Stroke Overview and Classification

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Questions and Answers

Which of the following diagnostic procedures is recommended as an immediate step in assessing a stroke?

Magnetic resonance imaging (MRI)

Immediate CT scan of the head (correct)

Electroencephalogram

Lumbar puncture

When assessing a patient for a possible stroke, which of the following questions is NOT included in the initial assessment process?

When did the symptoms begin?

What medications are they currently taking? (correct)

Is this a stroke?

Are focal deficits present?

In the context of acute stroke management, what is the primary goal regarding the ischemic penumbra?

To completely remove the clot

To ensure better blood circulation

To prevent herniation of the brain

To salvage the ischemic penumbra (correct)

What immediate assessments should be performed to check adequacy in a stroke patient?

Airway, breathing, and circulation (C) Signup and view all the answers

The Cincinnati Prehospital Stroke Scale is primarily used in which aspect of stroke assessment?

Brief neurological examination for focal deficits (B) Signup and view all the answers

Which test is essential for evaluating a patient's blood sugar level during stroke assessment?

Blood glucose test (A) Signup and view all the answers

If subarachnoid hemorrhage (SAH) is suspected but a CT scan is negative for blood, what procedure should be considered?

Lumbar puncture (B) Signup and view all the answers

Which of the following is NOT part of the recommended immediate diagnostic procedures for stroke?

Psychological assessment (A) Signup and view all the answers

What imaging modality should be prioritized for a patient with sudden neurological deficits?

CT and MRI (D) Signup and view all the answers

What is the recommended target for cerebral perfusion pressure when managing blood pressure in patients with suspected elevated ICP?

60 to 80 mm Hg (B) Signup and view all the answers

What is the first-line imaging technique for diagnosing subarachnoid hemorrhage?

CT without contrast (B) Signup and view all the answers

Which symptom is strongly associated with subarachnoid hemorrhage?

Sudden intense headache (C) Signup and view all the answers

In the management of blood pressure for a patient with an SBP >180 mm Hg and suspected elevated ICP, what action should be taken?

Consider aggressive reduction of blood pressure (D) Signup and view all the answers

What initiates the first steps in managing a patient with intracerebral hemorrhagic stroke?

Managing airway, breathing, and circulation (ABCs) (A) Signup and view all the answers

What condition can lead to spontaneous subarachnoid hemorrhage?

Cerebral aneurysms (D) Signup and view all the answers

Which of the following is a risk factor for aneurysmal subarachnoid hemorrhage?

Family history of SAH (B) Signup and view all the answers

Which of the following conditions would exclude a patient from receiving rt-PA treatment?

Serum glucose level of 190 mm Hg (C) Signup and view all the answers

What is the appropriate blood pressure threshold to maintain before administering rt-PA?

Systolic less than 185 mm Hg and diastolic less than 110 mm Hg (B) Signup and view all the answers

Which assessment should be performed every 15 minutes for the first 2 hours after administering rt-PA?

Neurologic status (D) Signup and view all the answers

If a patient with ischemic stroke has elevated intracranial pressure (ICP), what is the recommended position for their head during treatment?

Elevated to 30 degrees (B) Signup and view all the answers

Which medication should be avoided for the first 24 hours after rt-PA administration?

Aspirin (D) Signup and view all the answers

What initial nursing intervention is crucial before administering rt-PA?

Obtain an accurate patient weight (A) Signup and view all the answers

Which symptom requires immediate assessment for complications during and after rt-PA administration?

Bleeding (A) Signup and view all the answers

Which of the following constitutes a relative exclusion criterion for rt-PA administration?

Minor stroke symptoms (B) Signup and view all the answers

Study Notes

Stroke Overview

Stroke is now known as "brain attack" to highlight the urgency
Ischemic brain injury occurs when an arterial blockage lasts more than 2–3 hours

Stroke Definition

Stroke is a descriptive term for the sudden onset of acute neurological deficit lasting longer than 24 hours
Caused by interruption of blood flow to the brain

Stroke Epidemiology

Approximately 795,000 people experience a stroke each year
610,000 are first-time attacks
185,000 are recurrent attacks
Men have a higher incidence of stroke compared to women

Stroke Classification

Early stroke type identification is crucial for appropriate treatment; incorrect treatment can be fatal
Ischemic (80%): Thrombotic (75% - large vessel, 25% - small vessel "lacunar"); Embolic
Hemorrhagic (20%): Intracerebral (67%); Subarachnoid (33%)

Stroke Risk Factors

Age and sex
Hypertension
Hyperlipidemia
Atrial fibrillation
Prosthetic heart valves
Diabetes mellitus
Collagen disorders
Smoking
Oral contraceptive use
Cardiac disease
Recent neck trauma

Initial Assessment Tools

Cincinnati Prehospital Stroke Scale: Facial droop, arm drift, abnormal speech; a score of 1 abnormal sign = 72% probability of a stroke.
FAST: Facial drooping, arm weakness, speech difficulty, time to call 911. Patients should be assessed within 10 minutes of arrival in ED
Immediate computed tomography (CT) scan is essential for further assessment

Ischemic Stroke

Results from interruption of blood flow to the brain due to a thrombus or embolus blocking a cerebral artery.
Emboli often arise from the heart, following atrial fibrillation, MI, or surgery
Pathophysiology: Local thrombus/embolus, decreased blood flow, oxygen deprivation, microscopic necrosis of neurons, and infarction.
Ischemic cascade begins within seconds to minutes after perfusion failure, forming an area of irreversible infarction with a surrounding region of potentially salvageable tissues termed the ischemic penumbra
Goal of acute stroke management is to salvage the ischemic penumbra

Ischemic Stroke - Pathophysiology (Continued)

After a large thrombotic stroke, massive cerebral edema and a rise in intracranial pressure (ICP) can occur causing herniation and death.

Clinical Manifestations of Stroke

Sudden onset of facial weakness
Sudden onset of unilateral weakness
Sudden confusion or speech difficulty (expressive/receptive aphasia)
Sudden headache, nausea, and vomiting (most common with hemorrhagic stroke)
More subtle deficits may include: Dysphagia, sudden visual disturbance, ataxia, sudden numbness/tingling

Further Assessment and Diagnosis

Question 1 (Is this a stroke?): Determine if symptoms are due to a stroke or a stroke mimic (seizures, syncope, or hypoglycemia/hyperglycemia).
Question 2 (When did symptoms begin?): Obtain detailed time of symptom onset and last normal function from the patient, family, or bystanders.
Question 3 (Are airway, breathing, and circulation adequate? ): Rapid assessment of ABCs before transport to CT.
Question 4 (Are focal deficits present?): Initial neurological examination. Cincinnati Prehospital Stroke Scale.
Question 5 (What immediate diagnostic procedures are recommended?): Immediate CT scan of the head, blood glucose, serum electrolytes and renal function tests, 12-lead EKG, cardiac biomarkers, complete blood count including platelet count, PT, INR, activated partial thromboplastin time (aPTT), oxygen saturation, lumbar puncture (if SAH is suspected and CT is negative for blood).

In-depth Neurological Examination

American Stroke Association recommends the National Institutes of Health Stroke Scale (NIHSS) for assessing stroke deficits; conducted over 7 minutes; scores 0 (normal) to 20 (severe).

Therapeutic Interventions

Brain Attack Coalition sets time goals for delivering stroke care within 6 hours (“last seen normal”)
ED door-to-physician examination (10 minutes)
ED door-to-CT scan completed (25 minutes)
ED door-to-CT interpretation (45 minutes)
ED door-to-needle [rt-PA started] (60 minutes)
Goals of treating stroke patients: Restore blood flow, optimize hemodynamics and maintain cerebral perfusion; minimize damage and salvage penumbra;
Establish adequate ABCs; supplemental oxygen if oxygen saturation is less than 92%, consider advanced airway as needed, obtain second IV line with normal saline solution.

Intravenous Thrombolytic Therapy

Recombinant tissue-type plasminogen activator (rt-PA) is the approved treatment for ischemic stroke.
Goal: Begin fibrinolytic therapy within 3 hours of symptom onset.
Dose: 0.9 mg/kg, 10% IV bolus over 1 minute, 90% infusion over 1 hour

Inclusion/Exclusion Criteria for rt-PA

Detailed inclusion and exclusion criteria to evaluate patients for thrombolytic therapy.

Nursing Interventions for rt-PA Patients—Before Administration

Obtain accurate patient weight for dose calculation
Explain risks and benefits to the patient and family
Maintain SBP <185 mm Hg and DBP <110 mm Hg

Nursing Interventions for rt-PA Patients—During/After Administration

Assess for complications (bleeding, angioedema, allergic reaction, worsening neurology)
Perform neurological assessments and vital signs (every 15 minutes for the first 2 hours, then every 30 minutes for 4 to 6 hours)
Elevate the head of the bed to 30 degrees (for patients with elevated ICP or respiratory problems); otherwise, maintain head of bed flat
Record accurate intake and output
Do not administer antithrombotics ( aspirin, heparin, clopidogrel, warfarin, NSAIDs) for 24 hours after rt-PA.
Transfer to the ICU for close monitoring and treatment

Nursing Interventions for rt-PA Patients—During/After Administration (Continued)

Document time of onset of stroke symptoms or “last seen normal”
Document NIHSS on admission
Document patient weight
Document rt-PA dosage given
Document time of the rt-PA bolus
Document swallow screen results

Management of Blood Pressure in Stroke Patients

Cautiously lower blood pressure (15–25% in first 24 hours) when indicated
Labetalol (Trandate) is a first-line agent for stroke blood pressure control; working quickly, not too aggressive, and short acting.
Dose: 10 mg IV over 1-2 minutes; up to 20 mg. Observe for change in BP.

Transient Ischemic Attacks (TIA)

Brief episodes of neurological dysfunction from focal cerebral ischemia without permanent brain infarction.

TIA Risk Assessment—ABCD2 Scoring System

Tool for predicting risk of stroke after TIA.
Factors like age, blood pressure, clinical features, and duration of symptoms are used to assess risk.

Hemorrhagic Stroke

Stroke due to intracranial hemorrhage, not ischemia
Anticoagulants and fibrinolytics are contraindicated

Intracerebral Hemorrhage (ICH)

Bleeding directly into brain tissue
Causes: Hypertension, coagulopathy, anticoagulation, arteriovenous malformation (AVM), aneurysm, illicit drug use
Clinical manifestations: Rapidly deteriorating neurological deficits, severe headache, vomiting, high blood pressure.

Subarachnoid Hemorrhage (SAH)

Bleeding into the subarachnoid space
Approximately 3% of all stroke cases
High rate of disability and mortality (approximately 50% of patients die following initial injury)
Causes: Cerebral aneurysms (family history, hypertension, cigarette smoking, female gender, increasing age, alcohol abuse, use of stimulants)
Clinical manifestations are sudden/severe/unrelenting headache.

SAH—Diagnostic Procedures

First-line imaging: CT scan without contrast
CT negative: Lumbar puncture suspected SAH

SAH—Initial Treatment

Prevent rebleeding of aneurysm
Maintain systolic BP of 90–140 mm Hg
Administer analgesics as needed
Short-acting sedatives for agitated patients

SAH—Intensive Care Management

Perform frequent neurological assessment
Maintain body temperature < 37.5°C
VTE prophylaxis (elastic stockings or pneumatic compression devices; avoid anticoagulants)
Admission to an ICU.
Surgical clipping/endovascular coiling of aneurysm; anticipate/initiate transfer to a tertiary center.

General Nursing Interventions for Different Stroke Types

Establish ABCs (oxygen, airway, IV line)
Perform frequent neurological assessments
Maintain NPO until a swallow test is cleared
Manage increased ICP
Maintain normothermia
Maintain serum glucose below 140 mm Hg
Communicate effectively with the patient and family
Provide supportive care

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Description

This quiz covers the essential aspects of strokes, including definitions, epidemiology, types, and risk factors. Understand the urgency surrounding strokes, their classification, and the importance of timely treatment. Perfect for anyone looking to enhance their knowledge on this critical health issue.