Stroke 1

STROKE
Cerebrovascular Accident (CVA)

&
Brain Attack
Stroke
 Ischemia is inadequate blood flow

 Occurs when ischemia to part of the
brain results in death of brain cells
Stroke
 Movement, sensation, or emotions

controlled by affected area are lost or
impaired
 Loss of function varies with location
and extent of damage
Stroke
 Brain attack
– Term increasingly being used to
describe stroke and communicate
urgency of recognizing stroke
symptoms and treating their onset as
a medical emergency
National Stroke
Association
 10% of stroke survivors recover almost
completely
 25% recover with minimal impairment
 40% experience moderate to severe impairments
that require special care
 10% require care in a nursing home or other
long-term facility
 15% die shortly after the stroke
 Approximately 14% of stroke survivors
experience a second stroke in the first year
following a stroke
Risk Factors
Nonmodifiable
 Age
 Gender (women more likely to die)
 Race (African Americans)
 Heredity
Risk Factors
Modifiable
 Asymptomatic carotid stenosis
 Diabetes mellitus
 Heart disease, atrial fibrillation
 Heavy alcohol consumption
 Hypercoagulability
 Hyperlipidemia
Risk Factors
Modifiable
 Hypertension
 Obesity
 Oral contraceptive use
 Physical inactivity
 Sickle cell disease
 Smoking
Reduce You Stroke Risk
• Control high blood pressure

Don’t smoke
• Consume less sodium
• Lower cholesterol
• Lose excess weight
• Get physically active
Etiology and Pathophysiology
 Brain requires continuous supply of O2

and glucose for neurons to function
 If blood flow is interrupted
– Neurologic metabolism is altered in
30 seconds
– Metabolism stops in 2 minutes
– Cell death occurs in 5 minutes
 Atherosclerosis is a major cause of

stroke
– Can lead to thrombus formation and
contribute to emboli
Sites for Atherosclerosis
Fig. 56-2
 Around the core area of ischemia is a

border zone of reduced blood flow
where ischemia is potentially reversible
 If adequate blood flow can be restored
early (<3 hours) and the ischemic
cascade can be interrupted
– less brain damage and less neurologic
function lost
Transient Ischemic Attacks
(TIA)
 Temporary focal loss of neurologic
function caused by ischemia
 Most resolve within 3 hours
 May be due to micro-emboli that
temporarily block blood flow
 A warning sign of progressive
cerebrovascular disease
Types of Stroke
 Classification based on underlying

pathophysiologic findings
– Ischemic
 Thrombotic
 Embolic
– Hemorrhagic
Major Types of Stroke
Fig. 56-3
Ischemic Stroke
 Result of inadequate blood flow to brain
due to partial or complete occlusion of
an artery
 Constitute 85% of all strokes
 Most patients with ischemic stroke do
not have a decreased level of
consciousness in the first 24 hours
 Symptoms often worsen during first 72
hours d/t cerebral edema
Ischemic Stroke
 Thrombotic stroke
– Thrombosis occurs in relation to
injury to a blood vessel wall → blood
clot
– Result of thrombosis or narrowing of
the blood vessel
– Most common cause of stroke
Ischemic Stroke
 Thrombotic stroke
– Two-thirds are associated with HTN
and diabetes
– Often preceded by a TIA
Ischemic Stroke
 Embolic stroke
– Embolus lodges in and occludes a
cerebral artery
– Results in infarction and edema of the
area supplied by the vessel
– Second most common cause of stroke
Ischemic Stroke
 Embolic stroke
– Majority of emboli originate in heart,
with plaque breaking off from the
endocardium and entering circulation
– Associated with sudden, rapid
occurrence of severe clinical
symptoms
Ischemic Stroke
 Embolic stroke
– Patient usually remains conscious
although may have a headache
– Recurrence is common unless the
underlying cause is aggressively
treated
Hemorrhagic Stroke
 Account for approximately 15% of all

strokes
 Result from bleeding into the brain
tissue itself or into the subarachnoid
space or ventricles
Hemorrhagic Stroke
 Intracerebral hemorrhage
– Bleeding within the brain caused by a
rupture of a vessel
– Hypertension is the most important
cause
– Commonly occurs during activity
Hemorrhagic Stroke
 Intracerebral hemorrhage
– Often a sudden onset of symptoms
that progress over minutes to
hours b/c of ongoing bleeding
– Manifestations include neurologic
deficits, headache, decreased levels of
consciousness
Hemorrhagic Stroke
 Subarachnoid hemorrhage
– Bleeding into cerebrospinal space
between the arachnoid and pia mater
– Commonly caused by rupture of a
cerebral aneurysm
Clinical Manifestations of Stroke
 Affects many body functions

 Motor activity
 Intellectual function
 Spatial-perceptual alterations
 Personality
 Sensation
 Communication
Clinical Manifestations
Motor Function
 Most obvious effect of stroke
 Can include impairment of
– Mobility
– Respiratory function
– Swallowing and speech
– Gag reflex
– Self-care abilities
Motor Function
 Characteristic motor deficits (contra-
lateral)
– Loss of skilled voluntary movement
– Impairment of integration of
movements
– Alterations in muscle tone (flaccid →
spastic)
– Alterations in reflexes (hypo → hyper)
Communication
 Patient may experience aphasia when
stroke damages the dominant
hemisphere of the brain
– Aphasia: total loss of comprehension
and use of language
– Dysphasia: difficulty with
comprehension and use of language
 Classified as nonfluent or fluent
Communication
 Dysarthria
– Disturbance in the muscular control
of speech
– Impairments in pronunciation,
articulation, and phonation; NOT
meaning or comprehension
 May have difficulty controlling their

emotions
 Emotional responses may be
exaggerated or unpredictable
 Depression , impaired body image and
loss of function can make this worse
 May be frustrated by mobility and
communication problems
Intellectual Function
 Memory and judgment may be
impaired
 Left-brain stroke: more likely to result
in memory problems related to
language
Manifestations of Right and Left-Brain Stroke
Fig. 56-6
Spatial-Perceptual Alterations
 Stroke on the right side of the brain is
more likely to cause problems in spatial-
perceptual orientation
 However, this may occur with left-
brain stroke
 Spatial-perceptual problems may be
divided into four categories
1. Incorrect perception of self and
illness (may deny illness or body
parts)
2. Erroneous perception of self in
space (e.g., neglect all input from
affected side; distance judgement)
3. Inability to recognize an object by
sight, touch, or hearing
4. Inability to carry out learned
sequential movements on
command
Homonymous Hemianopsia (food on left side
is not seen)
Fig. 56-8
Diagnostic Studies
 When symptoms of a stroke occur,

diagnostic studies are done to
– Confirm that it is a stroke
– Identify the likely cause of the stroke
 CT is the primary diagnostic test used
after a stroke
F.A.S.T. IS
 Face Drooping-Does one side of the face droop or is it

numb? Ask the person to smile.
• Arm Weakness-Is one arm weak or numb? Ask the
person to raise both arms. Does one arm drift
downward?
• Speech Difficulty- are they unable to speak, or are they
hard to understand? Ask the person to repeat a simple
sentence. Is the sentence repeated correctly?
• Time-to call for ambulance to go hospital immediately.
Collaborative Care
Prevention
 Education and management of
modifiable risk factors to prevent a
stroke
 Close management of patients with
known risk factors
Collaborative Care
Prevention
 Antiplatelet drugs (usually Aspirin) to
prevent stroke in those with history of
TIA
 Coping
– A stroke is often a family disease,
affecting the family emotionally,
socially, and financially
– Changing roles and responsibilities
occur
– Clear explanations about what has
happened, diagnostic and therapeutic
procedures

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STROKE

Cerebrovascular Accident (CVA)

 Ischemia is inadequate blood flow

 Movement, sensation, or emotions

• Control high blood pressure

 Brain requires continuous supply of O2

 Atherosclerosis is a major cause of

 Around the core area of ischemia is a

 Classification based on underlying

 Account for approximately 15% of all

 Affects many body functions

 May have difficulty controlling their

 When symptoms of a stroke occur,

 Face Drooping-Does one side of the face droop or is it

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