CEREBROVASCULAR ACCIDENT

(CVA)
The Human Brain
CEREBROVASCULAR ACCIDENTS (CVA)
•A sudden focal neurological deficit due to cerebral vascular
disease; most common cause of brain disturbance.

•Characterized by the gradual or rapid, onset of neurologic

deficits that fit a known vascular territory and last for at least
24 hours.
•Occurs when impaired circulation in the brain disrupts the
supply of oxygen.
•Recovery from a CVA depends on how quickly and
completely circulation is restored. However, almost half of all
patients who survive a CVA are permanently disabled and
will suffer a recurrent attack.

•Alternate names: Cerebral Infarction, Stroke,

Cerebrovascular Disease
Causes of CVA:
A cerebrovascular accident results from impaired circulation in one or
more of the brain’s blood vessels. Impairments are usually caused by:

•THROMBUS
The most common cause of CVA, which is usually related to
atherosclerosis. Plaque and atheromatous deposits gradually occlude the
artery. Occlusion leads to ischemia and infarction of brain tissue, followed
by edema and necrosis. It usually occurs in the extracerebral vessels but
sometimes occurs in the intracerebral vessels.
•HEMORRHAGE
The most devastating cause of CVA, hemorrhage
occurs when a cerebral vessel ruptures and bleeds into
brain tissue or subarachnoid space. Usually results
from a rupturing arteriosclerotic vessel caused by
exposure to prolonged hypertension, a cerebral
aneurysm. Effects may be severe. More than 50% of
patients die within the first 3days from brain herniation.
 Photographs show acute, massive hypertensive
hemorrhages. Note that the blood here is under
enough driving pressure to destroy the tissue,
rupture through the ependymal lining and fill the
ventricle with blood. When massive, these tend to
be fatal events.
C. EMBOLISM

Usually, fragments
break off from a mural
thrombus in the left atrium
or ventricles or from
bacterial vegetations
affecting heart valves.
These emboli travel through
the carotid artery and
typically lodge in the
smaller cerebral vessels. It
may occur quite suddenly,
often followed by necrosis
and edema.
B. Risk factors.
1. Atherosclerosis
2. Hypertension
3. Anticoagulation therapy
4. Cardiac vascular disease
5. Synthetic valve and organ displacement
6. Atrial arrhythmias
7. Diabetes

C. Signs and Symptoms.

•persistent headache
•dizziness or slight headache
•altered LOC
•blurring of vision one or both eyes
•stumbling of speech
•bowel or bladder incontinence
D. Interruptions of blood supply to brain via carotid and
vertebral-basilar arteries--- causes’ cerebral anoxia.

E. Cerebral anoxia longer than ten minutes to a localized area

of brain—causes cerebral infarction (irreversible changes).
F. Surrounding edema and congestion causes further
dysfunction.

G. Lesion in cerebral hemisphere (motor cortex, internal

capsule, basal ganglia)—results in manifestations on the
contralateral side.

H. Permanent disability unknown until edema subsides. Order

in which function may return: facial, swallowing, lower limbs,
speech, arms.
Assessment:

•Evaluate transient ischemic attack (TIA), a

precursor symptom or warning of impending
ischemia.
A.Rapid onset and short duration (30 minutes
to 24 hours); No permanent neurological
deficit.
B.Most common symptoms: vision loss,
diplopia, contralateral hemiparesis, aphasia,
confusion, slurred speech and vertigo.
•Carotid endartectomy is a surgical procedure for
carotid stenosis—often done following TIA or
presence of stenosis.
•Procedure removes atherosclerotic plaque from
arterial wall.
•Monitor closely first 24 hours for cerebral
ischemia or thrombosis or intolerance from carotid
clamping.

•Observe for generalized signs: headache,

hypertension, changes in level of consciousness,
convulsions, vomiting, slow bounding pulse, Cheyne-
Strokes respirations.
D. Evaluate residual manifestations
• Lesion left hemisphere
• Behavior is slow, cautious, disorganized.
• Usually dominant, containing speech center, right
hemiplegia, aphasia, expressive and/or receptive.

• Lesion right hemisphere

• Left hemiplegia; spatial-perceptual deficits.
• Behavior is impulsive, quick; unaware of deficits; poor
judge of abilities, limitations; neglect of paralyzed side.

• General
• Memory deficits; reduced memory span; emotional
liability.
• Visual deficits such as homonomous hemianopia (loss of
half of each visual field).
• Apraxia (can move but unable to use body part for
specific purpose).
 NURSING MANAGEMENTS:
•Initial nursing objective is to support life and prevent
complications.
•Maintain patient airway and ventilation--- elevate
head of bed 20 degrees unless shock is present.
•Monitor clinical status to prevent complications.

•Neurological
•Include assessment of recurrent CVA,
increased intracranial pressure, hyperthermia.
•Continued coma--- negative prognostic’ sign
•Cardiovascular--- shock and arrythmias,
hypertension.
•Lungs--- Pulmonary emboli.
D. Maintain optimal positioning.
During acute stages, quiet environment
and minimal handling to prevent further
bleeding.

Upper motor lesion--- spastic paralysis,

flexion deformities, external rotation of
hip.
Position schedule--- 2hours on unaffected
side, 20minutes on affected side.

Complications common with

hemiplegia--- frozen shoulder, footdrop.
E. Maintain skin integrity: turn and provide skin care.
F. Maintain personal hygiene: encourage self-help.
G. Promote adequate nutrition, fluid, and electrolyte
balance.
•Encourage self-feeding.
•Food should be placed in unparalyzed side of mouth.
•Tube feedings or gastrostomy feeding may be
necessary.
H. Administer tube feedings.
I. Promote elimination.
•Bladder control may be regained within three to five
days.
•Retention catheter may not be part of treatment
regimen.
•Offer urinal or bedpan every two hours day and night.
I. Promote elimination.
•Bladder control may be regained within three to five
days.
•Retention catheter may not be part of treatment
regimen.
•Offer urinal or bedpan every two hours day and
night.

J. Provide emotional support.

•Behavior changes as consciousness is regained---
loss of memory, emotional liability, confusion,
language disorders.
•Reorient, reassure, and establish means of
communication.
K. Promote rehabilitation to maximal functioning.

•Comprehensive program--- begins during acute phase and follows

through convalescence.

•Guidelines to assist client with lesion left hemisphere.

1.Do not underestimate ability to learn.
2.Assess ability to understand speech.
3.Act out, pantomime communication; use client’s term to
communicate; speak in normal tone of voice.
4.Divide tasks into simple terms; give frequent feedback.

•Guidelines to assist client with lesion right hemisphere.

•Do not overestimate abilities,
•Use verbal cues as demonstrations; pantomimes may confuse.
•Use slow, minimal movements and avoid clutter around client.
•Divide tasks into simple steps; elicit return demonstration of skills.
•Promote awareness of body and environment on affected side.
Medical treatment:

Steroids/corticosteroids given in full stomach with antacid or

H2 receptor antagonists
Vitamin B complex – promote restitution of function of neurons
which have reversible damage.
Cerebral activator/stimulants – stimulate CNS function.
nootrophil- PIRACETAM
encephabol- PYRITINOL HCl
hydergine- CODERGOCRIN
Drugs if it is due to thrombus, give ANTI-COAGULANT
heparin- HEPARIN SODIUM
coamadin- WARFARIN SODIUM
Drugs if it due to hemorrhage with large hematoma
•patient may need operative removal of blood clot (craniotomy)
TRANSIENT ISCHEMIC ATTACK (TIA)

•Sudden, brief episodes of neurologic deficits

caused by focal cerebral ischemia. It usually lasts 5
to 20 minutes and is followed by a rapid clearing of
neurologic deficits (typically within 24 hours).
Recurrent attacks are common.

•A brief reversible episode of neurologic

dysfunction caused by temporary interruption of
blood supply to the brain.

•Also called “intermittent cerebrovascular

insufficiency”.
Causes:

Causes of TIAs include:

•vascular disorders
•blood disorders
•cerebrovascular insufficiency

Signs and Symptoms:

•sudden loss of consciousness
•slurring of speech
•drooling of saliva
Blood
Supply to
the Brain
What increases risk of a TIA?

•High blood pressure. You can lower your risk

of TIA by lowering your blood pressure.

•High cholesterol. High cholesterol increases

your risk of atherosclerosis, which can lead to
blood clots. By lowering your cholesterol, you
can lower your chance of having a TIA.

•Smoking. If you stop smoking, you can lower

your risk of having a TIA.
Heart disease. The higher your risk of
heart attack, the higher your chance of
having a TIA. By lowering your risk of heart
attack, you also reduce your chance of
having a TIA.

Age. Most TIAs occur after the age of 60.

Family and medical history. If one of your

family members has had a stroke or TIA or
you have had a previous TIA, you are more
likely to have a stroke or TIA.
Common Clinical Presentations of TIA
Excessive somnolence This symptom may indicate bilateral
hemispheric or brainstem involvement.

Agitation or psychosis Rarely, these symptoms may indicate

brainstem ischemia, particularly if they
occur in association with cranial nerve or
motor dysfunction.

Confusion or memory changes These rarely are isolated symptoms; more

frequently, they are associated with
language, motor, sensory, or visual
changes.

Inattention to surrounding environment, Depending on the severity of neglect, the

particularly to one side; if severe, patient physician may need to lift the patient's
may deny deficit or even his or her own arm to check for strength, rather than rely
body parts. on the patient to perform this task.
Diagnosis
The doctor will ask about your symptoms and
medial history, and perform a physical exam. A
primary goal is to determine your stroke risk.

Tests may include:

Blood Tests - including a complete blood
count, blood sugar, cholesterol, fat levels,
clotting levels, and a check of other elements
in the blood
Electrocardiogram (EKG) – to measure heart
rhythm and check for an irregular heart beat
Ultrasound– a test that uses sound waves to
help determine if there are blockages in the
arteries supplying the brain

MRI Scan – a test that uses magnetic waves

to make pictures of structures inside the
head

CT Scan – a type of x-ray that uses a

computer to make pictures of structures
inside the head

Magnetic Resonance Angiography–

performed prior to carotid artery surgery to
determine how much the artery has
Arteriogram - during a conventional arteriogram, a
contrast dye is injected and x-ray images are produced
to precisely locate the blockage and to determine how
much of the artery is blocked. This test is usually only
done to confirm the need for surgery.
Echocardiogram - an ultrasound test that looks for
blood clots and valve abnormalities within the heart
Electroencephalogram (EEG) - a test that can detect
seizures by measuring brain waves (used only if a
seizure is suspected)
Occupational Therapist
Rehabilitation after an injury may help some patients
regain lost functions or learn new ways of accomplishing
everyday tasks.