cerebrovascular accident

CEREBROVASCULAR ACCIDENT

Dr. Jayesh Patidarwww.drjayeshpatidar.blogspot.com

PATIENT PRESENTATION-1

Mr.X,67yrs

C/O weakness of RUL and RLL for 10 days

C/O slurred speech for 10 days

K/C/O T2 DM and on treatment (uncontrolled)

K/C/O systemic hypertension

H/O lt leg diabetic foot below great toe

H/O IHD

9/15/2014 2www.drjayeshpatidar.blogspot.com

Assessment

O/E conscious, obeying commands

Speech dysarthria

EOM-restricted

Right facial palsy, gag reflex(N)

Motor-hemiplegia

Sensory-pain/touch impaired on right side

DTR-++/++

No neck stiffness


Investigations

urine for c/s-no growth

ECG: normal sinus rhythm

Blood investigations

Cholesterol-294(200)

Triglyceride-129(150)

HDL-25/11.8(60)

LDL-201(100-159)9/15/2014 4www.drjayeshpatidar.blogspot.com

MRI-Acute infarct in the medial aspect of pons

Age related atrophic changes

BP-150/90 mmhg

HR-98b/mt

Spo2-100

RR-30b/mt

Temp-98.6 f


Medications

Inj. Clexane 0.4ml s/c od

Inj. Magnex forte 1.5gm in 100ml NS IV bd

Inj. Rantac 50mg IV bd

Inj. H.Actrapid according to CBG s/c tds

T. Clopitab 75 mg RT 0-1-0

T. Nicardia R 10 mg RT 1-0-19/15/2014 6www.drjayeshpatidar.blogspot.com


Mr. Y 60/m

C/O neck pain x 4 days

H/O fever x 2 days, low grade

H/O one episode of giddiness x vomiting, slurring of speech

Pain and touch impaired on the right side

Known HTN x 5yrs

Lt eye ptosis, nystagmus-gaze evoked ataxia, ltUL-4/5 RUL-5/5


Assessment

BP-140/80 mmhg

HR-92b/mt

Spo2-99%

RR-20breaths/mt

Temp-98.6 f


Medications

Inj. Fraseda 30 mg IV 100ml NS

Inj. Rantac 50 mg IV

Inj. Strocit 500 mg IV

T Clopilet 75 mg p/o 0-1-0

T Atorva 10 mg p/o 0-0-1


Investigations

RBS-177 PPBS-141

Na- 130

Cholesterol-239

Triglyceride-207

HDL-31/7.7

LDL-1779/15/2014 10www.drjayeshpatidar.blogspot.com

MRI-Sub acute infarct

Chronic infarct-rt cerebellum

Carotid Doppler- Carotid grade II intimal changes

Non visualization of the mid and distal portion of the basilar artery with very thin caliber vertebral arteries.

Vertebral Doppler study-lt vertebral minimal flow, rt vertebral normal



Mr.Z,40yrs/M Rt MCA infarct C/O weakness of LUL and LL for 4 days H/O slurring of speech Mouth deviating to rt side Chronic smoker and alcoholic-25yrs BP 150/80 mmhg Lt-UL:0/5,LL-0/5 rt- UL:5/5,LL-5/5


Assessment

GCS:15/15

Pupils:2mm reacting to light

Reflexes:++/++

Alk phophatase:105

Cholesterol-155

Triglycerides-112

HDL-35

LDL-98

CT brain: Acute infarct-Rt MCA territory

MRI: Rt MCA infarct


Medications

T.Nicardia R 10mg p/o tds

T.clopilet 75 mg p/o od

T.Statin 10 mg p/o od

Inj Fraseda 30mg in 100ml Ns IV bd

Inj Neksium 70 mg IV bd


15

What is a Stroke?

“Stroke” is a term used to describe neurological changes lasting more than 24 hours caused by an interruption in the blood supply to a part of the brain. If the blood flow ceases for an extended period of time, the cerebral tissues involved die causing permanent neurological deficits.


CEREBRAL CIRCULATION


17

LOCATION

http://www.nlm.nih.gov/medlineplus/ency/imagepages/18009.htm


CLINICAL MANIFESTATIONS


COMMON EFFECTS OF A RIGHT HEMISPERIC STROKE

Left visual field loss (homonymous hemianopsia)

Dysphagia

Usually retain language ability but may have difficulty producing speech(dysarthria)

Left-sided weakness (hemi paresis) or paralysis (hemiplegia)

Sensory impairment

Denial of paralysis, “forget” or “ignore” objects or people on their left side(neglect)

Impaired ability to judge spatial relationships (misjudge distances and depth leading to falls, unable to guide hands to button a shirt, problems with directions such as up / down, no concept of time)

Impaired ability to locate and identify body parts

Short-term memory impairments (difficulty remembering new information) and apraxia (inability to carry out learned movement in the absence of weakness or paralysis)

Behavioral changes such as impaired judgement or insight into limitations, overestimate physical ability, impulsivity, inappropriateness and difficulty comprehending and expressing emotions


COMMON EFFECTS OF A LEFT HEMISPERIC STROKE

Right visual field loss (homonymous hemianopsia) Dysphagia May develop aphasia (loss of language including spoken, written,

reading and comprehension) but may also have dysarthria Right-sided weakness (hemiparesis) or paralysis

(hemiplegia)

Sensory impairment Usually have normal perception Usually judgement is intact with good insight into

limitations Short-term memory impairments (difficulty remembering

new information) and apraxia (inability to carry out learned movement in the absence of weakness or paralysis)

Often develop a slow and cautious behavioral style. They need frequent instructions and feedback to complete tasks

Better able to comprehend and express emotions9/15/2014 20www.drjayeshpatidar.blogspot.com

TYPES OF STROKE

Ischemic 80 - 84%

Caused by blockage of the artery resulting in reduction of blood flow and cell death

Include thrombotic, lacunar, embolic cryptogenic

CT scan negative until a few days post stroke then hypodense area - indicates infarction


THROMBOTIC STROKE

Atherosclerosis in cerebral arteries

Similar to CAD – leading to MI

Atherogenesis – decades long process

In thrombotic stroke lumen of artery narrows to point of obstruction


LACUNAR STROKE

Atherosclerosis in cerebral arteries

Similar to CAD –leading to MI

Atherogenesis –decades long process

In thrombotic stroke lumen of artery narrows to point of obstruction


EMBOLIC STROKE

A clot travels from source outside of brain

Encounters vessel with lumen narrow enough to block its passage

Clot lodges there, blocking blood flow

Most common source - heart

Common conditions - atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta


HEMORRHAGIC STROKE

A clot travels from source outside of brain

Encounters vessel with lumen narrow enough to block its passage

Clot lodges there, blocking blood flow

Most common source - heart Common conditions - atrial

fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta


EMERGENCY MANAGEMENT

Neurological vital signs

Blood pressure

Glycemic control

Control of body temperature

Oxygenation

Hydration


HEMORRHAGIC STROKE

Treatment based on the underlying cause of the bleed and the extent of brain damage

Treatment includes medication and surgical intervention

Management of ICP with antihypertensives or surgical evacuation of hematoma

In patients with ruptured aneurysm - clip or embolization


Strategies to prevent a stroke

-Maintain a healthy weight - eat a reduced-fat diet

– Reduce alcohol intake to 1-2 drinks / day

– Exercise - 30 minutes 3-4 times / week

– Become smoke free and drug free

– Management of hypertension (ACE inhibitors)

– Management of heart disease (anticoagulants), diabetes and hyperlipidemia (statins)

– Carotid endarterectomy may be indicated with stenosis

– Antiplatelets for plaque / clot formation


NURSING DIAGNOSIS

Ineffective tissue perfusion r/t decreased cerebral blood flow or cerebral edema

Ineffective airway clearance r/t inability to raise secretions ,ineffective cough

Impaired physical mobility r/t neuromuscular and cognitive impairment, decreased muscle strength and control

Impaired verbal communication r/t residual aphasia

Risk for aspiration r/t inability to protect the airway

Altered sensory perceptual r/t altered LOC, impaired sensation and vision.


Unilateral neglect r/t visual field deficit and sensory loss on one side of the body

Impaired urinary elimination r/t impaired impulse to void or manage tasks of voiding

Impaired swallowing r/t weakness or paralysis of affected muscles

Situational low self esteem r/t actual or perceived loss of function.


NURSING MANAGEMENT

Airway management/ventilator management

Assessment and evaluation of neurologic status to detect patient deterioration

Blood pressure management

General supportive care and prevention of complications associated with:– Dysphagia, HTN, hyperglycemia, dehydration,

malnourishment, fever, cerebral edema, infection, and DVT, immobility, falls, skin care, bowel and bladder dysfunction.


SIGNS OF ↑ ICP

Early signs:

– Decreased LOC

– Deterioration in motor function

– Headache

– Changes in vital signs

Late signs

– Pupillary abnormalities

– Changes in respiratory pattern

– Changes in ABG’s


Airway management adequate O2 saturation

Preventing increased ICP and providing supportive care.

Hourly vitals/neuros including ICP, CPP, CVP.

Maintaining BP to ensure adequate CPP

Seizure precautions

Antibiotic prophylaxis

Stabilization

Prevention of complications

Monitoring neuro status

Family support and education


REHABILITATION


Do with the patient not for the patient

Management of impairment disability or handicap

Patient family and others


Positioning

Exercise

Skin

Communication

Swallowing

Elimination


cerebrovascular accident

Education

rt vertebral

absence of weakness

po tdst

rt sidechronic smoker

language ability

po odt

po odinj fraseda

patient presentation