Neuro Part 2

CVA, Guillain Barre (GB), Bell palsy

What is CVA?

CVA- Cerebral vascular accident

• this is a stroke! (brain attack)

  • medical emergency caused by blocked or bleeding blood vessels in the brain, resulting in brain cell death.\

  • brain can not store glucose or O2, so it needs a consistent flow of blood.

Types of CVA? (Ischemic)

• most common type—blockage of a cerebral or carotid artery

  • Thrombotic: Clot forms in one of arteries supplying in the brain (usually b/c atherosclerosis or plaque rupture= promoting clot formation), usually gradual onset and gradual improvements.

  • Embolic stroke: clot or debris forms elsewhere in the body and travels through the bloodstream to the brain, where it blocks a vessel! (Usually sudden onset with rapid improvements)

Types of CVA? (hemorrhagic)

• weak Blood vessels rupture = bleed inside brain/outside brain. (bleeds into brain tissue or subarachnoid space)

  • intracerebral hemorrhage (ICH): bleeding into the brain tissues (The most common cause is hypertension)

    • Bleeding leads to edema, irritation, displacement, and increased

      intracranial pressure

  • Subarachnoid hemorrhage (SAH):more common – bleeding into the

    subarachnoid space. (space between the brain and skull)

    • The most common cause is an aneurysm or arteriovenous malformation

What is the problem with a CVA?

Interruption in blood flow to the brain. cerebral tissues die → affects areas around the

infarct, the contralateral hemispheric side d/t brain edema or global changes in perfusion of the brain(the opposite side of brain is affected) .

Causes (Etiology) of CVA?

• usually attributed to both genetic and environmental factors.

symptoms of acute strokes?

CDC's 5 Common Symptoms of Acute Stroke

○ Sudden confusion or trouble speaking

○ Sudden numbness or weakness of the face or extremity

○ Sudden trouble seeing in one or both eyes

○ Sudden dizziness, difficulty walking, loss of balance/coordination

○ Sudden severe headache with no known cause

Symptom of hemorrhagic strokes?

• sudden, severe headache; "worst headache," N/V, photophobia; cranial

  nerve deficits; stiff neck; change in mental status

  • Photophobia: abnormal, painful sensitivity or intolerance to light, often causing eye discomfort, headaches, and a need to squint or avoid bright, artificial, or natural light

Symptoms with specific sides of brain stroke?

Left: language, speech, mathematical, aphasia, slow / cautious hesitant behavior

• has right sided weakness

Right: spatial problems, problems w/ social cues/tone, impulsive decisions. neglect syndrome (unaware of left sided surroundings)

• has left sided weakness

Types of aphasia?

• aphasia: inability to understand/produce speech b/c of brain damage

  • Brocas: can’t speak correctly, but understand whats being said to them.

  • Wernicke: doesn’t understand what’s being said to them .

Labs and diagnostics used for CVA’s?

Labs

• No definitive laboratory tests

  • H & H elevated to compensate for decreased O₂ in the brain (hematocrit & hemoglobin)

  • WBC elevated, indicating infection or inflammatory response

  • PT/PTT to establish a baseline before

    anticoagulation therapy

• Diagnostics

  • CT Perfusion Scan to assess ischemia and aneurysm ( measures cerebral blood flow)

  • Magnetic Resonance Angiography (visualise cerebral vessels)

  • Carotid Duplex Scanning (ultrasound that combines Doppler and B-mode imaging to assess carotid artery narrowing (stenosis) or plaque buildup crucial for identifying sources of carotid artery related stroke)

Priorities w/ strokes?

• Airway

  • KEEP NPO! (stroke pt’s risk for aspiration)

  • monitor blood glucose (hypo/hyper - glycemia mimics stroke)

  • O2 if <95%

  • treat fever (fever accelerating = brain cell death)

goal/treatment /plan or CVA’s?

• Improve cerebral perfusion, promote mobility and ADL, manage sensory changes, and promote effective communication

  • Monitoring for and managing neurological changes associated with increased ICP (most noticeable)

  • Rule out and manage hypoglycemia/hyperglycemia and hypoxia (Maintain glucose level between 140 and 180)

  • Treat if febrile (>100.4°F) to avoid accelerating brain cell injury

  • Maintain optimal BP (dependent on the type of stroke and the treatment options)

    • brain needs higher BP to perfuse around blockage (NOT HEMORRHAGIC BUT BLOCKAGE), don’t lower BP too aggresively!

treatment plan cont., management of BP for CVA?

• BP maintained based on stroke type

  • Ischemic stroke (stroke caused by blockage)

    • if not eligible for fibrinolytic therapy (clot busting treatment that breaks down dangerous blood clots): permissive HTN… allow BP to reach 220/120 to help remove blockage - treat HTN once goes over 220/110! & don’t lower too fast

    • If eligible for fibrinolytic therapy or mechanical thromboectomy: BP treatment must be initiated when reaches 185/110, (increased risk of brain hemmorhage w/ blood thinner)

  • Hemorrhagic stroke:

    • treat is SBP is 150-220, avoid abrupt drops.

      • drugs of choice: labetalol(1st choice), nicardipine, nitroprusside (ALL basically relax blood vessels)

      • After 24-48 hours, transition to long-term BP goals of <130/80 for most patients,

        or 140/90 for those with comorbidities or limited tolerance.

Key treatments for CVA?

• TPA (Tissue plasminogen activator)

• Dual antiplatelet therapy

• mechanical thromectmy

what does TPA do?

dissolves clots (FDA approved for only strokes)

• standard early intervention for acute ischemic stroke without contraindications

• TPA can be given within 3-4.5 hours of first symptoms

• BP is elevated, a rapid-acting anti-hypertensive can be administered before

  TPA per facility protocol

NOT for hemorrhagic stroke, as makes bleeding worse!

Whats Dual antiplatelet therapy?

• Aspirin + clopigrel : prevents more clots!

  • inhibits aggregation but increases bleeding risks!

  • Do not give within 24 hours if patient has taken TPA.

• Anticoagulants (heparin, warfarin): usually given if A-fib is present (can cause ICH -intracerebral hemorrhage)

why are drugs used to prevent cerebral vasospams in strokes and what are they?

• Drugs are used to prevent cerebral vasospasm (narrowing of brain arteries) after subarachnoid hemorrhage (a type of stroke) to reduce delayed cerebral ischemia, infarction, and poor neurological outcomes

  • Vasospasm occur between 4 and 14 days after SAH (subarachnoid stroke) stroke

    • CCB (nimodipine): relax vascular smooth muscle, enhancing neuroprotection, and preventing blood flow reduction.

Drugs for symptom management after an acute stroke?

• Stool softener – to avoid the Valsalva maneuver (straining) during defecation, preventing increased

ICP

• Pain and anti-anxiety drugs

Endovascular Interventions—For Acute Thrombotic Stroke

• Using imaging guidance, specialists insert a catheter, typically through the groin, to mechanically remove blood clots from brain arteries

  • Carotid endarterectomy or carotid stent placement (commonly performed): removes plaque or catheter w/ ballon used to widen artery & placing a mesh tube to keep it open

    • risk of hyperperfusion syndrome: where a suddenly restored, high-volume blood flow overwhelms a brain previously adapted to chronic low flow!

  • Intra-arterial thrombolysis: medical procedure that delivers clot-dissolving agents directly into a blocked artery via a catheter to treat acute ischemic strokes or acute limb ischemia

  • Mechanical embolectomy: image-guided procedure to remove blood clots from arteries or veins, typically used for acute ischemic stroke or severe vascular blockages.

How to recognize strokes?

BE-FAST

• B: balance (sudden loss of balance)

• E: Eyes (sudden vision problems)

• F: face (dropping)

• A: Arms (weakness/numb)

• S: speech (confused/slurred)
  T: TIME (call 911)

What is Bell palsy?