Ischemic and Hemorrhagic Stroke

Post-Thrombolytic Monitoring and Decompensation Risks

Risk of Post-Treatment Complications: Even after the removal of a clot, patients are at high risk for brain bleeds (hemorrhagic conversion).
Signs of Decompensation: Patients can decompensate extremely quickly. Indicators include:
    * Complaints of a "thunderclap headache."
    * Sudden onset of confusion.
    * Emergence of new neurological symptoms not present upon initial admission.
Monitoring Requirements: Continuous and close monitoring is essential to detect these rapid changes.
Medication and Imaging Restrictions:
* Antiplatelet and anticoagulation medications must be withheld for at least $24\,\text{hours}$ .
* These medications should only be administered after a follow-up CT scan confirms the absence of a bleed.
General Precautions:
* Bleeding Precautions: Necessary due to risk of spontaneous or trauma-induced hemorrhage.
* Fall Precautions: Vital to prevent head injuries (whacking the head) or joint injuries (hitting the knee) that could result in internal bleeding.

Specific Precautions for tPA (Tissue Plasminogen Activator) Patients

Duration: Patients remain on strict bleeding precautions for $24\,\text{hours}$ following tPA administration.
Prohibited Procedures: To prevent hemorrhage, the following "sticks" are strictly forbidden:
    * No Intramuscular (IM) injections.
    * No new Intravenous (IV) line insertions.
    * No Subcutaneous (sub-q) injections.
    * No fresh blood draws or venipunctures.
Blood Retrieval: All necessary blood samples must be drawn from existing IV lines to avoid new needle sticks.

Interventions for Non-tPA Patients and Secondary Prevention

Surgical and Endovascular Interventions:
    * Endovascular Devices: Mechanical tools used to address vascular blockages.
    * Carotid Stent: A mesh tube placed to keep the carotid artery open.
    * Endarterectomy: A surgical procedure to remove plaque buildup from the carotid arteries to restore blood flow.
Pharmacological Management:
    * Anticoagulation: Used in selected patients. Note: Heparin does not break up existing clots; it only ensures the clot does not increase in size.
    * Intracranial Pressure (ICP) Management: Critical for patients outside the thrombolytic window. While the clot cannot be removed, managing ICP prevents further brain damage from pressure-induced tissue death.
    * Blood Pressure Management: Maintaining stable, appropriate blood pressure levels is vital.
    * Secondary Prevention Medications:
        * Platelet inhibitors such as Aspirin or Clopidogrel.
        * Statins for cholesterol management.
Long-term Management: Focused on rehabilitation and risk factor management (to be discussed in further detail in the rehab section).

Mechanical Clot Retrieval (Mercy Retrieval)

Device Overview: The Mercy Retriever is a mechanical clot retrieval device.
Guidelines: In $2015$ , the American Heart Association (AHA) and American Stroke Association (ASA) established guidelines for the emergency treatment of ischemic stroke patients using mechanical removal.
Eligibility: This is an option for patients who are not eligible for tPA for various reasons.
Visual Evidence: Clinical imaging shows a lack of blood flow prior to the procedure and restored, increased blood flow after the physical clot is removed.
Distinction: Mechanical retrieval is distinct from "coiling," which is used for aneurysms.

Hemorrhagic Strokes: Types and Risk Factors

Definition: Occurs when a brain aneurysm bursts or a weakened blood vessel leaks. Blood spills into or around the brain, creating swelling and pressure that damages cells and tissues.
Classification:
* Intracerebral Hemorrhage: Bleeding located inside the brain tissue.
* Subarachnoid Hemorrhage (SAH): Bleeding into the subarachnoid space (the area between the arachnoid membrane and the pia mater).
Risk Factors:
    * Hypertension: The primary risk factor for both hemorrhagic and ischemic (clot) strokes.
    * Amyloid Angiopathy: Causes weakened blood vessels prone to leakage.
    * Medications and Substances: Anticoagulants, amphetamines, and cocaine.

Arteriovenous (AV) Malformations (AVM)

Definition: A congenital defect in the vascular system involving a "tangle" of abnormal vessels where an artery feeds directly into a vein.
Pathophysiology: Blood moves from a high-pressure arterial system directly into a low-pressure vascular system without the buffering effect of a capillary bed. These vessels are not built for such pressure, leading to rupture and hemorrhage.
Symptoms: Patients are often asymptomatic until a rupture occurs. Approximately $50\%$ of patients are diagnosed only after a bleed.
Subtle Symptoms: Intact AVMs may irritate brain tissue, causing seizures or headaches.
Treatment: Surgical resection performed by a neurosurgeon via a craniotomy (creating a small window in the skull).

Cerebral Aneurysms and Treatments

Definition: A weakness in the arterial wall resulting in abnormal "ballooning" of the vessel.
Etiology: Can be congenital, traumatic, or caused by hypertensive vascular disease and atherosclerosis.
Rupture Dynamics:
    * Occurs most frequently during activity.
    * Probability of rupture increases with the physical size of the aneurysm.
    * Rupture results in interrupted blood flow (ischemia) and hemorrhagic stroke.
Outcomes: Can range from the aneurysm clotting off (survival) to severe brain damage, paralysis, coma, or death.
Surgical Treatments:
    * Clipping: Applying an aneurysm clip to the base of the ballooning vessel.
    * Coiling: A coil is threaded via the groin up to the brain and placed inside the aneurysm to induce clotting and prevent rupture.
    * Stents: If the aneurysm opening is wide or horseshoe-shaped, a stent is placed first to hold the coils in place.

Management of Decreased Cerebral Blood Flow and Hypoxia

Role of the Nurse: Critical in managing complications and monitoring for rebleeding.
Rebleeding Window: For aneurysms, rebleeding is most frequent within $1$ to $2\,\text{weeks}$ after the initial hemorrhage.
Hemodynamic Management:
* Avoid extremes in hypertension and hypotension.
* Blood pressure in hemorrhagic stroke is generally controlled to a lower level than in ischemic stroke to minimize further bleeding.
Medical Reversal: If a patient was on Warfarin (e.g., for Atrial Fibrillation), the INR is corrected using Vitamin K or Fresh Frozen Plasma (FFP).
Oxygenation: Supplemental oxygen is used to maintain oxygen saturation ( $SaO_2$ ) greater than $92\%$ . Monitoring Hemoglobin and Hematocrit (H&H) is also essential.

Nursing Assessment and Cerebral Vasospasm

Assessment Protocol: Closely monitor for neuro changes, cerebral edema, or vasospasm.
Acute Changes: If neuro status declines, immediately elevate the head of the bed (HOB) to $30^{\circ}$ to decrease ICP and notify the physician for a repeat head CT.
Cerebral Vasospasm:
    * Cause: Irritation from blood circulating in the subarachnoid space.
    * Timing: Most frequent $7$ to $10\,\text{days}$ after the initial insult.
    * Clinical Impact: Leading cause of morbidity and mortality for hemorrhage survivors. Causes focal ischemia resulting in decreased Level of Consciousness (LOC), weakness, speech difficulty, and confusion.

Intracranial Pressure (ICP) Monitoring

Occurrence: Can occur with any stroke but is almost universal after Subarachnoid Hemorrhage (SAH).
Signs and Symptoms:
    * Changes in LOC.
    * Impaired eye movement and pupillary changes.
    * Decreased sensory-motor function.
    * Headache and vomiting.
    * Vital sign changes (Cushing's Triad): Increased blood pressure and decreased pulse.
    * Changes in respiratory patterns.
Pediatric/Infant Signs: Bulging fontanels, cranial suture separation, increased head circumference, and high-pitched cries.
Posturing:
* Decorticate: Limbs move towards the "core."
* Decerebrate: Limbs move outward (distal).
Prevention of Increased ICP:
    * Elevate HOB to $30^{\circ}$ .
    * Keep head in a midline position (no rotation).
    * Avoid excess hip flexion to maintain drainage.
    * Prevent straining (e.g., valsalva during bowel movements; use bowel regimens) and avoid pulling self up in bed.
    * Maintain a quiet, calm environment (low volume TV, limited visitors) to reduce anxiety-induced pressure.

Seizure and Venous Thromboembolism (VTE) Precautions

Seizure Precautions: Common after hemorrhagic stroke.
    * Padded side rails.
    * Suction equipment at the bedside.
    * Ensuring bed rails are up for safety.
VTE/DVT Prevention:
    * Constraint with Bleeds: Lovenox/Anticoagulants are prohibited in active bleeds.
    * Physical Interventions: Active Range of Motion (ROM), TED hose (compression stockings), and Sequential Compression Devices (SCDs).
    * Vena Cava Filter: If a patient has a known clot but cannot take anticoagulants due to a brain bleed, a filter is placed in the vena cava (around the midsection) to catch clots migrating from the legs.

Hyponatremia and Osmotic Therapy

Definition: Serum sodium less than $135\,\text{mEq/L}$ .
Causes: Dilution from excessive fluid, increased sodium loss (vomiting, diarrhea, NG suction), diuretics, and shifts from Intracellular Fluid (ICF) to Extracellular Fluid (ECF) caused by hypertonic solutions like Mannitol.
Symptoms: Lethargy, headache, confusion, apprehension, seizures, and coma.
Correction Rate Warning: Sodium must not be increased by more than $10\,\text{points}$ per day. Rapid correction causes demyelination (destruction of myelin sheaths), leading to permanent brain damage.

General Nursing Interventions for All Stroke Patients

Neuro Protection: Monitor for changes, avoid hypoxia and hypercarbia. Use osmotic diuretics or surgical decompression if necessary.
Vitals Management: Protect against hyperthermia (fever) and hyperglycemia (high blood sugar).
Mobility Management: Positioning, SCDs/TED hose, and "Cough and Deep Breathe" exercises to prevent pneumonia.
Independence: Encourage patients to perform tasks themselves (e.g., washing their own face) to promote rehabilitation, even if progress is slow.

NIHSS Stroke Scale

Function: A standardized scale providing common language and assessment methods for all healthcare providers.
Focus: Focuses on impairment of function and ensures consistent, thorough examination.
Requirement: Annual training and competency for ER and ICU nurses.
Updates: The scale was recently updated (visible on the NIHSS website) with new scene and object naming pictures.

Dysphagia and Nutritional Management

Definition: Difficulty swallowing due to impaired coordination of face, throat, and neck muscles.
Incidence: Estimated between $29\%$ and $50\%$ of stroke patients.
Signs/Symptoms: Choking, coughing during meals, drooling, food falling from the mouth, pocketing food in cheeks, and a "wet" or congested voice after eating.
Thin Liquids: Highly problematic due to fast transient time in the pharynx, leading to aspiration and pneumonia.
Malnutrition: $50\%$ of severe stroke patients are malnourished within $2$ to $3\,\text{weeks}$ .
Feeding Tubes: PEG or gastrostomy tubes may be needed. Maintain HOB greater than $30^{\circ}$ during feeds and check residuals regularly.
Swallowing Evaluation: Performed by a Speech-Language Pathologist (SLP). May involve a Barium Swallow (radiographic video imaging of the swallowing process).
Eating Safety Techniques:
    * Patients should be out of bed and sitting upright at $90^{\circ}$ (like at a kitchen table).
    * Provide small bites and ensure the mouth is clear after each bite.
    * Chin-to-Chest Tuck: Remind patients to tuck their chin to their chest when swallowing.
    * Danger of Head Tilt: Tilting the head back (common when taking pills) opens the airway—the same technique used by sword swallowers—making it a "straight shot" into the lungs.
    * Anecdote: Mrs. White does not let her children throw food in the air and catch it because it forces the head back and opens the airway, preventing safe swallowing.