Cerebrovascular Accident Study Notes

Overview of Cerebrovascular Accident (CVA)

  • Definition: Cerebrovascular Accident (CVA), commonly known as a stroke, involves the sudden loss of brain function due to a disturbance in the blood supply to the brain.

Types of Strokes

Ischemic Stroke
  • Results from inadequate blood supply to the brain cells.
  • Includes both Embolic and Thrombotic strokes.
1. Embolic Stroke
  • A clot forms elsewhere (e.g., heart) and travels to the brain, lodging in an artery.
2. Thrombotic Stroke
  • A clot forms within a blood vessel in the brain due to damage (often from atherosclerosis).
Hemorrhagic Stroke
  • Results from blood vessel rupture, leading to bleeding in or around the brain.
  • Subdivided into:
    • Intracerebral Hemorrhage: Bleeding directly into brain tissue.
    • Subarachnoid Hemorrhage (SAH): Bleeding between the arachnoid and pia mater membranes, often due to a ruptured aneurysm.
Transient Ischemic Attack (TIA)
  • A temporary decrease in blood supply to the brain, often considered a warning sign of stroke. Symptoms usually resolve quickly, but it requires immediate attention to rule out a stroke.

Statistics

  • 5th leading cause of death in the United States.
  • #1 leading cause of disability, with 15-30% of survivors facing permanent disability.

Risk Factors

Modifiable Risks
  • Tobacco use
  • Obesity
  • Diabetes
  • Hypertension
  • Obstructive sleep apnea
  • Metabolic syndrome
  • Unhealthy diet
  • Excessive alcohol use
  • Drug use
  • Hormonal factors (contraceptives, hormone replacement)
Nonmodifiable Risks
  • Age (more than 55 years)
  • Gender (males at higher risk)
  • Genetic predisposition (family history of SAH or aneurysms)
  • Ethnic background (Black Americans at a higher risk)

Pathophysiology

  • Ischemic Cause: Results from an obstruction that prevents blood flow to the brain, leading to cell death due to lack of oxygen.
    • Embolism: Movement of a clot through the bloodstream to the brain.
    • Thrombosis: Formation of a clot within the cerebral arteries.
  • Hemorrhagic Cause: Results from the rupture of a blood vessel leading to bleeding into or around the brain, causing cell death.

Signs & Symptoms of Stroke

  • Symptoms typically present unilaterally and can include:
    • Sudden weakness or paralysis on one side
    • Facial weakness
    • Slurred speech or inability to speak (aphasia)
    • Loss of fine motor control
    • Abnormal muscle tone or reflexes
    • Neglect of one side of the body
    • Changes in consciousness levels
    • Sudden and severe headaches (common in hemorrhagic stroke)
    • Seizures, nausea, or vomiting (especially with SAH)

Diagnosing Stroke

  • Diagnostic Tools:
    • CT Scan: To visualize the brain for bleeding or ischemic areas.
    • MRI: Provides detailed images of brain tissues.
    • CT Angiography (CTA): To assess blood vessels in the head and neck for blockages.
    • Cardiac Testing.
    • Lumbar Puncture: May be used to check for blood in cerebrospinal fluid.

Acute Nursing Care

  • Immediate interventions include:
    • Activating the Stroke Code or Transfer to a Stroke Center.
    • Keeping the patient NPO (nothing by mouth).
    • Monitoring vital signs and ensuring airway stability (ABCs).
    • Obtaining medical history including last known well (LKW) and current symptoms.
    • A detailed neurological assessment using NIHSS (National Institutes of Health Stroke Scale).
NIHSS Assessment
  • Measures stroke severity on a scale of 0-42:
    • 0: No stroke symptoms
    • 1-4: Minor stroke
    • 5-15: Moderate stroke
    • 16-20: Moderate to severe stroke
    • 21-42: Severe stroke
    • Assessment includes evaluating consciousness, motor skills, sensation, and language abilities to identify areas needing support.

Fibrinolytic Therapy for Ischemic Stroke

  • Alteplase (tPA) is the first-line thrombolytic therapy that can be administered if within 3-4.5 hours from symptom onset.
  • Criteria: Must rule out hemorrhagic stroke and ensure the patient meets age and health requirements.
Contraindications Include:
  • Uncontrolled hypertension
  • Active internal bleeding
  • Platelet count < 100,000
    • Complications to monitor for include: Sudden severe headaches, new neurological deficits, and signs of bleeding (gums, urine).

Endovascular Therapy

  • Mechanical Thrombectomy: A stent retriever is employed to remove clots from blocked arteries, typically through femoral or radial access.

Medical Management Based on Stroke Type

  • Ischemic Stroke (Embolic or Thrombotic)
    • IV thrombolysis (tPA) if within 4.5 hours.
    • Endovascular thrombectomy for large vessels.
    • Anticoagulation status monitored post-stabilization.
  • Hemorrhagic Stroke (SAH or Intracerebral)
    • Main therapy focuses on blood pressure control.
    • Surgical intervention may be necessary for large bleeds.

Rehabilitation Following Stabilization

  • Involves interdisciplinary care focusing on:
    • Physical Therapy (PT): Improving mobility.
    • Occupational Therapy (OT): Aiding independence in daily living activities.
    • Speech-Language Pathology: Addressing communication and swallowing difficulties.
  • Monitoring for complications: respiratory issues, infection risks, and emotional support (e.g., post-stroke depression).

Nursing Considerations for Rehabilitation

  • Continuous assessment of the patient's ability to perform activities of daily living (ADLs).
  • Encourage verbal and non-verbal communication techniques to aid interaction.
  • Attention to the affected side for mobility and safety considerations.
  • Regular reassessment of physical needs and adaptation of care plans based on individual progress.