Basic Stroke for the New Recruit Authors • Erin Conahan MSN, RN, ACNS-BC, CNRN, SCRN • Julie Fussner BSN, RN, CPHQ, SCRN • The authors have nothing to disclose. 1 Objectives • List causes of small vessel stroke vs large vessel stroke and differences in treatment • Describe inclusion/exclusion criteria for tPA and endovascular treatment • List elements of acute stroke work-up to identify risk factors Stroke Facts • Each year 795,000 strokes occur in the United States • Stroke is the 5th leading cause of death in the United States • Stroke is the leading cause of adult disability • Up to 80% of strokes are preventable • During a stroke ~32,000 brain cells are lost per second… ~2 million brain cells lost per minute. • The brain ages 3.6 years for each hour untreated… •Time is Brain 2 What is stroke? Stroke occurs when a blood vessel to the brain is blocked or ruptured causing brain cells in the blood vessel territory to die . What does it look like? • Ischemic Stroke • Hemorrhagic Stroke 3 Cerebral Circulation • Circle of Willis • Located at the base of the skull • Provides collateral circulation • Anterior Circulation • Carotid arteries • Anterior cerebral • Middle cerebral • Anterior communicating • Posterior Circulation • Vertebral • Basilar • Posterior cerebral • Posterior communicating http://www.merckmanuals.com/professional/neurologic_disorders/stroke_cva/overview_of_stroke.html 5 Stroke Syndromes 1. Left Hemisphere 2. Right Hemisphere 3. Cerebellar 4. Brainstem 5. Hemorrhage 4 Left Hemisphere Signs: • Aphasia • Right side weakness • Right side sensory loss • Right visual field cut • Left gaze Right Hemisphere Signs: • Neglect • Left side weakness • Left side sensory loss • Left visual field cut • Right gaze 5 Cerebellar Signs: • Ataxia • Gait disturbance • Vertigo • Nystagmus • Ipsilateral Findings Brainstem Retrieved on 9/25/15 from: http://biology.clc.uc.edu/fankhauser/Labs/Anatomy_&_Physiology/A&P202/202_lecture_notes/05_Mesencephalon_Diencephalon.Jan12. pdf 6 Brainstem The 5 D’s Dizziness Diplopia Dysarthria Dysphagia Dystaxia Retrieved 9/25/15 from: http://www.americannursetoday.com/assets/0/434/436/440/5120/5122/5154/5156/904adb93-6d32- 4770-83d7-e6f1ad1667d2.pdf Intracranial Hemorrhages 4 Types Epidural (trauma) Subdural (trauma) Subarachnoid (traumatic or stroke) Intracerebral hemorrhages (stroke) Note difference between intraCRANIAL and intraCEREBRAL – both abbreviated “ICH” 7 Hemorrhage Meninges (Outer to Inner) • Dura Mater – thick, fibrous covering of brain (and spinal cord) • Arachnoid Mater – thin web-like membrane between dura and pia, below which flows the CSF in the subarachnoid space • Pia Mater – delicate covering of the brain and directly adherent to tissue Retrieved from: http://www.mdguidelines.com/subarachnoid-hemorrhage-non-traumatic . Source: Medical Disability Advisor SAH Etiology – Traumatic (fall, blow to head) – Aneurysmal (ruptured aneurysm) – AVM (burst of AV malformation) Signs and symptoms – occur suddenly – “Worst headache of my life” (thunderclap HA) – Decrease/loss of consciousness/confusion – N/V – Photophobia – Hemiparesis/hemiplegia – Meningeal irritation 8 Intracerebral Hemorrhage • Clinical Presentation • SBP often >220 mmHg • HA • N/V • Ataxia • Dizziness/Vertigo • Dysarthria • Nuchal Rigidity • Alterations in LOC Stroke Assessments • Support airway/breathing/circulation • Vital signs • POC Glucose • CT • NIHSS • Labs, EKG, CXR • CTA or MRA assess vessels • LP for SAH 9 NIH Stroke Scale • Systematic assessment tool that provides a quantitative measure of stroke used world wide • 42 point scale • Higher the number the worse the stroke • NIHSS 2 or greater tPA given • “Too good” to treat research • www.nihss.org NIH Stroke Scale • Level of Consciousness Questions & Commands • Visual Fields • Facial Palsy • Motor arm & leg • Limb ataxia • Sensory • Best Language • Dysarthria • Neglect 10 What type of stroke did your patient have? • Large vessel occlusion • Lacunar Infarct • Transient Ischemic Attack • Stroke mimics AIS: Large Artery Atherosclerosis Thrombosis • Plaque narrows the vessel lumen resulting in turbulent blood flow. • The atherosclerotic plaque becomes unstable and ruptures, clotting factors are attracted and a thrombus forms. • Carotids / Aorta • Afib 11 AIS: Small Vessel Atherosclerosis • Small-vessel ischemia occurs when plaque occludes small perforating vessels. • Typically results in lacunar strokes which accounts for ~ 25% of ischemic strokes. • Chronic medical conditions such as DM, HTN, HLD and smoking increases risk of small vessel disease. TIA • “Mini stroke” - Avoid term • Brief episode of neurological dysfunction lasting < 1 hour • Symptoms usually last 10-20 mins • Old Definition: less than 24 hours • New Definition: Evidence on MRI imaging • Important determinant of stroke risk • 3-10% pts stroke within 2 days • 9-17% pts stroke within 90 days • Within 1 year of TIA =12% will die 12 Stroke Mimics • Hypoglycemia • Seizures • Migraine • Tumor • Abscess • Subdural Hematoma Imaging: CT vs MRI • Why do they order the scan? • CT better for seeing acute blood or skull fractures • MRI better for ischemic stroke and tumor • CTA/MRA looking for blood vessel abnormalities (“A” means angio) 13 Treatment options: Time is brain • Blood pressure control for all types!! • IV tPA • Endovascular • Pharmacologic • Mechanical • Neurosurgery • Aneurysmal SAH Clipping and Coiling • External Ventricular Device • Decompressive Hemi craniotomy • Research • Neuroscience ICU / Stroke unit **Find the cause to prevent future events! tPA Inclusion/Exclusion Criteria • Contraindications • ICH, SAH, active internal bleeding • Recent intracranial or intraspinal surgery or head trauma • Presence of intracranial conditions that may increase risk of bleeding • Bleeding diathesis • Uncontrolled hypertension • INR > 1.7 or use of NOAC • 3-4.5 hour window • >80 years old • Any anticoagulant use • History of CVA and diabetes 14 Modifiable Risk Factors • Cardiovascular disease (CVD) • Cigarette smoking • Hypertension (HTN) • Drug use ( cocaine) • Asymptomatic carotid stenosis • Alcohol • A Fib • Obesity • Diabetes mellitus (DM) • Physical inactivity • Dyslipidemia • Sickle cell disease • Postmenopausal hormone therapy • Hypercoagulable states Stroke Work-Up • Cardiac monitoring • Angiography (CTA, MRA, angio) • Carotid duplex • Echocardiogram/TEE • FLP, HgA1C, Hypercoag panels • Patient History!! 15 Importance of Nursing Assessment • Ongoing neuro exam: 30% of stroke patients deteriorate in 1 st 24 hours • Bleeding, edema, stroke in evolution; seizures; side effects of treatment • VS trending • BP goals, temperature management, cardiac monitoring, oxygenation, blood glucose monitoring Nursing Role of Preventing Complications • VTE, Pneumonia • Nutritional deficiency • Aspiration • Bowel or bladder dysfunction, UTI • Contractures/joint abnormalities • Skin breakdown • Depression • Falls 16.