Week 3: Increased intracranial pressure, TBI & stroke
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Which of the following symptoms is specifically associated with right-brain damage during a stroke?

  • Left-sided neglect (correct)
  • Slow performance, cautious
  • Paralyzed right side: hemiplegia
  • Impaired speech-language

    • What is the primary cause of an intracerebral hemorrhage?

  • Cocaine use
  • Chronic hypertension (correct)
  • Trauma to the head
  • Coagulation disorders

    • Which imaging technique is considered easier and faster for diagnosing strokes?

  • CTA
  • Cerebral angiography
  • CT scan (correct)
  • MRI

    • Which of the following is a common clinical manifestation of both ischemic and hemorrhagic strokes?

    <p>Dysphagia</p> Signup and view all the answers

    Which approach is NOT recommended for the prevention of strokes?

    <p>Ignore existing cardiac issues</p> Signup and view all the answers

    What is a common risk factor associated with hemorrhagic strokes?

    <p>Atrial fibrillation</p> Signup and view all the answers

    What neurological condition contributes to increased fall risk in stroke patients?

    <p>Ataxia</p> Signup and view all the answers

    Which treatment is primarily indicated for managing acute ischemic strokes?

    <p>Thrombolytic therapy</p> Signup and view all the answers

    Which of the following statements is true regarding the clinical manifestations of a stroke?

    <p>They depend on the location of the stroke.</p> Signup and view all the answers

    Which medication inhibits platelet aggregation by targeting the P2Y12 receptor on platelets?

    <p>Clopidogrel (Plavix)</p> Signup and view all the answers

    What is a crucial nursing consideration when administering Clopidogrel?

    <p>The effects last 7-10 days after the last dose.</p> Signup and view all the answers

    What is the primary goal of thrombolytic therapy in acute ischemic stroke management?

    <p>To dissolve blood clots.</p> Signup and view all the answers

    Which surgical procedure is appropriate for a patient with a hemorrhagic stroke?

    <p>Evacuation of the hematoma</p> Signup and view all the answers

    During rehabilitation after a stroke, which aspect is least likely to be a focus?

    <p>Medication adherence to prevent future strokes</p> Signup and view all the answers

    Which of the following is NOT a main component of acute stroke management?

    <p>Perform routine imaging and biopsy</p> Signup and view all the answers

    What differentiates surgical therapy for ischemic stroke from that for hemorrhagic stroke?

    <p>Hemorrhagic strokes require evacuation of the hematoma.</p> Signup and view all the answers

    Which statement about antiplatelet therapy is correct?

    <p>Recognizing signs of bleeding is an essential teaching point for patients on antiplatelet therapy.</p> Signup and view all the answers

    What is the most critical monitoring requirement for patients prescribed warfarin?

    <p>Regular monitoring of INR levels to ensure they remain within the therapeutic range.</p> Signup and view all the answers

    When is thrombolytic therapy most effective in acute stroke management?

    <p>When given within 3-4.5 hours of stroke onset.</p> Signup and view all the answers

    What potential interaction should patients on warfarin be aware of?

    <p>Certain supplements and foods can increase or decrease warfarin's effects.</p> Signup and view all the answers

    What is a vital consideration when managing a patient with a history of stroke during rehabilitation?

    <p>Monitoring the patient for signs of complications and adjusting rehabilitation accordingly.</p> Signup and view all the answers

    Which medication should be avoided when a patient is receiving antiplatelet therapy?

    <p>NSAIDs, due to an increased risk of bleeding.</p> Signup and view all the answers

    What is a common misconception about the administration of anticoagulants like apixaban?

    <p>Patients can stop it immediately without any consequences.</p> Signup and view all the answers

    In the context of acute stroke management, what is the purpose of performing frequent neuro vitals monitoring?

    <p>To ensure signs of neurological deterioration are swiftly identified.</p> Signup and view all the answers

    Which statement accurately describes the role of antiplatelet medications?

    <p>They help prevent new blood clots from forming.</p> Signup and view all the answers

    Match the following substances with their uses in the management of traumatic brain injury:

    <p>Mannitol = Osmotic diuretic for fluid management Sedatives = Decrease agitation and metabolic need Tube feeds = Early nutritional support Total Parenteral Nutrition (TPN) = Nutritional therapy via IV</p> Signup and view all the answers

    Match the following components of the Glasgow Coma Scale (GCS) with their corresponding assessments:

    <p>Eye opening = Response to verbal/painful stimuli Best verbal response = Ability to speak Best motor response = Ability to obey commands GCS score = Standardized assessment of consciousness</p> Signup and view all the answers

    Match the following abnormal motor responses with their clinical significance:

    <p>Abnormal flexion = Damage to both sides of the cerebral hemisphere Abnormal extension = More severe damage to the brainstem Eyes swollen = Condition affecting GCS accuracy Prior paralysis = Condition rendering GCS invalid</p> Signup and view all the answers

    Match the types of head injuries with their descriptions:

    <p>Scalp lacerations = Bleeding and infection risk Simple skull fracture = Non-depressed skull injury Basilar skull fracture = Injury at the base of the skull Depressed skull fracture = Skull inward indentation</p> Signup and view all the answers

    Match the following conditions that invalidate the Glasgow Coma Scale with their descriptions:

    <p>Nonverbal patient = May have dementia affecting response Infants = Developmental stage affecting assessment Language barrier = Difficulty in interpreting responses Blind patients = Visual impairment affecting assessment</p> Signup and view all the answers

    Match the types of cerebral edema with their descriptions:

    <p>Vasogenic = Fluid leaks from blood vessels due to disrupted blood-brain barrier Cytotoxic = Swelling of brain cells due to fluid accumulation inside them Interstitial = CSF leaks from the ventricles into surrounding brain tissue None of the above = A term not associated with cerebral edema</p> Signup and view all the answers

    Match the early signs of increased intracranial pressure (ICP) with their descriptions:

    <p>Altered LOC = Confusion or restlessness, often with unilateral pupil changes Variable signs = Focal findings indicating localized issues within the brain Unilateral hemiparesis = One-sided muscle weakness evident on examination Altered respiratory pattern = Irregular or bradypneic breathing observed</p> Signup and view all the answers

    Match the late signs of increased intracranial pressure (ICP) with their descriptions:

    <p>Dec LOC (stupor) = Decreased level of consciousness, might have pupillary changes Ineffective breathing pattern = Cheyne-Stokes respirations indicating severe dysfunction Abnormal motor response = Posturing such as decerebrate or decorticate responses HTN with widened pulse pressure = Indicates significant pressure effects in the brain</p> Signup and view all the answers

    Match the terminal signs of increased intracranial pressure (ICP) with their descriptions:

    <p>Coma = Unresponsive state with no motor response Bilaterally fixed and dilated pupils = Critical indicator of severe brain compromise Absence of motor response = Flaccidity indicating total loss of motor function Respiratory arrest = Complete cessation of breathing function</p> Signup and view all the answers

    Match Cushing's triad components with their corresponding symptoms:

    <p>Abnormal respiratory patterns = Changes in breathing rate and rhythm Bradycardia with full bounding pulse = Slow heart rate with strong pulse Increased SBP with widening pulse pressure = Elevated systolic blood pressure and varied difference Altered LOC = Change in consciousness and awareness of surroundings</p> Signup and view all the answers

    Cerebral herniation can occur due to brain tissue shifting downwards from the skull through the foramen magnum.

    <p>True</p> Signup and view all the answers

    CT scans are the least effective diagnostic test for detecting brain tumors and strokes in emergencies.

    <p>False</p> Signup and view all the answers

    Maintaining the head and neck in alignment can help reduce intracranial pressure.

    <p>True</p> Signup and view all the answers

    Hyperthermia is not considered a sign of cerebral herniation.

    <p>True</p> Signup and view all the answers

    Surgical intervention for managing cerebral herniation may include a decompressive craniotomy.

    <p>True</p> Signup and view all the answers

    What is the minimum cerebral perfusion pressure (CPP) required for adequate brain perfusion?

    <p>50 mmHg</p> Signup and view all the answers

    What physiological change occurs when CPP drops below 50 mmHg?

    <p>Cerebral ischemia</p> Signup and view all the answers

    Which of the following conditions is NOT a cause of increased intracranial pressure (ICP)?

    <p>Hydration</p> Signup and view all the answers

    How does switching to anaerobic metabolism affect vasodilation during hypoxia?

    <p>It increases lactic acid production.</p> Signup and view all the answers

    What is the relationship between mean arterial pressure (MAP) and intracranial pressure (ICP)?

    <p>CPP is calculated by subtracting ICP from MAP.</p> Signup and view all the answers

    Study Notes

    Stroke Prevention and Management

    • Lifestyle changes crucial: quitting smoking, regular exercise, and limiting alcohol intake.
    • Medication management beneficial for patients with prior transient ischemic attacks (TIA).

    Antiplatelet Medications

    • Aspirin (ASA):
      • Inhibits cyclooxygenase enzyme pivotal for thromboxane synthesis.
      • Thromboxane critical for platelet aggregation.
    • Clopidogrel (Plavix):
      • Inhibits platelet aggregation by blocking P2Y12 receptor.
      • Non-reversible effects last 7-10 days post discontinuation.
      • Can be prescribed alongside aspirin.

    Surgical Options

    • Suggested for patients with significant atherosclerosis leading to narrowing or blockages.

    Stroke: Acute Care Protocols

    • Essential to maintain airway, breathing, and circulation (ABCs) and cerebral oxygenation.
    • Balance fluids and electrolytes to support patient stability.
    • For ischemic stroke, thrombolytic therapy indicated to restore blood flow.
    • Address complications: bleeding, cerebral edema, and stroke recurrence.

    Surgical Interventions

    • Ischemic Stroke: Endovascular treatment may be used to clear clots.
    • Hemorrhagic Stroke: Surgery necessary to remove hematomas.
    • Treatment of aneurysms through clipping or coiling.

    Rehabilitation Importance

    • Essential for recovery post-stroke.

    Medication Overview

    • Thrombolytics (e.g., alteplase tPA):
      • Administered within 3-4.5 hours in acute ischemic strokes to dissolve clots.
      • Close monitoring for bleeding required.
    • Antiplatelets (ASA, clopidogrel):
      • Prevents future clot formation.
      • Educate patients about bleeding risk and adherence to prescription.
      • Caution against NSAID co-administration due to bleeding risks.
    • Anticoagulants (warfarin, apixaban):
      • Prevents clot formation; patients must be aware of bleeding signs.
      • Regular INR monitoring (for warfarin) is essential; dietary and drug interactions possible.
      • Apixaban, a direct oral anticoagulant (DOAC), also has interaction risks.

    Hemorrhagic Stroke Risk Factors

    • Major cause for intracerebral hemorrhage linked to chronic hypertension, can result in blood vessel rupture.
    • Consider trauma, coagulation disorders, and cocaine use, which is often associated with severe hypertension.
    • Subarachnoid hemorrhages stem from ruptured cerebral aneurysms or vascular malformations.

    Clinical Manifestations of Stroke

    • Symptoms vary with stroke location, common signs include:
      • Hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body.
      • Dysphagia (swallowing difficulty), dizziness, ataxia (coordination issues), and sensory deficits.

    Left vs Right Brain Damage Impacts

    • Left Brain Damage:
      • Right side paralysis and language comprehension deficits.
      • Patients often experience anxiety and depression.
    • Right Brain Damage:
      • Left side paralysis with potential neglect of the affected side.
      • Can display impulsivity and impaired judgment.

    Stroke Evaluation Techniques

    • Diagnostic imaging (CT or MRI) vital for identifying stroke type and location.
    • CT scans are more accessible, while CT angiography (CTA) provides detailed blood vessel imaging.
    • Cerebral angiography offers intricate details on vascular structures.

    Stroke Prevention Strategies

    • Control hypertension and diabetes, plus management of underlying cardiac conditions.
    • Lifestyle modifications and nutritional support (early nutrition post-TBI beneficial).
    • Consider osmotic diuretics like mannitol for fluid management and sedatives for patient calmness.

    Glasgow Coma Scale (GCS)

    • A standardized assessment for consciousness level in patients.
    • Includes eye opening, verbal response, and motor response criteria.
    • Conditions affecting assessment validity include nonverbal status, trauma, or language barriers.

    Traumatic Brain Injury (TBI)

    • Management of scalp lacerations for infection risks is critical.
    • Understanding different types of skull fractures is essential for treatment and monitoring.

    Cerebral Edema

    • Three types of cerebral edema are recognized: vasogenic, cytotoxic, and interstitial.
    • Vasogenic Edema: Most common; occurs when the blood-brain barrier is disrupted, allowing fluid to leak into brain tissue, primarily affecting white matter.
    • Cytotoxic Edema: Results from fluid accumulation within brain cells, increasing the risk of stroke.
    • Interstitial Edema: Caused when cerebrospinal fluid (CSF) leaks from the ventricles into surrounding brain tissue, often linked with hydrocephalus or meningitis.

    Clinical Manifestations of Increased Intracranial Pressure (ICP)

    • Change in level of consciousness (LOC) is the earliest indicator of increased ICP.
    • Vital signs are altered due to pressure on critical brain regions like the hypothalamus and medulla.
    • Cushing's Triad: Characterized by abnormal respiratory patterns, bradycardia with a full bounding pulse, and increased systolic blood pressure with widening pulse pressure.

    Signs of Increased ICP

    • Early Signs: Altered LOC (confusion, restlessness), unilateral pupil changes, altered respiratory patterns, unilateral hemiparesis.
    • Late Signs: Decreased LOC (stupor), abnormal pupil responses, ineffective breathing patterns, abnormal motor responses.
    • Terminal Signs: Coma, bilaterally fixed and dilated pupils, respiratory arrest, absence of motor response.

    Management of Increased ICP

    • Mannitol: Osmotic diuretic administered intravenously to shift fluid from extravascular to intravascular space; requires monitoring of fluids and electrolytes.
    • Sedatives: Help reduce agitation while decreasing metabolic needs.
    • Early nutritional therapy post-traumatic brain injury (TBI) improves patient outcomes and should ideally begin within five days of injury.

    Glasgow Coma Scale (GCS)

    • The GCS assesses patient LOC through three indicators: eye opening, best verbal response, and best motor response.
    • A GCS score of 3 indicates the lowest possible level of consciousness.
    • Certain conditions render the GCS assessment invalid, including language barriers and non-verbal status.

    Traumatic Brain Injury (TBI)

    • Head trauma is categorized into mild, moderate, and severe based on GCS.
    • Key Injuries: Scalp lacerations, skull fractures (including basilar), contusions, and concussions, with the leading cause being motor vehicle accidents.
    • Basilar skull fractures present with specific signs like periorbital and postauricular ecchymosis, rhinorrhea, and otorrhea.

    Types of Hematomas

    • Epidural Hematoma: Arterial bleeding between dura mater and skull; rapid deterioration in condition; requires surgical intervention.
    • Subdural Hematoma: Venous bleeding between dura and arachnoid; symptoms may develop weeks post-injury, including confusion and lethargy.
    • Intracerebral Hematoma: Bleeding within brain tissue that may result from trauma or ruptured aneurysms.
    • Subarachnoid Hemorrhage: Bleeding between arachnoid and pia, often associated with trauma and presenting as "worst headache ever."

    Stroke Overview

    • Stroke, or cerebral vascular accident (CVA), is a leading cause of disability and the third leading cause of death in Canada.
    • Common risk factors include hypertension, diabetes, cardiovascular disease, and certain contraceptive uses.

    Transient Ischemic Attacks (TIA)

    • TIAs involve temporary neurological deficits and serve as warning signs for possible ischemic stroke.
    • Symptoms may include unilateral weakness, diplopia, sudden confusion, and loss of balance.

    Ischemic Stroke Types

    • Thrombotic Stroke: Caused by atherosclerosis; risk factors include hypertension and diabetes.
    • Embolic Stroke: Results from an embolus occluding a cerebral artery; management includes antiplatelet medications.

    Acute Stroke Care

    • Focus includes maintaining ABCs, managing cerebral oxygenation and fluid balance, and restoring cerebral blood flow with thrombolytic therapy.
    • Surgical options may be necessary for ischemic and hemorrhagic strokes, along with rehabilitative care post-stroke.

    Medication Summary

    • Thrombolytics (e.g., alteplase): Used to dissolve blood clots during acute ischemic strokes; careful monitoring is essential.

    Cerebral Herniation

    • Life-threatening complication where brain tissue shifts downward into the brainstem through the foramen magnum.
    • Signs include unilateral, fixed dilated pupil; Cushing's triad indicates increased intracranial pressure (ICP).

    Diagnostic Tests

    • Aimed at identifying the underlying cause of symptoms.
    • CT scan provides quick insights into brain injuries, bleeding, or tumors.
    • MRI is more detailed but not suitable for emergencies; helpful for identifying tumors and strokes.
    • CTA/MRA offers non-invasive imaging of blood vessels.
    • ICP measurement is critical in neuro-monitoring settings like the ICU.

    Management of Increased ICP

    • Continuous monitoring of vitals, electrolytes, ICP, and brain tissue oxygenation is necessary.
    • Minimize environmental stimuli to reduce ICP.
    • Proper positioning can enhance venous drainage, with head of bed elevated at 30 degrees and head/neck alignment maintained.
    • Surgical options include decompressive craniotomy and hematoma evacuation.
    • Medications like osmotic diuretics (e.g., mannitol) help manage fluid levels while sedatives decrease metabolic needs.

    Glasgow Coma Scale (GCS)

    • Standardized tool for assessing a patient's level of consciousness (LOC).
    • Consists of three indicators: eye opening, best verbal response, and best motor response.
    • Conditions such as dementia, trauma, or language barriers may invalidate the GCS.

    Traumatic Brain Injury (TBI)

    • Types include diffuse (generalized) and focal (localized) injuries.
    • Common causes include car accidents and impacts to the head.
    • GCS classifications: Mild (13-15), Moderate (9-12), Severe (3-8).

    Types of Brain Injuries

    • Diffuse Axonal Injury (DAI): Shearing or tearing of axons due to rapid movements; significant implications.
    • Focal Brain Injury: Localized damage, potentially from lacerations or contusions.

    Concussions

    • A mild TBI resulting from jarring impact leading to cerebral dysfunction; can be diagnosed with just one symptom.
    • Red flags for severe concussion include severe headaches, loss of consciousness, and progressive neurological symptoms.

    Hematomas

    • Epidural Hematoma: Bleeding between dura mater and skull, typically arterial; urgent surgical intervention often needed.
    • Subdural Hematoma: Bleeding between dura and arachnoid layers usually from venous injury; symptoms may take weeks to appear.
    • Intracerebral Hematoma: Bleeding within the brain tissue itself; can develop from trauma or ruptured vessels.
    • Subarachnoid Hemorrhage: Bleeding between arachnoid and pia mater, often associated with trauma.

    Stroke

    • Leading cause of disability and the third leading cause of death in Canada.
    • Risk factors include hypertension, type 2 diabetes, cardiovascular disease, and atrial fibrillation.

    Types of Stroke

    • Transient Ischemic Attacks (TIA): Temporary neurological deficits; warning signs for ischemic stroke.
    • Ischemic Stroke: Caused by arterial blockages leading to brain tissue death.

    Stroke Management

    • Focus includes airway maintenance, restoring cerebral blood flow via thrombolytics, managing complications, and rehabilitation.
    • Surgical therapy may be necessary to remove clots or evacuate hematomas.

    Medication Summary

    • Thrombolytics (e.g., alteplase) dissolve blood clots during acute ischemic stroke emergencies.

    Hemodynamics and Autoregulation

    • Low levels lead to constriction for adequate perfusion.
    • Anaerobic metabolism produces lactic acid, increasing H+ concentration, which causes vasodilation and loss of autoregulation.

    Cerebral Hemodynamics

    • Cerebral perfusion pressure (CPP) measures blood flow needed for brain tissue.
      • Normal CPP: 70-100 mmHg.
      • Minimum CPP: 50-60 mmHg for adequate perfusion.
      • CPP < 50 mmHg indicates cerebral ischemia.
    • Mean arterial pressure (MAP) averages pressure during the cardiac cycle.
      • MAP formula: DBP + 1/3(SBP-DBP) or SBP + 2(DBP).
      • Normal MAP: 70-110 mmHg.
    • CPP affected by MAP and intracranial pressure (ICP).

    Pressure-Volume Curve

    • Intracranial compliance represents volume change per pressure change.
    • Four stages from high to low compliance:
      • High compliance: small volume changes do not affect ICP.
      • Low compliance: small volume increases lead to significant ICP changes.

    Causes of Increased ICP

    • Brain Tissue: Tumors, contusions, abscesses, and edema.
    • Blood: Hemorrhages, hematomas, hypoxia, and hypercapnia.
    • Cerebrospinal Fluid (CSF): Hydrocephalus due to excess CSF or tumors affecting CSF flow.

    Cerebral Edema

    • Increases ICP by fluid accumulation in brain tissue.
    • Causes include lesions, tumors, hemorrhages, and infections.
    • Types of edema:
      • Vasogenic: Blood-brain barrier disruption leads to fluid leakage into brain tissue.
      • Cytotoxic: Cellular swelling increases risk for stroke.
      • Interstitial: CSF leaks into brain tissue, often seen in hydrocephalus and meningitis.

    Clinical Manifestations of Increased ICP

    • Early indicator: change in level of consciousness (LOC).
    • Vital sign changes due to pressure on brain structures.
    • Cushing's Triad: Abnormal respiratory patterns, bradycardia with a full bounding pulse, increased systolic blood pressure with widened pulse pressure.
    • Change in LOC: confusion or restlessness to stupor or coma.

    Glasgow Coma Scale (GCS)

    • Measures LOC through eye opening, verbal, and motor responses.
    • Conditions making GCS assessment invalid include dementia, cultural/language barriers, and facial trauma.

    Traumatic Brain Injury (TBI)

    • Types: scalp lacerations, skull fractures, and concussions.
    • Signs include headache, dizziness, coordination issues.
    • Management includes bed rest, gradual return to activity, and monitoring for red flags.

    Diffuse Axonal Injury (DAI)

    • Axonal damage occurs due to shearing, tearing, or stretching.
    • Develops within 12-24 hours post-injury; signs include decreased LOC and increased ICP.

    Focal Brain Injury

    • Localized injuries: lacerations and contusions.
    • Coup-contrecoup injuries involve damage from initial impact and rebound.

    Brain Anatomy Protection

    • Brain protected by skull, CSF, and meninges (dura mater, arachnoid mater, pia mater).

    Hematomas

    • Epidural Hematoma: Bleeding between dura mater and skull, often arterial, requires rapid intervention.
    • Subdural Hematoma: Bleeding between dura and arachnoid mater, venous, can be acute or chronic.
    • Intracerebral Hematoma: Bleeding within brain tissue; clinical manifestations vary by location.
    • Subarachnoid Hemorrhage: Bleeding in the space between arachnoid and pia mater.

    Stroke Overview

    • Leading cause of disability and third leading cause of death in Canada.
    • Major risk factors include hypertension, diabetes, cardiovascular disease, and atrial fibrillation.

    Transient Ischemic Attacks (TIA)

    • Temporary neurological deficits, warnings for ischemic stroke.

    Ischemic Stroke Types

    • Thrombotic Stroke: Often due to atherosclerosis, involves clot formation.
    • Embolic Stroke: Occurs when embolus blocks cerebral artery; common emboli include blood clots.

    Stroke Management

    • Immediate treatment is crucial for thrombolytics within 3-4.5 hours.
    • Antiplatelets (Aspirin) and anticoagulants (Warfarin, Apixaban) to prevent further clots.
    • Patient education is essential for recognizing bleeding signs and adherence to medication.

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