Stroke Management Spring 2024-25 PDF

Management of Patients with Cerebrovascular Disorders: Stroke Spring 2024-25 Outline Understand stroke and its types Stroke pathophysiology & clinical manifestations Diagnosis & acute management of stroke Nurse’s role Prevention Rehabilitation Stroke Brain Attacks, Cere...

Management of Patients with Cerebrovascular Disorders: Stroke Spring 2024-25 Outline Understand stroke and its types Stroke pathophysiology & clinical manifestations Diagnosis & acute management of stroke Nurse’s role Prevention Rehabilitation Stroke Brain Attacks, Cerebrovascular Accident (CVA), or Cerebral Infarction. Stroke is the third leading cause of death in the United States. It is an emergency situation that needs attention. Stroke is characterized by the sudden loss of O2 rich circulation to an area of the brain, resulting in death of nerve cells and a corresponding loss of neurological function. It can lead to serious long-term disability or even death. Stroke is either: 1. Ischemic: 80 to 85% of the cases 2. Hemorrhagic: 15 to 20% of the cases  Modifiable Hypertension Risk Factors Cardiovascular disease ( arterial anomalies, atrial fibrillation, Nonmodifiable valvular disease) Age (older than 55 Elevated cholesterol years); though younger adults may have it too Obesity Male gender Diabetes African American Smoking descent Drug and alcohol abuse Hispanics & Asian ethnicity Oral contraceptive use Sedentary lifestyle Previous TIA Clinical Approach to Stroke Ischemic Stroke Hemorrhagic Stroke Causes Causes Large artery thrombosis due to Intracerebral hemorrhage; atherosclerosis (20%) Subarachnoid hemorrhage; Cerebral Small penetrating artery aneurysm; thrombosis/ lacunar (25%) Arteriovenous malformation. Cardiogenic embolism (20%) due to valvular disease, and atrial fibrillation Cryptogenic (30%) ( unknown cause) Other (5 %) due to drug use Main Presenting Main Presenting Symptom Symptom Numbness or weakness of the face, Exploding headache arm, or leg, especially on one side of Decreased level of consciousness the body. Functional Recovery Functional Recovery Ischemic Stroke Pathophysiology of Ischemic Stroke Disruption of the blood supply to the artery caused by an obstruction, usually a THROMBUS or EMBOLUS, that causes infarction of brain tissue. The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.  Infarction/Penumbra Seconds to minutes of the loss of perfusion to a portion of the brain leading to a central area of irreversible infarction surrounded by an area of potentially reversible ischemic penumbra. Definition of Penumbra: A border of mild to moderately ischemic tissue lying between tissue that is normally perfused and the area in which infarction is evolving, may remain viable for several hours. The penumbra is where pharmacologic interventions are most likely to be effective. During the evolution of a stroke, there usually is a central core of dead or dying cells, surrounded by an ischemic area of minimally perfused cells called the penum Whether the cells of the penumbra continue to survive depends on the successful return of adequate circulation and the volume of toxic products released by the neighboring dying cells. 10  Time Lost is Brain Lost Around 1.9 million neurons lost in a minute The time of restoring cerebral blood flow is a critical factor. Reperfusion must occur within 3-4.5 hours for the ischemic penumbra to be saved (therapeutic window) The central goal of therapy in acute ischemic stroke is to salvage the ischemic penumbra and reduce time of ischemia. The longer the ischemia the more the symptoms. Ischemia can be stopped by administration of thrombolytic therapy or surgical thrombectomy. Symptoms depend on the location, size, presence of collaterals in the affected area oNumbness or weakness of face, arm, or leg, especially on one side oTrouble speaking or understanding speech oDifficulty in walking, dizziness, or loss of balance or coordination oConfusion or change in mental status oVisual disturbances oSudden, severe headache oWatch the video BEFAST- https://youtu.be/UiHXIBTkKu4  How to Recognize a Stroke BEFAST: ‘Balance, Eyes, Face, Arms, Speech, Time' Can the person smile and show their teeth without one side of the face seeming to droop? Can they hold both arms out without one arm sinking? Can they speak with their usual clarity? If you are outside hospital and the answer to any of these questions is 'no', call an ambulance and say that you suspect a stroke. 14  Motor loss Hemiplegia: Paralysis of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere. Hemiparesis: Weakness of the face, arm, and leg on the same side due to a lesion in the opposite Manifestation hemisphere. Dysphagia: Difficulty in s swallowing. Ataxia: unsteady gait & balance Communication lossfeet together, and inability to keep or walking Dysarthria: Difficulty speaking, problem in articulation- caused by paralysis of the muscles responsible for producing speech- slurred speech. Aphasia: Expressive aphasia – comprehends but is unable to speak (damage to the Broca’s  Sensory loss Sudden loss of vision in one or both eyes Hemianopsia: Loss of half of the visual field Neglect Syndrome: Unaware of existence of the paralyzed side Agnosia: Inability to recognize previously familiar object Paresthesia: a sensory deficit that occurs on the Manifestati side opposite the lesion. Sensation of numbness, tingling, or a “pins and needles” sensation + ons Cognitive loss Difficulty with proprioception. Frontal lobe damage: difficulties in comprehension, forgetfulness, and lack of motivation. Cognitive deficits: Short- and long-term memory loss + Decreased attention span + Impaired ability to concentrate + Poor abstract reasoning + Altered judgment, Limited learning capacity Psychological loss Depression, emotional lability, hostility, frustration, resentment, and lack of cooperation Homonymous Hemianopsia of the Right side Neglect syndrome Neglect Syndrome of the Left side 18 Agnosia A. Failure to recognize familiar objects perceived by the senses  COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES Right hemispheric Left Hemispheric ( dominant ) Paralysis or weakness on the left side of Paralysis or weakness on the right side of the body the body Left visual field deficit- lft side neglect Right visual field deficit Spatial-perceptual deficits- shapes Aphasia (expressive, receptive or global); issues with writing Increased distractibility; short attention Altered intellectual ability; issues with math span Impulsive behavior and poor judgment Slow, cautious behavior; aware of their limits Lack of awareness of deficits; denial of Depression, anger & frustration limitations  Assessment of stroke NIH Stroke Scale NIH Stroke Scale helps health care providers assess the severity of a stroke. Health care providers use it to measure neurological function and deficits by asking the person to answer questions and perform several physical and mental tests. This checklist of questions and tasks scores a person's level of alertness and ability to communicate and perform simple movements. Using a numerical scale to determine stroke severity, health care providers record the person’s performance in 11 categories. Level of consciousness; Best Gaze; Visual; Facial Pulsy, Motor Arm; Motor leg; Limb ataxia; sensory; best language; Dysarthia; Extinction and attention; Score ranging from 0-42 Characteristics of Stroke Dependent on Vascular Territory Affected 22 23  Transient Ischemic Attack: TIA Transient ischemic attacks (TIAs) precede nearly 15% of ischemic strokes. TIA is characterized by ischemic cerebral neurologic deficits that last for few minutes or hours- less than 24 hours. TIA or MINI-STROKE is equivalent to BRAIN ANGINA and reflects a temporary disturbance in cerebral blood flow, which reverses before infarction occurs restoring blood flow; analogous to angina in relation to heart attack. Thus the clot disintegrates and there is no evidence of infarction.  Short lived neurologic deficit (less than few hours) resulting from a temporary impairment of blood flow Transie Although most TIAs last only a few minutes, all TIAs should be nt evaluated with the same urgency as a stroke to prevent recurrences Ischemi and/or strokes. c Attack “Warning of an impending stroke” (TIA) TIA is still a medical emergency. If left untreated, TIAs lead to ischemic stroke The initial diagnostic test is a CT scan performed within the first 25 minutes of patient arrival to ED.  Immediate/ acute nursing actions Assessment (ABCDs): secure airway, breathing and circulation, good oxygen saturation >92% : Measure BP, P , RR, T & SpO2 Cannulate ( start an IV) and take blood samples.(CBC, PT, PTT, INR, BS) Complete a 12 lead ECG/electrocardiogram. Measure BS- Hypoglycemia may mimic stroke or TIA; and severe hypoglycemia alone can cause neuronal injury. Make neurological assessments every 15 minutes; CN and LOC Keep head of bed elevated 30 degrees when signs of increased ICP or at zero level- neutral position- before surgery; unless contraindicated Arrange emergency CT scan without contrast; and carotid ultrasound. stabilize vital physiologic functions before sending the patient Supportfor an imaging friends study. and family Management: Acute Phase of Stroke Stroke is a medical emergency needing prompt diagnosis and treatment: brain imaging and a careful history to determine whether the patient meets the criteria for thrombolytic therapy. Some of the contraindications for intravenous thrombolytic therapy include symptom onset greater than 3 hours before admission (expanded to 4.5 hours in some centers), a patient who is anticoagulated (with an INR above 1.7), a patient who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma). The goal is that diagnostic results from imaging are completed within 25 minutes of the patient’s arrival to the ED. Eligibility Criteria for Tissue Plasminogen Activator CT scan isAdministration negative for bleeding; Age ≥18 years Time of onset of stroke known and is 3 (or 4.5) hours before admission SBP ≤185 mm Hg and DBP ≤110 mm Hg Platelet count ≥100,000/mm3 No minor stroke or rapidly resolving stroke No seizure at onset of stroke Not taking warfarin; PT ≤15 seconds or INR ≤1.7. Did not receive heparin during the past 48 hours with elevated PTT No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm No major surgical procedures within 14 days No serious head injury, or intracranial surgery within 3 months No gastrointestinal or urinary bleeding within 21 days  Dosage of t-PA Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. Ten percent of the calculated dose is administered as an IV bolus over 1 minute. The remaining dose (90%) is administered IV over 1 hour via an infusion pump. Side Effects of t-PA Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding (IV insertion sites, urinary catheter site, endotracheal tube, nasogastric tube, urine, stool, emesis, other secretions). No anticoagulant agents are administered for the next 24 hours. A 24-hour delay in placement of nasogastric tubes and urinary catheters is recommended. Monitor BP; avoid unnecessary IV pricks or injections  Thrombectomy Thrombectomy or mechanical thrombectomy is a relatively new procedure used to treat some ischemic stroke patients. Thrombectomy involves using a specially-designed clot removal device inserted through a catheter to pull the clot to restore blood flow. Evidence shows thrombectomy can significantly reduce the severity of disability a stroke can cause. Thrombectomy is most effective the faster it is used following a stroke and it is normally only performed up to six hours after symptoms start. It is only used in the very short term. Thrombectomy can currently only be used to treat patients with blood clots in the brain’s large central vessels. It cannot be used to treat hemorrhagic strokes (bleeds to the brain)  Nursing Monitoring Providing supplemental oxygen if oxygen saturation is below 92%. Monitor issues with swallowing/ oral secretions- suction at the bedside Keep head in neutral position. HOB may be elevated to 30 degrees or kept at 0 for thrombectomy. Continuous hemodynamic monitoring. Low HR, low and shallow RR and high BP are indicative of high ICP. Frequent neurologic assessments: cranial nerves- pupils, swallowing , facial nerves, gaze, gag reflex, ect. Assess visual field side to side to prevent injury or fall ( neglect phenomenon) Monitoring for hypo or hyperglycemia  Nursing Monitoring Assess bowel function: incontinence or retention ( bedpan, foley catheter) Skin integrity: positioning every 2 hrs, Passive range of motion Diet: Difficulty swallowing- thick fluids, crushed meds, mechanically soft diet; assist with the food ( pouching food in the cheek- aspiration) Fluid replenishment when patient is volume depleted Possible hemicraniectomy for increased ICP from brain edema in a very large stroke. Intubation with an endotracheal tube to establish a patent airway, if necessary. Multidisciplinary approach: speech therapy, dietician, occupational therapy, physical therapy Incorporate the family in the care of the patient Nursing Interventions for impaired communication For receptive aphasia: unable to comprehend use short phrases and simple details Use gestures and point the things you are talking about Be patient with them- no rushing Remove distractions; rephrase comments and repeat Use language etiquette – do not shout Maintain eye contact and allow the patient to see your mouth; do not turn away when speaking. Give the patient plenty of time to respond. For expressive aphasia: comprehend but trouble responding back Be patient, let them speak Do not rush; Ask 1 question at a time- be direct and make them simple Use other communication methods  Surgical Prevention of Ischemic Stroke Carotid Endarterectomy is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries. This surgery is indicated for patients with symptoms of TIA or mild stroke (those without symptoms) that are found to have severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) stenosis with other significant risk factors.  Preventive Treatment and Secondary Prevention It is estimated that 70% of strokes could be prevented by: Effective management of hypertension, atrial fibrillation, diabetes mellitus, cholesterol and addressing lifestyle factors such as smoking, sedentary lifestyles. Carotid endarterectomy Anticoagulant therapy Antiplatelet therapy: aspirin, dipyridamole plus aspirin (Aggrenox), Clopidogrel (Plavix) Statins Antihypertensive medications  Nursing Diagnosis 1. Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury. 2. Acute pain (painful shoulder) related to hemiplegia and disuse. 3. Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae. 4. Impaired physical comfort related to altered sensory reception, transmission, and/or integration. 5. Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating.  Nursing Diagnosis 6. Impaired swallowing. 7. Constipation related to change in mental status or difficulty communicating. 8. Acute confusion related to brain infarction. 9. Impaired verbal communication related to brain damage. 10. Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility. 11. Interrupted family processes related to catastrophic illness and caregiving burdens. 12. Sexual dysfunction related to neurologic deficits or fear of failure. Collaborative Problems/ Potential Complications 1. Decreased cerebral blood flow due to increased ICP 2. Inadequate oxygen delivery to the brain 3. Pneumonia 4. Risk for infection 5. Risk for injury Long term Nursing goals 1. Improving Mobility and Preventing Joint Deformities 2. Preventing Shoulder Pain 3. Enhancing Self-Care – empowering the patient 4. Adjusting to Physical Changes 5. Assisting with Nutrition: Dysphagia Screening 6. Attaining Bladder and Bowel Control 7. Improving Thought Processes 8. Improving Communication 9. Maintaining Skin Integrity 10. Improving Family Coping 11. Helping the Patient Cope with Sexual Dysfunction Hemorrhagic Stroke  Pathophysiology of Hemorrhagic Stroke Hemorrhagic stroke is bleeding into brain tissue, the ventricles, or subarachnoid space. Normal brain metabolism is disrupted by:  The brain’s exposure to blood  An increase in ICP resulting from the sudden entry of blood into the subarachnoid space, which compresses and injures brain tissue  Secondary ischemia of the brain resulting from the reduced perfusion pressure and vasospasm that frequently accompany subarachnoid hemorrhage.  Two subtypes of hemorrhagic stroke: intracerebral and subarachnoid Intracerebral hemorrhage: In an intracerebral hemorrhage (ICH), bleeding occurs within the brain. This damages the brain as blood collects and puts pressure on the surrounding tissue. Some common causes of ICH include: High blood pressure Injury- trauma Bleeding disorders Deformities in blood vessels, such as an aneurysm (a weakening in the lining of the blood vessel) Subarachnoid hemorrhage: Subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain ruptures. The blood builds up and causes pressure in the "subarachnoid" space, which is between two layers of the tissue covering the brain. The most common early symptom of a subarachnoid hemorrhage is a severe headache called "thunderclap headache," which many patients describe as the worst headache of their life. Intracranial (Cerebral) Aneurysm This is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. They usually occur at the bifurcations of large arteries at the circle of Willis. An aneurysm may be due to atherosclerosis, which results in a defect in the vessel wall with subsequent weakness of the wall; a congenital defect of the vessel wall; hypertensive vascular disease; head trauma; or advancing age. The cerebral arteries most commonly affected are the : internal carotid, anterior cerebral, anterior communications, posterior communicating, posterior cerebral and middle cerebral arteries. Arteriovenous Malformations Most AVMs are caused by an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed. The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture. AVM is a common cause of hemorrhagic stroke in young people. Manifestations of hemorrhagic stroke Early and sudden Similar to Severe/ changes in ischemic EXPLODING LOC ( due to stroke headache brainstem involvement) Nausea & Hypertension Seizures Vomiting The 30-day Associated mortality rate with higher for mortality hemorrhagic rates stroke is 50%. Assessment and Diagnostic Findings CT scan: to determine the type of stroke, the size and location of the hematoma, and the presence or absence of ventricular blood and hydrocephalus; sometimes need to be repeated after 12-24 hrs Cerebral Angiography: to confirm the diagnosis of an intracranial aneurysm or AVM. Lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage. Lumbar puncture in the presence of increased ICP could result in brain stem herniation or re-bleeding. When diagnosing a hemorrhagic stroke in a patient younger than 40 years, some clinicians obtain a toxicology screen for illicit drug use.  Complications Potential complications of hemorrhagic stroke include: Cerebral hypoxia and decreased blood flow Re-bleeding or hematoma expansion Increased ICP seizures Cerebral vasospasm resulting in cerebral ischemia Cerebral Hypoxia & Decreased Blood Flow Management Adequate hydration (IV fluids) must be Avoid extremes of Administer ensured to reduce hypertension or supplemental oxygen blood viscosity and hypotension to ( maintain the ABCs) improve cerebral prevent changes in blood flow. (favorably cerebral blood flow. NSS) Observe for seizure Maintaining Hb and activity A seizure can HcT at acceptable also compromise levels to maintain cerebral blood flow, tissue oxygenation. resulting in further injury to the brain.  Vasospasm/ re- bleeding Narrowing of the lumen of the involved cranial blood vessel. Mechanism is not clear. The body naturally responds to bleeding by narrowing the blood vessel to slow blood flow. Vasospasm is often heralded by a worsening headache, a decrease in LOC (confusion, lethargy, and disorientation), or a new focal neurologic deficit (aphasia, hemiparesis). Vasospasm most frequently occurs 7 to 10 days after initial hemorrhage, when the clot undergoes lysis (dissolution), and the chance of re-bleeding is increased. It impedes cerebral blood flow and causes brain ischemia and infarction. Early surgery to clip the aneurysm prevents re-bleeding and may prevent vasospasm.  Vasospasm/ re- bleeding  The most frequently used calcium channel blocker is Nimodipine.  The primary function of nimodipine is to block calcium channels avoiding this influx, to prevent vasoconstriction.  It has a preference to act on cerebral blood vessels since it can cross the blood-brain barrier.  Current guidelines recommend that Nimodipine be prescribed for all patients with subarachnoid hemorrhage.  Early surgery to clip the aneurysm prevents rebleeding may prevent vasospasm. Increased Intracranial Pressure An increase in ICP can occur after either an ischemic or a hemorrhagic stroke but almost always follows a subarachnoid hemorrhage, usually because of disturbed circulation of CSF. Neurologic assessments are performed frequently, and if there is evidence of deterioration from increased ICP, CSF drainage may be done by ventricular catheter drainage. Mannitol ( osmotic dieuretic) may be administered to reduce ICP. When mannitol is used as a long-term measure to control ICP, dehydration and disturbances in electrolyte balance (↑↓ Na; ↑↓ K) may occur. Mannitol pulls water out of the brain tissue by osmosis and reduces total body water through diuresis. The patient’s fluid balance is monitored continuously and is assessed for signs of dehydration and for rebound elevation of ICP. Other interventions may include 0 degree head positioning sedation, hyperventilation, and use of hypertonic saline.  Hypertension Systolic BP may be lowered to prevent hematoma enlargement. If BP is elevated, antihypertensive therapy (Labetalol, Nicardipine, Nitroprusside, Hydralazine) may be prescribed. During the administration of antihypertensive agents, hemodynamic monitoring is important to detect and avoid a precipitous drop in blood pressure, which can produce brain ischemia. Stool softeners are used to prevent straining, which can elevate the blood pressure. In acute ischemic stroke lowering BP is associated with poor outcome  Medical Management The goals of medical treatment for hemorrhagic stroke are to: allow the brain to recover from the initial insult (bleeding) prevent or minimize the risk of rebleeding prevent or treat complications Management may consist of: bed rest with sedation to prevent agitation and stress, management of vasospasm  If seizures occur, they are treated with antiseizure drugs such as Phenytoin. Hyperglycemia should also be treated, and normo-glycemia is recommended. Analgesic agents may be prescribed for head and neck pain. Fever should be treated with acetaminophen (Tylenol), iced saline boluses, and devices such as cooling blankets.  The patient is fitted with sequential compression devices or anti-embolism stockings to prevent deep vein thrombosis (DVT). If the patient is not mobile after 1 to 4 days from the onset of the hemorrhage and there is documentation of the bleeding ceasing, then DVT prevention medications (low-molecular- weight heparin or unfractionated heparin) may be prescribed. After discharge, most patients will require antihypertensive medications to decrease their risk of another intracerebral hemorrhage.  Alert If the bleeding is caused by anticoagulation with warfarin, the INR may be corrected with fresh- frozen plasma and vitamin K. Reversing the anticoagulation effect of the newer anticoagulants is more complicated. Surgical Management In many cases, a primary intracerebral hemorrhage is not treated surgically. However, if the patient is showing signs of worsening neurologic examination, increased ICP, or signs of brain stem compression, then surgical evacuation is recommended for the patient with a cerebellar hemorrhage. Surgical evacuation is most frequently accomplished via a craniotomy.  Rehabilitation Physical therapist Occupational therapist Speech therapist ( for speech and swallowing) Deititian