Stroke and Symptoms Overview

Stroke/Apoplexy/Brain Attack/Cerebrovascular Accident (CVA)

• Stroke is a medical emergency
• Occurs due to interruption in blood supply to a part of the brain
• Leads to cell death and loss of function in affected area
• Stroke happens when there is ischemia (inadequate blood flow) or hemorrhage into the brain, causing brain cell death
• A stroke or cerebrovascular accident (CVA) is a rapidly developing focal or global disturbance of cerebral function that lasts for 24 hours or longer, or leads to death, with no apparent cause other than a vascular origin.

Signs and Symptoms

• Weakness on one side of the body, which can include the face
• Inability to rise from a sitting or lying position
• Sudden falls
• Loss of speech
• Difficulty walking, dizziness, or balance issues
• Coordination difficulties
• Loss of consciousness in some patients
• Seizures
• Paralysis of a limb or face
• Initial limpness/flaccidity, followed by spasticity and exaggerated reflexes
• Loss of half of the visual field (homonymous hemianopsia)
• Hemiplegia (paralysis of one side of the body) due to a lesion on the opposite side of the brain
• Neck stiffness (in subarachnoid hemorrhage)
• Severe headache and/or neck pain (subarachnoid hemorrhage)
• Dysarthria (difficulty speaking) due to muscle paralysis
• Dysphasia (impaired speech) or aphasia (loss of speech) which could be expressive, receptive, or global (mixed).
• Apraxia (inability to perform learned actions), possibly with verbal substitutions
• Loss of self-control
• Emotional lability
• Reduced stress tolerance
• Depression
• Withdrawal or feelings of isolation
• Fear, hostility, and anger

Types and Causes of Stroke

• Ischemic Stroke: Blood supply to a part of the brain is reduced, leading to dysfunction and necrosis of brain tissue. This accounts for approximately 80% of all strokes.

  • Thrombotic stroke: Caused by a blood clot forming in a blood vessel within the brain. Clots build up at sites of atherosclerosis, causing narrowing.
    • Common cause of stroke.
    • Often associated with hypertension or diabetes.
    • Preceded by TIA in 30-50% of individuals.
  • Embolic stroke: Caused by a blood clot forming elsewhere in the body and travelling to the brain. It lodges in and occludes a cerebral artery, causing area infarction and edema.
    • Second most common cause of stroke (accounting for ~24%).
    • Emboli commonly originate in the endocardium of the heart.

• Hemorrhagic Stroke: Bleeding occurs within or around the brain tissue. Common causes:

  • Intracerebral hemorrhage: Bleeding within the brain tissue
    • Typically due to hypertension
    • Prognosis is often poor.
  • Subarachnoid hemorrhage: Bleeding into the subarachnoid space
    • Can be due to cerebral aneurysms or arteriovenous malformations.

Transient Ischemic Attack (TIA)

• A "mini-stroke"
• Temporary reduction in blood flow to a part of the brain.
• Stroke-like symptoms.
• Symptoms resolve within 24 hours, usually within minutes to hours.
• Warning sign for potential future strokes.

Risk Factors

• Non-modifiable:

  • Increasing age (risk doubles each year after age 55)
  • Race (higher in blacks and Hispanics)
  • Gender (men have a 50% higher risk)
  • Family history of stroke or TIA

• Modifiable:

  • High blood pressure
  • Smoking
  • Diabetes
  • High cholesterol
  • Physical inactivity
  • Obesity
  • Excessive alcohol consumption
  • Heart disease (specifically atrial fibrillation)
  • Sickle cell anemia
  • High cholesterol levels
  • Drug abuse
  • Hormone replacement therapy (HRT)
  • Use of birth control pills or oral contraceptives

Investigations

• CT Scan: Distinguishes between ischemic and hemorrhagic stroke
• MRI: Detects early ischemic changes and small infarcts.
• Blood tests: Rule out other causes and assess clotting, check for underlying conditions
• Angiography: Visualizes blood vessels in the brain and identifies blockages
• Echocardiogram: Assesses the heart (for potential embolic sources)
• Electrocardiogram (ECG): Detects cardiac arrhythmias (like atrial fibrillation)
• FBC
• ESR
• Blood glucose
• Serum lipid profile
• Blood urea, electrolytes, and creatinine
• Uric acid
• Chest X-ray
• Complete physical and neurologic examinations
• Clinical manifestations

Treatment Objectives

• Limit the progression of brain damage
• Protect patients from unconsciousness and immobility
• Treat the underlying cause, if possible
• Improve functional recovery
• Support and rehabilitate patients with residual disability
• Prevent recurrence of cerebrovascular lesions.

Non-Pharmacological Treatment

• Admit and monitor vital signs and neurological signs frequently.

• Establish an adequate airway in unconscious patients.

• Nurse the patient in the lateral position, with suctioning as needed.

• Prevent pressure sores by repositioning (every 2 hours).

• Maintain adequate hydration

• Insert nasogastric tube as soon as possible for feeding and medications (especially for unconscious or swallowing-impaired patients)

• Insert urethral/condom catheter

• Early physiotherapy.

Pharmacological Treatment

• Hemorrhagenic strokes

  • Antihypertensive medications (gradually reduce blood pressure over several days)
  • Control other comorbidities (like diabetes)

• Ischemic strokes

  • Aspirin (75 mg daily)
  • Statins (like atorvastatin, 10-40 mg daily; or rosuvastatin 5-10 mg daily, or simvastatin 20 mg daily irrespective of lipid levels)

Nursing Management

• Visual problems:
  • Place objects within the patient's intact visual field
  • Approach from the side of the intact field
  • Instruct to turn head to compensate for visual loss
  • Encourage use of glasses if available.
  • When teaching, maintain correct visual position
  • Utilize assistive devices (like canes)
• Management of paralysed site:
  • Keep objects within patient's reach (non-affected side)
  • Exercise unaffected side for strength
  • Range-of-motion exercises (affected side).
  • Immobilization if needed
• Positioning: Maintain body alignment in functional position; support patient to prevent falls (esp. initially).
• Mobility: Provide supportive devices (walkers, canes)
• Communication: Alternative methods (bell, sufficient time, support for difficulties, language therapy with speech therapist)
• Nutrition: pharyngeal reflexes assessment before feeding, dietary modifications, feeding assistance, adequate hydration, frequent small servings.
• Prevent burns (from hot meals), monitor fluids.
• Swallowing therapy: health care team collaboration, sitting upright, forward flexion.
• Maintain sitting position after meals, emergency choking instructions given to the person. Check mouth to prevent food from being trapped and to prevent putrefaction and aspiration. Mouth care.
• Psychological care: alleviate anxiety, support during outbursts of emotion, encourage group activities, handle stressful situations, encourage conversation, involve family and friends, promote social support
• Urinary habit training: record voiding patterns and use toileting schedules. Train the patient to consciously hold urine until the scheduled toileting times, giving reinforcement.
• Other nursing management: rest and sleep, observation, personal hygiene, education.

This quiz covers the critical aspects of stroke, including its definition, types, and physiological impacts such as cell death due to disrupted blood supply. It also examines the various signs and symptoms that can help in identifying a stroke, facilitating prompt medical attention and intervention.