Management of Patients with Cerebrovascular Disorders

Ischemic Stroke

• An ischemic stroke, formerly referred to as a cerebrovascular disease (stroke) or “brain attack,”

is a sudden loss of function resulting from disruption of the blood supply to a part of the brain.

Pathophysiology

• In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a
blood vessel.

• This disruption in blood flow initiates a complex series of cellular metabolic events referred to as
the ischemic cascade.

• The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of
blood per minute.

• At this point, neurons are no longer able to maintain aerobic respiration.

• The mitochondria must then switch to anaerobic respiration, which generates large amounts of
lactic acid, causing a change in the pH.

• This switch to the less efficient anaerobic respiration also renders the neuron incapable of
producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization
processes.

• The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to
function.

• Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region,
exists around the area of infarction.

• The penumbra region is ischemic brain tissue that may be salvaged with timely intervention.
Clinical Manifestations

• The patient may present with any of the following signs or symptoms:

1. Numbness or weakness of the face, arm, or leg, especially on one side of the body

2. Confusion or change in mental status

3. Trouble speaking or understanding speech

4. Visual disturbances

5. Difficulty walking, dizziness, or loss of balance or coordination

6. Sudden severe headache

Prevention

• Primary prevention of ischemic stroke remains the best approach.

• A healthy lifestyle including not smoking, engaging in physical activity (at least 40 minutes a day,
3 to 4 days a week), maintaining a healthy weight, and following a healthy diet (including
modest alcohol consumption), can reduce the risk of having a stroke.

• Specific diets that have decreased risk of stroke include the Dietary Approaches to Stop
Hypertension (DASH) diet (high in fruits and vegetables, moderate in lowfat dairy products, and
low in animal protein), the Mediterranean diet (supplemented with nuts), and overall diets that
are rich in fruits and vegetables.
Medical Management

• Patients who have experienced a TIA or stroke should have medical management for secondary
prevention.

• Those with atrial fibrillation (or cardioembolic strokes) are treated with dose-adjusted warfarin
(Coumadin) with a target international normalized ratio (INR) of 2 to 3.

• Other newer anticoagulants that may be prescribed as alternative drugs include dabigatran
(Pradaxa), apixaban (Eliquis), edoxaban (Savaysa), or rivaroxaban (Xarelto), unless they are
contraindicated.

• If anticoagulants are contraindicated, aspirin alone is the best option, although the addition of
clopidogrel (Plavix) to aspirin is also a reasonable therapy.

1. Thrombolytic Therapy

• Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that is
blocking blood flow to the brain.

• Recombinant t-PA is a genetically engineered form of t-PA (a thrombolytic substance made

naturally by the body)

• The goal is for intravenous (IV) t-PA to be given within 60 minutes of the patient arriving to the
ED.
• The patient is weighed to determine the dose of t-PA. Typically, two or more IV sites are
established prior to administration of t-PA (one for the tPA and the other for administration of
IV fluids).

• The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg.

2. Surgical Prevention of Ischemic Stroke

• The main surgical procedure for selected patients with TIAs and mild stroke is carotid
endarterectomy (CEA).

• A CEA is the removal of an atherosclerotic plaque or thrombus from the carotid artery to
prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.

• Carotid artery stenting (CAS), with or without angioplasty, is a less invasive procedure.
Nursing Interventions

• IMPROVING MOBILITY AND PREVENTING JOINT DEFORMITIES

• PREVENTING SHOULDER PAIN

• ENHANCING SELF-CARE

• ADJUSTING TO PHYSICAL CHANGES

• ASSISTING WITH NUTRITION

• ATTAINING BLADDER AND BOWEL CONTROL

• IMPROVING THOUGHT PROCESSES

• IMPROVING COMMUNICATION

• MAINTAINING SKIN INTEGRITY

• IMPROVING FAMILY COPING

• HELPING THE PATIENT COPE WITH SEXUAL DYSFUNCTION

• MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Hemorrhagic Stroke

• Hemorrhage accounts for approximately 13% of strokes and are primarily caused by intracranial
(7%), subarachnoid hemorrhage (8%), and other causes.

• Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the
subarachnoid space.

• Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for
approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.

1. Intracerebral Hemorrhage

• An intracerebral hemorrhage, or bleeding into the brain tissue, is most common in patients with
hypertension and cerebral atherosclerosis.

2. Intracranial (Cerebral) Aneurysm

• An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral artery that develops as
a result of weakness in the arterial wall.

3. Arteriovenous Malformations

• Most AVMs are caused by an abnormality in embryonal development that leads to a tangle of
arteries and veins in the brain that lacks a capillary bed.
 4. Subarachnoid Hemorrhage

• A subarachnoid hemorrhage (hemorrhage into the subarachnoid space) may occur as a result of
an AVM, intracranial aneurysm, trauma, or hypertension.

Clinical Manifestations

• The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits,
similar to the patient with ischemic stroke.

• The conscious patient most commonly reports a severe headache.

• Rupture of an aneurysm or AVM usually produces a sudden, unusually severe headache and
often loss of consciousness for a variable period of time.
 • There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to
meningeal irritation.

• Visual disturbances (visual loss, diplopia, ptosis) occur if the aneurysm is adjacent to the
oculomotor nerve.

• Tinnitus, dizziness, and hemiparesis may also occur.

Assessment and Diagnostic Findings

• Any patient with suspected stroke should undergo a CT scan or MRI scan to determine the type
of stroke, the size and location of the hematoma, and the presence or absence of ventricular
blood and hydrocephalus.

• Because hemorrhagic stroke is an emergency, CT scan is usually obtained first because it can be
done rapidly.

• Cerebral angiography using the conventional method or CT (CTA) confirms the diagnosis of an
intracranial aneurysm or AVM.

Prevention

• Primary prevention of hemorrhagic stroke is the best approach and includes managing
hypertension and ameliorating other significant risk factors.

• Control of hypertension can reduce the risk of hemorrhagic stroke.

• Additional risk factors are increased age, male gender, certain ethnicities (Latino, African
American, and Japanese) and moderate or excessive alcohol intake (Hickey, 2014).

• Stroke risk screenings provide an ideal opportunity to lower hemorrhagic stroke risk by
identifying individuals or groups at high risk and educating patients and the community about
recognition and prevention.

Complications

• Cerebral Hypoxia and Decreased Blood Flow

• Cerebral Vasospasm

• Increased Intracranial Pressure

• Hypertension

Medical Management

• The goals of medical treatment for hemorrhagic stroke are to allow the brain to recover from
the initial insult (bleeding), to prevent or minimize the risk of rebleeding, and to prevent or treat
complications.

• Management may consist of bed rest with sedation to prevent agitation and stress,
management of vasospasm, and surgical or medical treatment to prevent rebleeding.
 • If the bleeding is caused by anticoagulation with warfarin, the INR may be corrected with fresh-
frozen plasma and vitamin K.

Surgical Management

• In many cases, a primary intracerebral hemorrhage is not treated surgically.

• However, if the patient is showing signs of worsening neurologic examination, increased ICP, or
signs of brainstem compression, then surgical evacuation is recommended for the patient with a
cerebellar hemorrhage (Hemphill et al., 2015).

• Surgical evacuation is most frequently accomplished via a craniotomy

Nursing Interventions

• OPTIMIZING CEREBRAL TISSUE PERFUSION

1. Implementing Aneurysm Precautions

• RELIEVING ANXIETY

• MONITORING AND MANAGING POTENTIAL COMPLICATIONS

1. Vasospasm

2. Seizures

3. Hydrocephalus

4. Rebleeding

Increased ICP

- increased ICP due to increase in 1 of the intra- cranial components:

Predisposing factors:

- head injury

- tumor

- localized abscess

- hemorrhage

- cerebral edema

- hydrocephalus

- inflammatory conditions

- meningitis, encephalitis
Increased ICP – an emergency – cerebral cortex – tolerates hypoxia for 4 to 6 minutes

Medulla oblongata – tolerates hypoxia – 10 to 15 minutes

S/Sx

Earliest Sign:

decreased visual acuity – diplopia

- decrease LOC

- restlessness to confusion

- disorientation to lethargy

- sudden quietness

Late Signs: Change in V/S

- BP increase

- Widening pulse pressure

- normal adult: BP 120/80

120-80 = 40 (normal)

- RR decrease

- HR decrease

- headache

- projectile vomiting

Cushing’s response – Increase BP, decrease HR, decrease RR

Vomiting – due to compression of medulla oblongata

Decorticate - disruption of the lateral corticospinal tract which facilitates motor neurons in the lower
spinal cord supplying flexor muscles of the lower extremities. he rubrospinal tract facilitates motor
neurons in the cervical spinal cord supplying the flexor muscles of the upper extremities.
Decerebrate posturing indicates brain stem damage, specifically damage below the level of the red
nucleus (e.g. mid-collicular lesion). It is exhibited by people with lesions or compression in
the midbrain and lesions in the cerebellum. Progression from decorticate posturing to decerebrate
posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation.

Brain Hernation occurs when the brain shifts across structures within the skull. Because herniation puts
extreme pressure on parts of the brain and thereby cuts off the blood supply to various parts of the
brain, it is often fatal.
Nsg Mgt to Increased ICP

H - Head of the bed

E - Evaluation (Neurological Checks, PERRLA)

A - Airway (Intubation and ventilation)

D - Drainage (CSF)

S - Safety

- No sedatives and narcotics

- no coughing

- limit suctioning

Nursing Priority

1. Assess neurologic status

- 1 to 2 hours

2. Head and neck

- should be in neutral position to promote venous drainage

3. Prevention of hypoxia

Hypoxia – inadequate tissue oxygenation

Shock – inadequate tissue perfusion

Early symptoms of hypoxia

R- Restlessness

A- Agitation

T- Tachycardia

Late signs of hypoxia:

B- Bradycardia

E- Extreme Restlessness

D- Dyspnea

C- Cyanosis

4. Prevent increase ICP

a. Maintain quiet and comfortable environment

b. Avoid use of restraints – lead to fractures

c. Side rails up

d. Instruct patient to avoid the ff:

- valsalva maneuver – give laxative

- excessive cough – antitussive (Dextromethosphan)

- excessive vomiting – anti-emetic (Plasil)

- lifting of heavy objects

- Bending and stooping

Administer meds as ordered:

1. Osmotic diuretic

- Manitol / Osmitrol

- promotes cerebral diuresis by decompressing brain tissue

- SE: Decrease BP

Nursing Consideration:

- monitor BP – SE of Hypotension

- monitor I & O every hour: report if < 30 cc output

- administer via side drip

- regulate fast drip

- prevent crystal formation

- instruct pt. that he will feel flushing sensations as drugs is introduced

2. Loop diuretics

- lasix (Furosemide)

- acts in loop of Henle

- 6 hours

Nursing Mgt.:

-same as manitol except:

- lasix is given via IV push (except urination after 10- 15 mins) should be in the morning

Increased ICP meds:

a. Corticosteroids

- dexamethasone (Decadron)

– decreases cerebral edema

b. Mild analgesics

- codeine SO4 – for headache

c. Anti-convulsants

- Dilantin (Phenytoin)

OPITAES (narcotics) and Sedatives are contraindicated to the client with INCREASED ICP

- Can cause respiratory depression and acidosis