stroke Flashcards
which is most significant in precipitating a haemorrhagic stroke?
hypertension
hyperlipidemia
old age
previous stroke
hypertension, d/t vessel weakening, aneurysm formation, microbeeds, BBB breakdown
haemorrhagic stroke onset
- upon exertion
- sudden onset
- often a/w severe headache, vomiting, seizures
how would a thalamic bleed lead to personality changes
- impact emotional regulation
- impact limbic system (responsible for mood control)
- involved in cognitive & executive functioning (may be impaired)
- effect on frontal lobe connection (higher-order functions eg planning & judgement) → impulsivity, disinhibition
decorticate vs decerebrate posture
decorticate: elbows extended
decerebrate: elbows flexed
ICH neurological complications [4]
- brainstem compression
- cerebellar herniation
- hydrocephalus
- recurrent haemorrhage within 24h
ganglionic haemorrhage presentation
contralateral hemiplegia worsening to drowsiness & coma
thalamic haemorrhage presentation
contralateral hemiplegia with 3rd nerve involvement (oculomotor)
pontine haemorrhage presentation
quadriplegia, pin-point pupils, death
cerebellar haemorrhage presentation
ataxia, altered sensorium, death
common causes of SAH
- aneurysm rupture (usually arterial bleed)
- trauma eg RTA (usually venous)
SAH presentation
- thunderclap headache
- vomiting
- possible LOC
- usually no focal neurological deficits
haemorrhagic stroke: med management [5]
- stop antiplatelet & antocoag, reverse antithrombotic effect
- BP control
- monitor neuro condition
- control ICP
- BG 6-10
BP management for haemorrhagic stroke
ICH: SBP 120-160
SAH: MAP 80-130
post surgery: SBP 120-140
surgical management for Haemorrhagic stroke
- EVD [hydrocephalus, ↓ ICP d/t swelling, monitor ICP]
- aneurysm clipping
- aneurysm coiling
[prevent re-bleed]
post-surgical management of haemorrhagic stroke
- ↓ re-bleeding risk: maintain SBP 120-140
- prevent vasospasm: nimodipine
- prevent seizure: phenytoin, valporate
- control ICP, BG, temp
broca’s aphasia vs wernicke’s aphasia
broca: expressive (2: slurred speech, incomprehensible sounds)
wernicke’s: receptive (3: inappropriate words)
extracranial factors affecting stroke
- systemic BP (MAP)
- cardiac output
- viscosity of blood
intracranial factors affecting stroke
- intracranial pressure
- atherosclerosis
- blood vessels eg aneurysm?
which type of stroke is most common
ischaemic sroke
causes of ischaemic stroke
- thrombotic (atherosclerosis, MCA infarct, lacunar infarct) [arterial disease, blood disorders]
- embolic (dislodged blood clots d/t AFib, carotid paque, atherosclerotic plaque)
causes of ICH
- hypertension
- thrombolytic drugs
Nursing management in A&E [13]
- ABC, vitals
- O2 if hypoxemic
- airway support (if gcs<8)
- obtain IV access (18G x2)
- bloods: BGM, RP, clotting, d-dimer, cardiac enzymes, BNP, thyroid profile)
- neuro assessment
- monitor temp
- activate stroke team, stat CT
- 12 lead ECG
- fluid & electrolyte management (give isotonic fluids)
- NBM, NGT?
- weight
- history taking (AMPLE)
diagnostic tests for stroke [6]
- CT brain
- MRI
- angiogram
- carotid ultrasound
- 2d echo
- EEG
CT: pros & cons
+ overview of structures, identifying haemorrhage
+ quick to obtain
+ bone injury
– does not immediately show ischaemia
– radiation
CT angio: pros & cons
+ identify thrombosis in major vessels
+ identify vascular malformations
+ “spot sign” → shows active bleeds
– contrast: allergy/kidney injury
MRI: pros & cons
+ MRI > CT for acute ischaemic stroke w/in 12h
stroke: supportive measures
- Airway & ventillation
- temp management [TTM (targeted temp management) — therapeutic hypothermia, controlled normothermia, fever treatment]
- BG control
indications of carotid artery involvement
- transient unilateral vision loss
- hemiparesis
- inability to speak
indication of vertebrobasilar artery involvement
- tinnitus
- vertigo & blurred vision
- hemiparesis
what is stroke-in-evolution
increasing obstruction → involve proximal branch of artery → increase deficit
anterior cerebral artery superficial branch involvement: presentation
prefrontal lobe: confusion, disorientation
medial surface: paralysis, sensory loss in opp. leg
apraxia, abulia, urinary incontinence in bilateral lesions
anterior cerebral artery deep branch involvement: presentation
well tolerated d/t collateral flow: hardly any clinical features
middle cerebral artery deep branch involvement: presentation
contralateral paralysis
middle cerebral artery superficial branch involvement:
superior: facial & hand paralysis, conjugate gaze paralysis, motor aphasia
inferior: conduction/sensory aphasia, construction/dressing apraxia
manifestations: right brain damage (isch) [5]
- L sided paralysis
- spacial-perceptual deficits
- behavioural style: quick, impulsive
- memory deficits: performance
- indifference to disability
manifestations: left brain damage [5]
- R sided paralysis
- speech-language deficits
- behavioural style: slow, cautious
- memory deficits: language
- distress & depression r/t disability
tPA MOA
- bind to fibrin → convert plasminogen to plasmin → fibrinolysis → ↓ region affected by stroke
nursing considerations: IV alteplase [6]
- swirl, not shake
- double check dose w/ 2nd clinician
- check neuro status within 15min before administration [NIHSS>4]
- BP goals:
- before: <185/110
- after: <180/105 for 24h
- permissive hypertension up to 220/110
- avoid sudden reduction of BP, decrease gradually w/ IV labetalol (onset 5min) or nicardipine
- 15% lowering over 24h
- ACS/HF/ARF/hypertensive encephalopathy → treat BP
tPA inclusion criteria [4]\
- > 18 y/o
- <4.5h from last seen well
- ischaemic stroke
- significant neurological deficit (NIHSS>4)
tPA exclusion criteria
- evidence of bleeding (ICH, SAH, internal)
- stroke/HI/intracranial/intraspinal surgery w/in last 3/12
- persistent BP elevation (>185/110)
- on anticoagulants, INR>1.5, PT>15
- platelet < 100,000
- heparin w/in 48h, ↑ aPTT
- BG <2.7/>22.2
preventive/alternative treatment for ischaemic
anticoagulants
- warfarin (short term 3/12)
- heparin
antiplatelets:
- aspirin — 81-325mg/day
- clopidogrel — 75mg/day
endovascular thrombectomy (surgically remove plaque)
angioplasty/stenting
EVT (endovascular thrombectomy) inclusion criteria
- large vessel obstruction
- symptom onset <6h
- NIHSS>6
EVT management
- CRIB 6h for groin puncture site
- monitor bleeding, swelling, haematoma, pain
- keep leg straight
- neurovascular chart
EVT complications
- retroperitoneal haematoma
[hypotension, flank pain] - arterial occlusion
[leg parasthesia, pain, pallor]
warfarin counselling
[4]
- consistent vit K
- monitor INR, 2-3
- monitor bleeding S/E
- special precaution: pregnant, PUD, alcohol, blood disorders
which of the following may not be present in cerebral stroke
hemiplegia
monoplegia
quadroplegia
paraplegia
paraplegia (lower limbs) [spinal cord injury]
hemiplegia: one-sided
monoplegia: one arm
quadroplegia: all limbs
clopidogrel vs aspirin
aspirin has lower bleeding risk
GCS scoring
eye opening
1. none
2. pain
3. speech
4. spontaneous
best verbal response:
1. none
2. incomprehensive sounds
3. inappropriate words
4. confused
5. orientated
best motor response:
1. none
2. extension to pain
3. abnormal flexion
4. flexion to pain
5. localised pain
6. obeys command
what is d-dimer
protein that breaks down clots.
high d-dimer: clots present in body.
if pt is on antiplatelets/coag, question pt’s med compliance
frontal lobe responsible for
- movement
- intelligence
- behaviour
- memory
parietal lobe responsible for
intelligence
language
sensation
reading
nurse is assessing pt’s ability to obey commands, asks him to raise his left hand and touch his nose. pt raised is left hand 5cm above bed before resting it back on bed. the nurse should:
- chart his best motor response as 6
- chart his motor strength for R arm as 3
- ask him to do the same with his R
- ask him to resist the nurse’s hands hen she presses down on his L hand
ask him to do the same with his R
haem stroke –> increased ICP management
[7]
- head of bed >30
- hypertonic saline (3%) if Na is normal
- osmotic diuretic (mannitol)
- CSF drainage (EVD)
- surgical decompression
- hyperventilation (PCO2 25-30mmHg)
- analgesics for headache
complication of major rupture
- vasospasm
- hydrocephalus & increased ICP
- rerupture
dilated pupils is a sign of
brainstem (midbrain) involvement (contains CNIII oculomotor
one pupil: ipsilateral compression OR incal herniation d/t temporal lobe bleed
signs of increased ICP [8]
- pupillary changes (brainstem involvement)
- GCS<8 (thalamic/brainstem involvement)
- decreased SpO2 (respi compromise d/t brainstem [medulla oblongata] involvement)
- headache, photophobia
- n&v
- altered level of consciousness
- papilloedema (swollen optic disc)
- cushing reflex
- decorticate/decerebrate position
** 4, 5, 6 –> early
EVD indications [4]
- hydrocephalus
- relieve/monitor increased ICP
- drain infected/bloodstained CSF
- administer meds (abx, thrombolytics)
EVD contraindications [2]
- anticoag therapy/coag problems
- scalp/brain infx
EVD complications & management [5]
- mechanical (blockage, dislodgement)
- infection
- under drainage –> increase ICP, brain damage
- over drainage –> ventricular collapse –> subdural haematoma –> change in pressure gradient –> brain herniation
- trauma –> intraventricular haemorrhage, parenchymal haemorrhage, aneurysm rupture
how often to perform levelling/verification of EVD [3]
- receiving patient
- taking over patient
- patient moves/repositions
care of EVD system [7]
- catheter & tubing coiled
[prevent traction, secure, no kinks, clots, bubbles. leaks –> prevent dislodgement & blockage] - ensure patency
[ EVD column oscillation, ICP waveform pulsation, observe for drainage] - label
- prevent infection
[1. aseptic technique - sterile, closed system
- insertion site care eg change dressing
- monitor infection s&s]
importance of levelling/verification of EVD
- ensure accurate pressure level
epidural haemorrhage causes & presentation
head trauma > fracture > laceration of arterial vessels (meningeal artery)
triphasic presentation: \
1. brief LOC > lucid interval >
2. headache > altered consciousness, contralateral hemiparesis >
3. ipsilateral pupillary dilation
- large force is req `
subdural haemorrhage presentation
nonspecific: AMS, hemiparesis, headache, nonconvulsive seizure
intraparenchymal haemorrhage cause & presentation
damage BV d/t
- hypertension
- trauma
- aneurysm
- atherosclerosis
FAST + headache
without warning
what is cushing reflex
indicates increased ICP
1. bradycardia (/initial tachycardia)
2. widening pulse pressure
3. altered breathing pattern
what is CPP and what is the target range for haemorrhagic stroke
cerebral perfusion pressure
maintain >60 mmHg
craniotomy vs craniectomy
craniectomy: bone flap not replaced immediately
craniotomy: bone flap replaced
