Neurological Disorders

Stroke

Cerebrovascular accident (CVA)
• A type of stroke
• The term was created to have a similar connotation to a heart attack
• Time is pertinent
• Must act quickly to preserve what we can, similar to a heart attack
• If cell death is severe enough → death

• Result of impaired blood flow to the brain → brain cell death

• Blood on neurons → neuron death

Death of brain cells caused by

• Lack of blood supply (ischemic)
• Bleeding in the brain (hemorrhagic)

Blood-brain barrier

Prevents blood from reaching neurons, which would result in brain tissue damage

Hemiparesis

• Muscle weakness or paralysis on one side of the body

  • Face, upper/lower body, or combination

Aphasia

• Difficulty communicating
  ○ Difficulty understanding
  ○ Or both

Brain requires 20% of CO

If this is altered → cell death occurs within 5 minutes

Autoregulation

The brain regulates blood flow via this process, allowing significant changes in blood pressure, as it can affect blood flow to the brain itself.

Factors impacting blood flow to brain

• Cardiac output

• Blood viscosity

• Blood pressure

Collateral circulation

Done via Circle of Willis (a structure that sits at the base of the brain), which allows for blood to find a new path despite the slow narrowing of arteries.

Nonmodifiable risk factors

• Age
• Gender
• Ethnicity
• Family history
• Transient ischemic attack (TIA)

Modifiable risk factors

• Hypertension
• Heart disease
• Diabetes
• Smoking
• Obesity
• Sleep apnea
• Metabolic syndrome
• Sedentary lifestyle
• Drugs
• Alcohol

Age (stroke risk)

Risk of stroke doubles with each decade after age 55

Gender (stroke risk)

Women have a higher incidence of stroke and a higher death rate

Transient ischemic attack (stroke risk)

Lack of blood supply to an area of the brain, but not significant enough to cause an infarction

• Many people who have a TIA will have a stroke within the same year

Hypertension (stroke risk)

Listed number one stroke risk and is often the target of stroke risk reduction due to how strongly it is connected to stroke (ischemic and hemorrhagic)

Heart disease (stroke risk)

• Afib is associated with the development of blood clots due to blood pooling in the atria, which can lodge in the brain

• CAD: if you have plaque in the heart, it is likely in the brain (it is not cardioselective)

Diabetes (stroke risk)

• Damaging to the vascular system, which increases the risk of clots from platelets attempting to repair the damage. 

Smoking (stroke risk)

• Increases the risk of hemorrhagic stroke 

• The client must quit smoking

• Can take up to 10 years to remove the risk of stroke due to smoking

Obesity (stroke risk)

Linked to other risk factors on the list: high blood pressure, hyperlipidemia, and diabetes

Sleep apnea (stroke risk)

• Increases the risk of stroke and heart disease

• During periods of apnea, which causes significant stress

Blood pressure goal for stroke risk reduction

Less than 120 systolic and less than 80 diastolic

TIA characteristics

• Transient episode of cerebrovascular insufficiency
• One-third of TIA patients will have a stroke within a year
• Lasts less than 20 minutes
• No radiographic evidence of ischemia

TIA symptoms

• Symptoms are similar to a stroke
• Neuro exam may be normal between attacks

TIA duration

• Symptoms typically shorter than 20 min

• If longer than 20 min → treat as a stroke

TIA education

• Educate them on how to prevent having a future stroke and permanent disability 

• We don’t want them to think it was a false alarm or no need for concern

• Strong chance they will have an actual stroke that same year

• Changing risk factors will be so pertinent in preventing this 

• Modifying what we can

Ischemic stroke

• Approximately 87% of strokes are ischemic
• Can occur in large or small vessels
• Something is blocking blood flow to an area of the brain, a physical obstruction or blockage

Two kinds of ischemic stroke

• Thrombotic

• Embolic

Thrombotic stroke

Blockage forms in the vessel

• More common of the two types 

• Damage to a blood vessel → vessel injury → formation of a clot

• Atherosclerosis is accelerated by diabetes and hypertension (which is why they are both risk factors for thrombotic stroke)

• Can present as a TIA for some patients due to reduced flow, but not a total occlusion. Brief symptoms from lack of oxygen, but flow is still present

• If plaque ruptures → platelets rush to the area to correct damage → complete occlusion of the vessel → infarct in brain tissue → stroke 

Embolic stroke

Blockage comes from somewhere else

• The second most common type of stroke

• A clot or embolism breaks off from somewhere else in the body and lodges into brain 

• Travels from elsewhere

• Commonly traveled from the heart 

• Afib patients carry a high risk of stroke, which is why they are placed on anticoagulants to mitigate that risk (Elliquis, warfarin

• Artificial valves, endocarditis (damage to vessels)

• Air and fat emboli can cause as well 

Hemorrhagic stroke

Bleeding into the brain tissue

• Blood in contact with neurons → extremely damaging to neurons

• Ruptured vessel or aneurysm (weakening of vessel + outpouching of blood → risk for rupture) 

  • Hypertension increases this risk

• When blood comes in contact with brain tissue → neurons are destroyed

• If the vessel ruptures → tissue distal to the vessel is not receiving any blood flow or oxygen → area of infarct

Two kinds of hemorrohagic stroke

• Intracerebral

• Subarachnoid

Intracerebral hemorrhage

• Fairly deep in brain tissue

• Common cause: ruptured vessel, specficically basal ganglia

• Could be bleeding in just the brain itself or could be occurring in ventricles depending on what else is involved

• Prognosis is very poor

• More than half of patients die within 48 hours of injury (minutes to hours)

• Usually associated with activity 

• Risk factors: hypertension (main), anticoagulants, brain tumors, trauma 

Subarachnoid hemorrhage

• Occurs between the arachnoid (sub=below arachnoid) and pia mater layers

• Pia layer is very delicate and sits directly on brain

• More superficial in comparison to intracerebral 

• The subarachnoid layer comprised of arteries and CSF

• Cause is usually ruptured aneurysm 

• Common place for aneurysms to occur is bifurcations aka Circle of Willis (place for backup route) 

  • Because it’s a circle with several roads, lots of bifurcations → more aneurysm risk 

  • We see more aneurysms here

• Silent killer → not any symptoms assosciated 

• Patients with this bleed will most likely die, with some instantly

Other types of hemorrhages

• Not in textbook but still slightly relevant

• Epidural and subdural hematoma

Epidural and subdural hematoma

• Dural layer, more superficial 

• Subdural is typically a venous bleed → slower

  • Fall or motor vehicle accient

  • May not have initial symptoms

  • Older adult patients may have frequent falls and frequent subdural hematomas without even knowing due to natural atrophy of aging

• Epidural are most often arteriole in natural

  • Due to an injury in the front of the back of the head (fall, motor vehicle accident, trauma)

  • More severe symptoms due to arteriole in nature, rapid bleed

Stroke clinical manifestations

• Depends on where in the brain the infarct occurs.

• Not a notable difference in ischemic and hemorrhagic stroke

• Symptoms will present contralateral to the side of the brain that is impacted

  • Right will affect left and vice versa

• The lobe of the brain that is impacted will influence clinical manifestations 

• Strong chance that multiple lobes are impaired, depending on vessel location and what is fed or perfused by that vessel 

• Injury to the brainstem, the lowest part of the brain (breathing, vital signs), is not compatible with life and will typically result in brain death

Stroke & motor fxn impairment

Difficulty swallowing, decreased swallow reflex, hemiplegia

Stroke & communication impairment

• Aphasia

• Receptive aphasia: can’t understand or comprehend

• Expressive aphasia: can’t produce words to speak language they’ve always known

• Global aphasia: both receptive and expressive

• Common in temporal lobe injuries → difficulty understanding 

• Common in parietal lobe injuries → difficulty speaking, MCA damage, posterior cerebral artery damage

• “Trapped in your own brain.”

Stroke & changes in affect

• Physical inability to manipulate facial expressions 

• Don’t process emotions the same

• Feelings of hopelessness and depression due to the inability to perform ADLs

• Not able to communicate

• Impulsive and restless → frontal lobe damage (personality and behaviors)

Stroke education acronym

BE FAST

BE FAST → Balance

• Sudden difficulty with balance

• Walking, the gait looks strange

BE FAST → Eyes

Sudden vision problems in one or both eyes 

BE FAST → Face

• Facial droop/uneven smile

BE FAST → Arm

• Arm weakness/numbness

  • Check for arm drift (motor)

  • Hold up both their arms parallel to the ground

  • Ideally tested with eyes closed 

  • Progressive lowering of the arm if the eyes are closed

BE FAST → Speech

• Slurred speech, difficulty speaking or understanding

  • Dysphasia, dysarthria (slurred), or aphasia

  • Tell the patient to say “You can’t teach an old dog new tricks.”

BE FAST → Time

• Time is brain, time is tissue, the faster we address the infarct → better prognosis

  • Call 911

  • Call the emergency response team

  • Rapid response

  • Code white

Stroke diagnostics

• Onset of symptoms

• Blood sugar level

• CT head/brain w/o contrast

• MRI

• CT angiogram (CTA)

• CT perfusion (CTP)

Stroke diagnostic → onset of symptoms

• NIH stroke scale

• Can impact treatment, especially if ischemic

• More time in the hospital → clinicians have a better idea when symptoms began

• Ischemic stroke can be treated if the onset is 4 ½ hours or less in the hospital

• Pre-hospital will be 3 ½ hours or less

• The timing has to do with the preservation of brain tissue over the associated risk of treatment (ex. bleeding)

• The symptoms can quickly diagnose an ischemic stroke

Stroke diagnostic → blood sugar level

• Low blood sugar can mimic a stroke!

• Hypoglycemia stroke-like symptoms: weakness, confusion, speech changes

• Doing a quick blood sugar check can prevent unnecessary stroke testing

Stroke diagnostic → CT head/brain w/o contrast

• Standard 

• Can be done quickly without needing to know hx

• Won’t be able to see an acute ischemic stroke, but will be able to see a brain bleed

• Rules out hemorrhagic stroke or not, which determines treatment steps

Stroke diagnostic → MRI

• Requires a screening form

• Higher risk test

• Contrast dye on the kidneys is contraindicated in low GFR or kidney impairment

• If we don’t know this information, time is tissue → CT head is faster

• Does give better visualization of vessels

• MRI may be done for admitted patients with a known history

Stroke diagnostic → CT angiogram (CTA), CT perfusion (CTP)

Allows for looking at the impacted vessel, the size of the stroke, and where in the brain it is impacted to better tailor treatment

Stroke reoccurence

• If a patient has had a stroke and has not modified any of the risk factors → still at risk for developing another stroke!! 

• Prevention of future strokes is pertinent

  • Reducing BP, associated cardiovascular risks, fat intake, and cessation of smoking (takes 10 years)

Stroke & nursing care/management

• Medications

  • Antiplatelet 

  • Anticoagulant 

  • Antihypertensives 

• Rehabilitation care

  • Musculoskeletal function

  • Skin protective measures

  • Dysphagia precautions

  • Assistive feeding devices

  • Fall precautions

  • communication

Stroke & antiplatelets

• Plavix (clopidogrel), Aspirin 81 mg

• Prevents clots caused by platelets

Stroke & anticoagulants

• Elliquis, Warfarin (Coumadin), Pradaxa

• Important for patients for afib or artificial valves

Stroke & antihypertensives

• Key!

• Hypertension is strongly linked to both ischemic and hemorrhagic stroke

• Type depends on patient response

• May require more than one

• 120/80 or less

Stroke & statins

• Atorvastatin (Lipitor)

• Lower cholesterol reduces the incidence of atherosclerosis buildup

• Smooths out existing plaque formation to be less “sticky” to platelets

• Less likely to form clots

Stroke & rehabilitation care

• Musculoskeletal function

• Skin protective measures

• Dysphagia precautions

• Assistive feeding devices

• Fall precautions

• communication

Stroke & musculoskeletal function rehab

• ROM, passive, active

• Focus on preserving function

• Affected limb → elevate to reduce edema

• Focus on reducing the injury of the affected limb; don’t pull on the arm because they can’t feel it

• Prevent foot drop → encourage them to wear their own shoes 

• Hand cones to prevent contractions

• Transfer to chair; slide board

Stroke & skin protective measures

• Special mattresses, cushions for wheelchairs, keeping the skin clean, applying lotion to prevent skin dryness, and promoting ambulation/positioning 

Stroke & dysphagia precautions

• Sit them high while eating at 45-90 degrees

• Thickened liquids 

• Speech therapy

• Mouth care → stimulate awareness and create moisture 

Stroke & assistive feeding devices

• Promotes nutrition and ADLs

• The more the patient can do for themselves, the better 

• Non-slip pads for dishes, rocker knife

Stroke & fall precautions

You know this.

Stroke & therapeutic communication

• Allow the patient to feel like a person

• Talk to them even if they can’t talk back

• Assume they know what you are saying

• Be patient and give them time

• Communication boards

Spinal cord injury

• Damage to the spinal cord

Most common causes of spinal cord injury

• Falls

• Motor vehicle accidents (most common)

• Violence

• Sports injuries (least common)

Types of spinal cord injruy

• Primary injury

• Secondary injury

Primary injury

• Direct trauma to the spinal cord itself 

• Stabbed, violence, compressed

Secondary injury

• Symptoms that following initial injury

• Swelling → tissue death

• When something swells, it pushes up against everything around it, and we don’t have a lot of extra space → surrounding damage

Classifications of spinal cord injury

• Mechanism

• Level

• Degree

Mechanism of spinal cord injury

• Look at the position the patient was in when the injury occurred

• How was the spine manipulated?

• Flexion? Hyperextension? 

• What were they doing?

• In a car? On a horse?

Level of spinal cord injury

• Where in the spine did the injury occur?

• Higher injury → more severe deficits 

Degree of spinal cord injury

• Complete or incomplete

• Complete → total loss of function below the level of injury, complete thickness

• Partial → some portion of the spine is intact, some function below injury

Spinal cord injury clinical manifestations

• Higher levels of injury, C3 or higher → inability to manage breathing or airway → requiring ventilators for life-sustaining treatment 

• Cervical injuries may prevent the patient from being able to clear secretions and protect the airway → oxygenation, or even ventilation

• Injury T6 or higher → sympathetic nervous system dysfunction (which increases HR and BP) → these patients can’t do that now → bradycardia, hypotension

Dermatones

• The body is innervated via dermatomes 

• Depending on where the injury occured → dermatones at and below the level of injury are anticipated to be affected

Spinal cord injury diagnostic

• CT Scan

  • Assesses the degree and level of injury to anticipate effects on the patient, however…

  • Spinal and neuro injuries are a waiting game to see what is affected.

Spinal cord injury nursing management

• Prevention – education

• ABC’s

• Spinal immobilizer 

• Bladder and bowel management

• Inpatient rehabilitation 

Spinal cord injury & prevention

Helmets, seatbelts

Spinal cord injury & ABCs

Med-surg care will typically be provided to patients with lower-level spinal cord injuries because their airway is still intact

Spinal cord injury & spinal mobilizer

• Until we see healing

• Before, during, after

• Brace, wedges, collars

Spinal cord injury & bladder/bowel management

• Bladder training: lost sensation of having a full bladder → have patient go to bathroom at set intervals 

• Try to avoid an indwelling Foley

•  Straight catheterizations rather than indwelling

• Likely incontinent and requires perineal care

Spinal cord injury & inpatient rehab

• Team approach: OT, PT, speech therapy, nurse, physicians

• Some hospitals have on-site facilities, and patients will go to these facilities

• Restoring function and independence. 

• Physical therapy is typically 2-4 hours in length, depending on what the patient can tolerate