CVA and Ischemic Stroke Overview

CVA (Stroke)

• Leading cause of CVA is stroke
• Risk factors include hypertension, trauma, illicit drug use, obesity, smoking, and excessive alcohol consumption.
• All strokes can cause seizures.
• Primary prevention is key to stroke prevention

Ischemic Stroke

• Disruption of blood supply due to obstruction
• Types include large artery thrombosis, atrial fibrillation (A-fib) - blood pooling causing clot formation, cryptogenic (unknown cause), and illicit drug use (e.g., cocaine).
• Symptoms include severe headache, numbness/weakness on one side of the body (face, arms, or legs), changes in mental status, ataxia, hemiplegia (complete weakness), hemiparesis (partial weakness), dysarthria (difficulty speaking), and aphasia (language impairment)
• BEFAST is a quick assessment tool: Balance, Eyes, Facial drooping, Arm weakness, Speech difficulties, and Time.
• Treatment for ischemic strokes includes tPA (thrombolytic therapy) also known as clot busters.

tPA Guidelines

• Administered within 3-4.5 hours of stroke onset
• Contraindicated in cases of hemorrhagic stroke, history of intracranial hemorrhage, recent seizure at stroke onset, or GI/UT hemorrhages within the last 3 weeks.
• Use if there is a clinical diagnosis of ischemic stroke and a baseline CT scan that shows no evidence of hemorrhage

Transient Ischemic Stroke (Mini Stroke)

• Stroke that resolves on its own
• Temporary neurological deficits
• Warning sign of an impending stroke
• Possible causes include plaque buildup or stenosis of the carotid arteries

Prevention Treatments

• Anticoagulant therapy
• Antiplatelet therapy (e.g., clopidogrel and aspirin)
• Statins to decrease plaque formation
• Antihypertensives
• Carotid endarterectomy may be necessary

Hemorrhagic Stroke

• Sudden loss of consciousness (LOC)
• Severe headache
• Increased intracranial pressure (ICP)
• Low systemic blood pressure
• Bleeding or hemorrhagic shock
• Vomiting
• Common cause is hypertension

Stroke Care and Monitoring

• Maintain airway and ventilation
• Monitor vital signs (VS)
• Elevate head of bed (HOB) 30 degrees
• Monitor for bleeding
• Monro-Kellie doctrine; the sudden increase in blood volume within the skull due to bleeding will cause a compensatory decrease in the volume of either cerebrospinal fluid (CSF) or brain tissue, aiming to maintain a constant intracranial pressure within the rigid cranial vault
  • Low BP, Tachycardia, Low Cardiac Output, Low Urine Output – check BUN and Creatinine ; increased levels mean you need to give isotonic fluids
• Monitor for neurological function changes (e.g., motor, speech, pupil responses)
• Assess mental status, perception, motor control, swallowing, skin integrity, and nutritional status
• Thickened foods or pureed diets, may need total parenteral nutrition (TPN)
• Elevated be to 90 degrees when feeding and have them tuck in chin
• Use pillows to prop, align limbs, look for fecal impaction or bladder problems
• Provide a bathroom schedule and give laxatives, they may need catheterization
• Monitor for infection risk

Concussion vs. Contusion

• Concussion: temporary neurological impairment
• Contusion: bruising of the brain tissue
• Hematomas: (Epidural, subdural, and intraduarl) bleeding in the brain

Primary vs Secondary Prevention

• Primary: addressing the initial cause of the stroke (e.g., skull fractures, contusions)
• Secondary: focuses on managing complications that arise after the initial stroke (e.g., increased intracranial pressure (ICP), hypoxia, hypotension, hyperthermia)

Skull Fractures

• Increased infection risk
• CSF leaks into nose/ears
• Raccoon and Battle signs (bruising around eyes/ears)

Glasgow Coma Scale

• Assessing motor, eye opening, and verbal function. Lower score means more severe coma.
• Herniation of the brain
• Compression of cranial nerve III (Cushing's Triad)

Cushing's Triad

• High blood pressure
• Low heart rate
• Irregular breathing

Seizures

• If seizures occur, treat with sedation first before paralytic agents
• Anticonvulsants like Keppra and Dilantin are given
• EEG monitors brain conductivity

Autonomic Dysreflexia

• Life-threatening medical emergency
• Overreaction of the autonomic nervous system, often in those with spinal cord injuries above T6.
• Usually caused by stimuli below the level of the injury (e.g., bladder distention or urinary infection).
• Symptoms include uncontrolled hypertension, cardiac dysrhythmias, and potentially respiratory depression (the diaphragm may become paralyzed).

Meningitis

• Inflammation of the meninges (Dura mater, Arachnoid, Subarachnoid space, and pia mater).
• Bacterial (septic): caused by bacteria like Streptococcus pneumoniae or Neisseria meningitidis
• Viral: caused by herpes or HIV

Other Conditions

• Myasthenia Gravis
• Guillain-Barré syndrome
• Parkinson's Disease.