a key part of his recovery plan
Home help
- Even after his time in the rehabilitation unit at the hospital, Barry still required 24 hour supervision and supportive care. It was recommended that he move to a care home facility, but he and his family wanted him home. So Barry was discharged to his own home with his wife as his primary caregiver, supported by in-home carers at various times throughout a day.
- A number of rehabilitation and support services were involved in Barry’s care while at hospital and in forming Barry’s in-home care plan, including speech language therapy, physiotherapy, occupational therapy, clinical psychology, nursing & social work.
treatment of a hemorrhagic stroke
- stop bleeding
- monitor ICP because changes in the volume will increase ICP and when it increases is puts pressure on the brain and causes damage to neurons
comparison to other conditions- hemorrhagic stroke and TIA
hemorrhagic stroke is from damaged blood vessels and bleeding
There are two classifications:
1. Intercerebral- due to hypertension or aneurysms that form within cerebral vessels
2. Subarachnoid- due to injury
Blood loss - damages surrounding tissues including neurons and causes Ischemia beyond vessel damage. Both of these cause neuronal death
TIA- transient ischemic attack: temporary decrease in blood flow with subsequent recovery (within 24 hours)- big warning sign
