STROKE

DEFINITION
A

stroke, sometimes referred to by the older term cerebrovascular accident (CVA), is the rapid loss of brain function due to disturbance in the blood supply to the brain.
stroke is a medical emergency and can cause permanent neurological damage and death.

Risk factors
Potentially treatable risk factors

High blood pressure risk of stroke begins to increase at blood pressure readings higher than 120/80 millimeters of mercury (mm Hg). Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors. Cigarette smoking or exposure to secondhand smoke. High cholesterol a total cholesterol level above 200 milligrams per deciliter (mg/dL), or 5.2 millimoles per liter (mmol/L). Diabetes. Being overweight or obese. Physical inactivity. Obstructive sleep apnea (a sleep disorder in which the oxygen level intermittently drops during the night).

Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart rhythm. Use of some birth control pills or hormone therapies that include estrogen. Heavy or binge drinking. Use of illicit drugs such as cocaine and methamphetamines. Personal or family history of stroke, heart attack or TIA. Being age 55 or older. Race Americans have higher risk of stroke than people of other races. Gender Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they are more likely to die of strokes than men.

TWO CLASSIFICATION OF STROKE

ISCHEMIC
In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally) 2. Embolism (obstruction due to an embolus from elsewhere in the body, see below), 3. Systemic hypo blood supply, e.g., in shock) 4.

perfusion

(general decrease in

Venous thrombosis.

Stroke episode is classified as :

total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI).

A stroke is classified as being due to:

(1) thrombosis or embolism due to atherosclerosis of a large artery (2) Cardiac embolism origin (3) occlusion of a small blood vessel,

(4) other determined cause,

(5) undetermined cause (two possible causes, no cause identified, or incomplete investigation).

1.

Thrombosis

In thrombotic stroke a thrombus (blood clot) usually forms around atherosclerotic plaques. " Two types of thrombosis can cause stroke: Large vessel disease involves the common and internal carotids, vertebral, and the Circle of Willis.. Small vessel disease involves the smaller arteries inside the brain: branches of the circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery.

2.

Embolic Stroke

An embolic stroke refers to the blockage of an artery by an arterial embolus, a travelling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g., from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis).

3.

Systemic Hypo perfusion

Because the reduction in blood flow is global, all parts of the brain may be affected, especially "watershed" areas - border zone regions supplied by the major cerebral arteries. A watershed stroke refers to the condition when blood supply to these areas is compromised. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur.

4.

Venous thrombosis

Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.

Hemorrhagic
Hemorrhagic strokes result in tissue injury by causing compression of tissue from an expanding hematoma or hematomas. This can distort and injure tissue.

Intracerebral Hemorrhage

It generally occurs in small arteries or arterioles and is commonly due to hypertension, intracranial vascular malformations , cerebral amyloid angiopathy, or infarcts into which secondary haemorrhage has occurred. The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. A third of intracerebral bleed is into the brain's ventricles.

PATHOPHYSIOLOGY

ASSESSMENT
The symptoms depend on the area of the brain affected. Neurological Assessment in Stroke

Changes in LOC
Signs of Increasing intracranial pressure Assessment of cranial nerves :

>CRANIAL NERVE V: Difficulty with chewing

>CRANIAL NERVE VII: Facial paralysis or paresis >CRANIAL NERVES IX & X: Dysphagia

>CRANIAL NERVE IX: Absent Gag Reflex

>CRANIAL NERVE XII: Impaired tongue movement

Signs & Symptoms

If the area of the brain affected contains one of the three prominent central nervous system pathways the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include: hemiplegia and muscle weakness of the face numbness reduction in sensory or vibratory sensation initial flaccidity (hypotonicity), replaced by spasticity (hypertonicity), hyperreflexia, and obligatory synergies.

cont..

Right-brain damage
( stroke on right side of the brain)

Left-Brain damage
( stroke on the left side of the brain) > Paralyzed right side: hemiplegia

Paralyzed left side: hemiplegia

Left-sided neglect
Spatial- perceptual deficits

>Impaired speech/language Aphasias

>Impaired right/left discrimination

Tends to deny or minimize problems >Slow performance, cautious

Impaired judgement
Impaired time concepts

>Aware of deficits: depression anxiety

>Impaired comprehension related to language/ math

If the cerebral cortex is involved, aphasia (difficulty with verbal expression, auditory comprehension, reading and/or writing Broca's or Wernicke's area typically involved)

dysarthria (motor speech disorder resulting from neurological injury) apraxia (altered voluntary movements)

Hemianopsia (blindness in half the visual field)

memory deficits (involvement of temporal lobe)

hemineglect (involvement of parietal lobe)

disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe) lack of insight of his or her, usually stroke-related, disability If the cerebellum is involved, the patient may have the following:

altered walking gait

altered movement coordination vertigo and or disequilibrium

What is a transient ischemic attack (TIA)?

A transient ischemic attack (TIA, mini-stroke) is a short-lived stroke that gets better and resolves. It is a short-lived episode (less than 24 hours) of temporary impairment of brain function that is caused by a loss of blood supply. A TIA causes a loss of function in the area of the body that is controlled by the portion of the brain affected. The loss of blood supply to the brain is most often caused by a clot that spontaneously forms in a blood vessel within the brain (thrombosis). Many people refer to a TIA as a "mini-stroke."

COMPLICATIONS

Paralysis or loss of muscle movement. Sometimes a lack of blood flow to the brain can cause you to become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm. Difficulty talking or swallowing. A stroke may cause you to have less control over the way the muscles in your mouth and throat move, making it difficult for you to talk, swallow or eat.

For example, some people may experience slurred speech (dysarthria), due to incoordination of muscles in your mouth. You also may have difficulty with language (aphasia), including speaking or understanding speech, reading or writing.

Memory loss or thinking difficulties.

Others may have difficulty thinking, making judgments, reasoning and understanding concepts. These complications may improve with rehabilitation therapies.

Emotional problems. People who have had strokes may have more difficulty
controlling their emotions, or they may develop depression.

Pain. Some people who have had strokes may have pain, numbness or other strange
sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. Some people may be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication generally develops several weeks after a stroke, and it may improve over time. But because the pain is caused by a problem in your brain, instead of a physical injury, few medications may treat CPS.

Changes in behavior and self-care. People who have had strokes may become
more withdrawn and less social or more impulsive. They may lose the ability to care for themselves and may need a caretaker to help them with their grooming needs and daily chores.

How is stroke diagnosed?

Physical assessment - blood pressure tests and blood tests to see cholesterol levels, blood sugar levels, and amino acid levels

Ultrasound - a wand waved over the carotid arteries in the neck can provide a picture that indicates any narrowing or clotting Arteriography - a catheter is inserted into the arteries to inject a dye that can be picked up by X-rays

Computerized tomography (CT) scan - a scanning device that creates a 3-D image that can show aneurysms, bleeding, or abnormal vessels within the brain

Magnetic resonance imaging (MRI) - a magnetic field generates a 3-D view of the brain to see tissue damaged by stroke

CT and MRI with angiography - scans that are aided by a dye that is injected into the blood vessels in order to provide clearer and more detailed images Echocardiography - an ultrasound that makes images of the heart to check for embolus

Eye-movement analyzer may diagnose stroke -. The electronic device is a small, portable, video-oculography machine. It detects eye movements that most doctors find hard to notice.

TREATMENT AND DRUGS

Ischemic stroke

To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.

Emergency treatment with medications. Therapy with clot-busting drugs (thrombolytics) must start within 4.5 hours if they are given into the vein and the sooner, the better. Quick treatment not only improves your chances of survival but also may reduce the complications from your stroke. You may be given:
Aspirin. Aspirin, an anti-thrombotic drug, is an immediate treatment after an ischemic stroke to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming. In the emergency room, you may be given a dose of aspirin.. Other blood-thinning drugs, such as heparin, also may be given, but this drug isn't proven to be beneficial in the emergency setting so it's used infrequently. Clopidogrel (Plavix), warfarin (Coumadin), or aspirin in combination with extended release dipyridamole (Aggrenox) may also be used, but these aren't usually used in the emergency room setting.

Intravenous injection of tissue plasminogen activator (TPA).

>also called alteplase, usually given through a vein in the arm. >This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it's given into the vein. >This drug restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully. consider certain risks, such as potential bleeding in the brain,

 Carotid

In a carotid endarterectomy, a surgeon removes fatty deposits (plaques) from your carotid arteries that run along each side of your neck to your brain. The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.

endarterectomy.

Angioplasty

In an angioplasty, a surgeon inserts a catheter with a mesh tube (stent) and balloon on the tip into an artery in your groin and guides it to the blocked carotid artery in your neck.

and stents.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be used to help reduce future risk. Emergency measures. If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract their effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure or prevent seizures. People having a hemorrhagic stroke can't be given clot-busters such as aspirin and TPA, because these drugs may worsen bleeding. Once the bleeding in your brain stops, treatment usually involves bed rest and supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, surgery may be used in certain cases to remove the blood and relieve pressure on the brain. Surgical blood vessel repair. Surgery may be used to repair certain blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if you're at high risk of a spontaneous aneurysm or arteriovenous malformation (AVM) rupture: Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged.

Coiling (endovascular embolization). In this procedure, a surgeon inserts a catheter into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides tiny detachable coils into the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into the aneurysm and causes the blood to clot. Surgical AVM removal. Surgeons may remove a smaller AVM if it's located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if it's too large or if it's located deep within your brain. Stroke recovery and rehabilitation Following emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged. If your stroke affected the right side of your brain, your movement and sensation on the left side of your body may be affected. If your stroke damaged the brain tissue on the left side of your brain, your movement and sensation on the right side of your body may be affected. Brain damage to the left side of your brain may cause speech and language disorders. In addition, if you've had a stroke, you may have problems with breathing, swallowing, balancing and vision. Most stroke survivors receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and your degree of disability from your stroke. Your doctor will take into consideration your lifestyle, interests and priorities, and availability of family members or other caregivers.

Your rehabilitation program may begin before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or your home. Every person's stroke recovery is different. Depending on your condition, your treatment team may include:

Doctor trained in brain conditions (neurologist) Rehabilitation doctor (physiatrist) Nurse Dietitian Physical therapist Occupational therapist

Recreational therapist
Speech therapist Social worker Case manager

Psychologist or psychiatrist

PREVENTION

Knowing your stroke risk factors, following your doctor's recommendations and adopting a healthy lifestyle are the best steps you can take to prevent a stroke. If you've had a stroke or a TIA, these measures may help you avoid having another stroke. Many stroke prevention strategies are the same as strategies to prevent heart disease. In general, healthy lifestyle recommendations include: Controlling high blood pressure (hypertension). One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control. If you've had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke. Exercising, managing stress, maintaining a healthy weight, and limiting the amount of sodium and alcohol you eat and drink are all ways to keep high blood pressure in check. Adding more potassium to your diet also may help. In addition to recommending lifestyle changes, your doctor may prescribe medications to treat high blood pressure.

Lowering the amount of cholesterol and saturated fat in your diet. Eating less cholesterol and fat, especially saturated fat and trans fats, may reduce the plaque in your arteries. If you can't control your cholesterol through dietary changes alone, your doctor may prescribe a cholesterol-lowering medication.

Quitting tobacco use. Smoking raises the risk of stroke for both the smoker and nonsmokers exposed to secondhand smoke. Quitting tobacco use reduces your risk of stroke.
Controlling diabetes. You can manage diabetes with diet, exercise, weight control and medication. Maintaining a healthy weight. Being overweight contributes to other stroke risk factors, such as high blood pressure, cardiovascular disease and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol levels.

Eating a diet rich in fruits and vegetables. A diet containing five or more daily servings of fruits or vegetables may reduce your risk of stroke.

Exercising regularly. Aerobic exercise reduces your risk of stroke in many ways. Exercise can lower your blood pressure, increase your level of highdensity lipoprotein (HDL, or "good") cholesterol, and improve the overall health of your blood vessels and heart. It also helps you lose weight, control diabetes and reduce stress. Gradually work up to 30 minutes of activity such as walking, jogging, swimming or bicycling on most, if not all, days of the week. Drinking alcohol in moderation, if at all. Alcohol can be both a risk factor and a preventive measure for stroke. Heavy alcohol consumption increases your risk of high blood pressure, ischemic strokes and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol may help prevent ischemic stroke and decrease your blood's clotting tendency. Treat obstructive sleep apnea, if present. Your doctor may recommend an overnight oxygen assessment to screen for obstructive sleep apnea (OSA). If OSA is detected, it may be treated by giving you oxygen at night or having you wear a small device in your mouth. Avoiding illicit drugs. Certain street drugs, such as cocaine and methamphetamines, are established risk factors for a TIA or a stroke. Cocaine reduces blood flow and can cause narrowing of arteries.

PREVENTIVE MEDICATION

If you've had an ischemic stroke or TIA, your doctor may recommend medications to help reduce your risk of having another stroke. These include:
Anti-platelet drugs. Platelets are cells in your blood that initiate clots. Antiplatelet drugs make these cells less sticky and less likely to clot. The most frequently used anti-platelet medication is aspirin. Your doctor can help you determine the right dose of aspirin for you. Your doctor may also consider prescribing Aggrenox, a combination of lowdose aspirin and the anti-platelet drug dipyridamole, to reduce the risk of blood clotting. If aspirin doesn't prevent your TIA or stroke, or if you can't take aspirin, your doctor may instead prescribe an anti-platelet drug such as clopidogrel (Plavix).

Anticoagulants. These drugs, which include heparin and warfarin (Coumadin), reduce blood clotting. Heparin is fast acting and may be used over a short period of time in the hospital. Slower acting warfarin may be used over a longer term. Warfarin is a powerful blood-thinning drug, so you'll need to take it exactly as directed and watch for side effects. Your doctor may prescribe these drugs if you have certain blood-clotting disorders, certain arterial abnormalities, an abnormal heart rhythm or other heart problems. Other newer blood thinners may be used if your TIA or stroke was caused by an abnormal heart rhythm.

THANK YOU!!!
Prepared by: Precious Pabico Jefferson Salamena Geneva G. San Juan BSN4A