W ha t i s a B r ai n Aneu r ysm?

A brain aneurysm, also called a cerebral or intracranial aneurysm, is an abnormal bulging

outward of one of the arteries in the brain. It is estimated that up to one in 15 people in
the United States will develop a brain aneurysm during their lifetime.

Brain aneurysms are often discovered when they rupture, causing bleeding into the brain
or the space closely surrounding the brain called the subarachnoid space, causing a
subarachnoid hemorrhage. Subarachnoid hemorrhage from a ruptured brain aneurysm can
lead to a hemorrhagic stroke, brain damage and death.

The main goals of treatment once an aneurysm has ruptured are to stop the bleeding and
potential permanent damage to the brain and to reduce the risk of recurrence. Unruptured
brain aneurysms are sometimes treated to prevent rupture. Learn more about treatment
options for a brain aneurysm.

In cidenc e Ra tes of Br ain Aneu r ys ms

• Approximately 0.2 to 3 percent of people with a brain aneurysm may suffer from
bleeding per year
• The annual incidence of aneurysmal subarachnoid hemorrhage in the U.S.
exceeds 30,000 people. Ten to 15 percent of these patients will die before
reaching the hospital and over 50 percent will die within the first thirty days after
rupture. Of those who survive, about half suffer some permanent neurological
deficit
• Brain aneurysms can occur in people of all ages, but are most commonly detected
in those ages 35 to 60
• Women are actually more likely to get a brain aneurysm than men, with a ratio of
3:2

Symp toms o f Br ain An eur ys ms

Ruptur ed Cer ebr al Aneur ysm Symptoms

Sometimes patients describing "the worst headache in my life" are actually experiencing
one of the symptoms of brain aneurysms related to having a rupture. Other ruptured
cerebral aneurysm symptoms include:

• Nausea and vomiting

• Stiff neck or neck pain
• Blurred vision or double vision
• Pain above and behind the eye
• Dilated pupils
• Sensitivity to light
• Loss of sensation
Unruptured Cerebral Aneurysm Symptoms

Before an aneurysm ruptures, patients often experience no symptoms of brain aneurysms.

In about 40 percent of cases, people with unruptured aneurysms will experience some or
all of the following cerebral aneurysm symptoms:

• Peripheral vision deficits

• Thinking or processing problems
• Speech complications
• Perceptual problems
• Sudden changes in behavior
• Loss of balance and coordination
• Decreased concentration
• Short-term memory difficulty
• Fatigue

Because the symptoms of brain aneurysms can also be associated with other medical
conditions, diagnostic neuroradiology is regularly used to identify both ruptured and
unruptured brain aneurysms.

Dia gnos is of Br ain Aneu r ys ms

Diagnosis of a ruptured cerebral aneurysm is commonly made by finding signs of
subarachnoid hemorrhage on a CT scan (Computerized Tomography, sometimes called a
CAT scan). The CT scan is a computerized test that rapidly X-rays the body in cross-
sections, or slices, as the body is moved through a large, circular machine. If the CT scan
is negative but a ruptured aneurysm is still suspected, a lumbar puncture is performed to
detect blood in the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord.

To determine the exact location, size and shape of an aneurysm (ruptured or unruptured),
neuroradiologists will use either cerebral angiography or tomographic angiography.

Cerebral angiography, the traditional method, involves introducing a catheter (small

plastic tube) into an artery (usually in the leg) and steering it through the blood vessels of
the body to the artery involved by the aneurysm. A special dye, called a contract agent, is
injected into the patient's artery and its distribution is shown on X-ray projections. This
method may not detect some aneurysms due to overlapping structures or spasm.

Computed Tomographic Angiography (CTA) is an alternative to the traditional method

and can be performed without the need for arterial catheterization. This test combines a
regular CT scan with a contrast dye injected into a vein. Once the dye is injected into a
vein, it travels to the brain arteries, and images are created using a CT scan. These images
show exactly how blood flows into the brain arteries.
Tr ea tment of B r ain A neur ysms
Surgery or minimally-invasive endovascular coiling techniques can be used in the
treatment of brain aneurysms. It is important to note, however, that not all aneurysms are
treated at the time of diagnosis or are amenable to both forms of treatment. Patients need
to consult a neurovascular specialist to determine if they are candidates for either
treatment.

Sur gical T rea tment

To get to the aneurysm, surgeons must first remove a section of the skull, a procedure
called a craniotomy. The surgeon then spreads the brain tissue apart and places a tiny
metal clip across the neck to stop blood flow into the aneurysm. After clipping the
aneurysm, the bone is secured in its original place, and the wound is closed.

Minimally-Invasive Treatment
Coil Embolization or Endovascular Coiling

Endovascular therapy is a minimally invasive procedure that

accesses the treatment area from within the blood vessel. In
the case of aneurysms, this treatment is called coil
embolization, or "coiling". In contrast to surgery,
endovascular coiling does not require open surgery. Instead,
physicians use real-time X-ray technology, called
fluoroscopic imaging, to visualize the patient's vascular
system and treat the disease from inside the blood vessel.

Endovascular treatment of brain aneurysms involves insertion

of a catheter (small plastic tube) into the femoral artery in the
patient's leg and navigating it through the vascular system,
into the head and into the aneurysm. Tiny platinum coils are
threaded through the catheter and deployed into the
aneurysm, blocking blood flow into the aneurysm and
preventing rupture. The coils are made of platinum so that
they can be visible via X-ray and be flexible enough to
conform to the aneurysm shape. This endovascular coiling, or
filling, of the aneurysm is called embolization and can be
performed under general anesthesia or light sedation. More
than 125,000 patients worldwide have been treated with
detachable platinum coils
 Transient Ischemic Attack
A transient ischemic attack (TIA, often colloquially referred to as "mini stroke") is
caused by the temporary disturbance of blood supply to a restricted area of the brain,
resulting in brief neurologic dysfunction that usually persists for less than 24 hours.

 Symptoms

Symptoms vary widely from person to person, depending on the area of the brain
involved. The most frequent symptoms include temporary loss of vision (typically
amaurosis fugax); difficulty speaking (aphasia); weakness on one side of the body
(hemiparesis); numbness or tingling (paresthesia), usually on one side of the body; and
loss of consciousness. If there are neurological symptoms persisting for more than 24
hours, it is classified as a cerebrovascular accident, or stroke.

 Prognosis

Patients diagnosed with a TIA are sometimes said to have had a warning for an
approaching cerebrovascular accident. If the time period of blood supply impairment lasts
more than a few minutes, the nerve cells of that area of the brain die and cause permanent
neurologic deficit. One third of the people with TIA later have recurrent TIAs and one
third have a stroke due to permanent nerve cell loss.
The ABCD2 score can predict likelihood of subsequent stroke. The score is calculated

as:
Age ≥ 60 years = 1 point

Blood pressure at presentation ≥ 140/90 mm Hg = 1 point

Clinical features

unilateral weakness = 2 points

speech disturbance without weakness = 1 point

Duration of attack

≥ 60 minutes = 2 points

10–59 minutes = 1 point

Diabetes = 1 point
Interpretation of score, the risk for stroke:
Score 0-3 (low)

•2 day risk = 1.0%

•7 day risk = 1.2%
Score 4-5 (moderate)

•2 day risk = 4.1%

•7 day risk = 5.9%
Score 6–7 (high)

•2 day risk = 8.1%

•7 day risk = 11.7%
 Causes

The most common cause of a TIA is an embolus (a small blood clot) that occludes an
artery in the brain. This most frequently arises from an atherosclerotic plaque in one of
the carotid arteries (i.e. a number of major arteries in the head and neck) or from a
thrombus (i.e. a blood clot) in the heart due to atrial fibrillation

Other reasons include excessive narrowing of large vessels due to an atherosclerotic

plaque and increased blood viscosity due to some blood diseases. TIA is related with
other medical conditions like hypertension, heart disease (especially atrial fibrillation,
migraine, cigarette smoking, hypercholesterolemia, and diabetes mellitus.

 Prevention

Primary prevention
The use of anti-coagulant medications, heparin and warfarin; or anti-platelet medications

such as asprin.
Secondary prevention

Tertiary prevention

Treatment

The mainstay of treatment following acute recovery from a TIA should be to diagnose
and treat the underlying cause. It is not always immediately possible to tell the difference
between a CVA (stroke) and a TIA. Most patients who are diagnosed at a hospital's
Accident & Emergency Department as having suffered from a TIA will be discharged
home and advised to contact their primary physician to organize further investigations.

The initial treatment is Aspirin, second line is clopidogrel, third line is ticlopidine. If TIA
is recurrent after Aspirin treatment, the combination of Aspirin and dipirydamole is
needed (Aggrenox).

An electrocardiogram (ECG) may show atrial fibrillation, a common cause of TIAs, or
other arrhythmias that may cause embolisation to the brain. An echocardiogram is useful
 Ar teri oveno us Malf or ma tion

From A cerebral arteriovenous malformation (AVM) is a congenital disorder of

blood vessels within the brain, characterized by tangle(s) of veins and arteries.
While an arteriovenous malformation can occur elsewhere in the body, this article
discusses malformations found in the brain.

Symp toms
The most frequently observed problems related to an AVM are headache and
seizure. Moreover, AVMs in certain critical locations may stop the circulation of the
cerebrospinal fluid, causing accumulation of the fluid within the skull and giving
rise to a clinical condition called hydrocephalus.

Symptoms of bleeding within the brain (intracranial hemorrhage) include loss of

consciousness, sudden and severe headache, nausea, vomiting, incontinence, and
blurred vision. A stiff neck can occur as the result of increased pressure within the
skull and irritation of the meninges. Impairments caused by local brain tissue
damage on the bleed site are possible, including seizure, one-sided weakness
hemiparesis, a loss of touch sensation on one side of the body, or deficits in language
processing (aphasia). A variety of other symptoms can accompany this type of
cerebrovascular accident.

Generally, intense headache, perhaps coincident with seizure or loss of bodily

consciousness, is the first indication of a cerebral AVM. Estimates of the number of
AVM-afflicted people in the United States range from 0.1% to 0.001%.[1][2] of the
population.

Dia gnos is
An AVM diagnosis is established by neuroimaging studies. A computed tomography
scan of the head (head CT) is usually performed; this can reveal the site of the bleed.
More detailed pictures of the tangle of blood vessels that compose an AVM can be
obtained by using radioactive reagents injected into the blood stream, then observed
using a fluoroscope or Magnetic Resonance Imaging (MRI). A spinal tap (lumbar
puncture) can be used to examine spinal fluid for red blood cells; this condition is
indicative of leakage of blood from the bleeding vessels into the subarachnoid space.
The best images of an AVM are obtained through cerebral angiography. This
procedure involves using a catheter, threaded through an artery up to the head, to
deliver a contrast agent into the AVM. As the contrast agent flows through the AVM
structure, a sequence of X-ray images can be obtained to ascertain the size, shape
and extent of that structure.
 Pathoph ysio log y
While the cause of AVMs remains unknown, the main risk is intracranial
hemorrhage. This risk is difficult to quantify. Approximately 40% of cases with
cerebral AVM are discovered through symptoms caused by sudden bleeding due to
the fragility of abnormally-structured blood vessels in the brain. However, some
patients may remain asymptomatic or have minor complaints due to the local effects
of the tangle of vessels. If a rupture or bleeding incident occurs, the blood may
penetrate either into the brain tissue (cerebral hemorrhage) or into the
subarachnoid space. This space is located between the sheaths (meninges)
surrounding the brain (subarachnoid hemorrhage).

Once an AVM bleeds, the probability of rebleeding may increase. However, as long
as the AVM is unruptured, the risk of hemorrhage may be relatively low.

AVMs that do not bleed may cause symptoms such as epileptic seizures, headaches,
or fluctuating neurological symptoms. Many of them may even remain
asymptomatic.

Trea tment
The treatment in the case of sudden bleeding is focused on restoration of vital
function. Anticonvulsant medications such as phenytoin are often used to control
seizure; medications or procedures may be employed to relieve intracranial
pressure. Eventually, curative treatment may be required to prevent recurrent
hemorrhage. However, any type of intervention may also carry a risk of creating
new neurological deficits in about 10%.

In the U.S., surgical removal of the blood vessels involved (craniotomy) is the
preferred curative treatment for most types of AVM. While this surgery results in an
immediate, complete removal of the AVM, risks exist depending on the size and the
location of the malformation.
Radiation treatment (radiosurgery) has been widely used on smaller AVMs with
considerable success. The Gamma Knife, developed by Swedish physician Lars
Leksell, is one apparatus used in radiosurgery to precisely apply a controlled
radiation dosage to the volume of the brain occupied by the AVM. While this
treatment is non-invasive, two to three years may pass before the complete effects
are known. Complete occlusion of the AVM may or may not occur, and 8%-10% of
patients develop long term neurological symptoms after radiation.

Embolization, that is, occlusion of blood vessels with coils or particles introduced by
a radiographically guided catheter, is frequently used as an adjunct to either
surgery or radiation treatment. However, embolization alone is rarely successful in
completely blocking blood flow through the AVM.

The benefit of invasive treatment for unruptured AVMs has never been proven, as
the risk of intervention may be as high as the spontaneous bleeding risk. An
international study is currently under way to determine the best therapy for
patients with unruptured AVMs
 CEREBROVASCULAR ACCIDENT
GENERAL INFORMATION:

What is a cerebrovascular accident? A cerebrovascular accident is also called a

CVA, brain attack, or stroke. It occurs when blood flow to a part of the brain is
suddenly stopped and oxygen cannot get to that part. This lack of oxygen may
damage or kill the brain cells. Death of a part of the brain may lead to loss of certain
body functions controlled by that affected part.

What causes a cerebrovascular accident? A CVA may be caused by any of the

following:

• A piece of fatty plaque (debris) that is formed in a blood vessel breaks away
and flows through the bloodstream going to the brain. The plaque blocks an
artery which causes a stroke. This is called an embolic stroke.

• A thrombus (blood clot) formed in an artery (blood vessel) and blocked blood
flow to the brain. This is called a thrombotic stroke.

• A torn artery in the brain, causing blood to spill out. This is called a cerebral
hemorrhage or hemorrhagic stroke. It often results from high blood pressure.

• Blockage of certain small blood vessels inside the brain.

What puts me at a higher risk to have a cerebrovascular accident? The following

factors may put you at a higher risk of having a CVA:

• Cigarette smoking, cocaine use, or drinking too much alcohol.

• Diabetes (high blood sugar).

• You or a close family member has had a stroke.

• Atherosclerosis (hardening of the arteries) or fatty cholesterol deposits on

artery walls.

• Heart disease, such as coronary artery disease.

• High blood cholesterol (fat).

• High blood pressure.

What are the signs and symptoms of a cerebrovascular accident? Signs and
symptoms of a stroke depend upon the part of the brain affected and how much
damage occurred. During a CVA, you may have numbness (no feeling), tingling,
weakness, or paralysis (cannot move) on one side of the body. You may have trouble
walking, swallowing, talking, or understanding. Your vision (sight) may be blurred
or doubled. You may have a severe headache, feel dizzy, confused, or pass out. These
signs or symptoms may appear within minutes or hours.

How is a cerebrovascular accident diagnosed? You may have any of the following
tests to diagnose CVA:

• CT scan:
o This is also called a CAT scan. A special x-ray machine uses a
computer to take pictures of your brain. It may be used to look at
bones, muscles, brain tissue, and blood vessels.

o You may be given dye before the pictures are taken. The dye is usually
given in your IV. The dye may help your caregiver see the pictures
better. People who are allergic to iodine or shellfish (lobster, crab, or
shrimp) may be allergic to some dyes. Tell the caregiver if you are
allergic to shellfish, or have other allergies or medical conditions.

• Magnetic resonance imaging: Using magnetic waves, this test, also called an
MRI, takes pictures of your head. An MRI may show the cause of a CVA.

• Carotid ultrasonography

• Arteriography

How is a cerebrovascular accident treated? Treatment of a CVA depends upon the

type of stroke:

• Ischemic stroke: An ischemic stroke includes strokes caused by a blockage in

a blood vessel.

o Anticoagulant medicine: Treatment for an ischemic stroke includes

anticoagulant medicines which are also called blood thinners. This
medicine group keeps clots from forming in the blood

o Antiplatelet aggregating medicine: These medicines interact with

platelets to prevent blood clots from forming. Platelets are a type of
blood cell that join to form clots.

o Thrombolytic medicine: This medicine group is used in a stroke

caused by a clot in a blood vessel. Thrombolytics break apart clots
and restore blood flow.
 • Hemorrhagic (bleed) stroke: This type of stroke may require surgery.

Can a cerebrovascular accident be prevented?

• Take your high blood pressure medicine regularly.

• Do not smoke or drink too much alcohol. Alcohol is found in beer, wine,
liquor, like vodka or whiskey, and other adult drinks. Different people have
different ideas about what too much means. It is important to remember that
how often you drink is as important as how much you drink.

• If you have atrial fibrillation (an irregular or fast heart beat), you may need
to take antithrombotic medicine. Having a recent heart attack may also
require you to take antithrombotics.

• Keep your blood cholesterol level in a normal range. Eat foods low in fat to
decrease the risk of developing plaque (fatty deposits) in your blood vessels.
If you have hyperlipidemia (high blood cholesterol level), talk to your
caregiver about ways to lower it.

• Monitor and control your blood sugar level if you have diabetes.

Head injury
 Is a trauma to the head, that may or may not include injury to the
brain (see also brain injury).

The incidence (number of new cases) of head injury is 300 per 100,000 per
year (0..3% of the population), with a mortality of 25 per 100,000 in North
America and 9 per 100,000 in Britain. Head trauma is a common cause of
childhood hospitalization.

Types of head injury

Head injuries include both injuries to the brain and those to other parts of
the head, such as the scalp and skull.

Head injuries may be closed or open. A closed (non-missile) head injury is

one in which the skull is not broken. A penetrating head injury occurs when
an object pierces the skull and breaches the dura mater. Brain injuries may
be diffuse, occurring over a wide area, or focal, located in a small, specific
area.

A head injury may cause a skull fracture, which may or may not be
associated with injury to the brain. Some patients may have linear or
depressed skull fractures.

If intracranial hemorrhage, or bleeding within the brain occurs, a hematoma

within the skull can put pressure on the brain. Types of intracranial
hematoma include subdural, subarachnoid, extradural, and
intraparenchymal hematoma. Craniotomy surgeries are used in these cases
to lessen the pressure by draining off blood.

Brain injury can be at the site of impact, but can also be at the opposite side
of the skull due to a contrecoup effect (the impact to the head can cause the
brain to move within the skull, causing the brain to impact the interior of the
skull opposite the head-impact).

If the impact causes the head to move, the injury may be worsened, because
the brain may ricochet inside the skull (causing additional impacts), or the
brain may stay relatively still (due to inertia) but be hit by the moving skull.

Specific problems after head injury can include:

o Skull fracture
o Lacerations to the scalp and resulting hemorrhage of the skin
o Traumatic subdural hematoma, a bleeding below the dura mater
which may develop slowly
o Traumatic extradural, or epidural hematoma, bleeding between the
dura mater and the skull
o Traumatic subarachnoid hemorrhage
 o Cerebral contusion, a bruise of the brain
o Concussion, a temporary loss of function due to trauma
o Dementia pugilistica, or "punch-drunk syndrome", caused by
repetitive head injuries, for example in boxing or other contact sports
o A severe injury may lead to a coma or death
Symptoms

Presentation varies according to the injury. Some patients with head trauma
stabilize and other patients deteriorate. A patient may present with or
without neurologic deficit.

Patients with concussion may have a history of seconds to minutes

unconsciousness, then normal arousal. Disturbance of vision and equilibrium
may also occur.

Common symptoms of head injury include those indicative of traumatic

brain injury:

o loss of consciousness,
o confusion,
o drowsiness,
o personality change,
o seizures,
o nausea and vomiting,
o headache,
o a lucid interval, during which a patient appears conscious only to
deteriorate later

Symptoms of skull fracture can include:

o leaking cerebrospinal fluid (a clear fluid drainage from nose, mouth

or ear) may be and is strongly indicative of basilar skull fracture and
the tearing of sheaths surrounding the brain, which can lead to
secondary brain infection.
o visible deformity or depression in the head or face; for example a
sunken eye can indicate a maxillar fracture
o an eye that cannot move or is deviated to one side can indicate that a
broken facial bone is pinching a nerve that innervates eye muscles
o wounds or bruises on the scalp or face.
o Basilar skull fractures, those that occur at the base of the skull, are
associated with Battle's sign, a subcutaneous bleed over the mastoid,
hemotympanum, and cerebrospinal fluid rhinorrhea and otorrhea..

Because brain injuries can be life threatening, even people with apparently
slight injuries, with no noticeable signs or complaints, require close
observation. The caretakers of those patients with mild trauma who are
 released from the hospital are frequently advised to rouse the patient several
times during the next 12 to 24 hours to assess for worsening symptoms.

The Glasgow Coma Scale is a tool for measuring degree of unconsciousness

and is thus a useful tool for determining severity of injury. The Pediatric
Glasgow Coma Scale is used in young children.

Management

Unfortunately, once the brain has been damaged by trauma, there is no quick
fix. However, there are some steps that can be taken to prevent secondary
damage. If left untreated many patients with head injury will rapidly develop
complications which may lead to death or permanent disability. Prompt
medical treatment may prevent the worsening of symptoms and lead to a
better outcome. Medical treatment should begin at the scene of the trauma.
Paramedics will generally immobilize the patient to insure no further
damage to the spine or nervous system, insert an airway to insure
uninterrupted breathing, and perform endotracheal intubation if indicated.
One or more IVs will be inserted to maintain perfusion status. In some cases
medications may be administered to sedate or paralyze the patient to prevent
additional movement which may worsen the brain injury. The patient should
be delivered promptly to a hospital with neurosurgical capabilities. The
management of brain injury requires the involvement of subspecialists who
are generally available only at larger hospitals. Primary treatment involves
controlling elevated intracranial pressure. This can include sedation,
paralytics, cerebrospinal fluid diversion. Second line alternatives include
decompressive craniectomy (Jagannathan et al. found a net 65% favorable
outcomes rate in pediatric patients), barbiturate coma, hypertonic saline and
hypothermia. Although all of these methods have potential benefits, there has
been no randomized study that has shown unequivocal benefit.

Delirium
- disturbance of consciousness and cognition
- usually reversible, with acute onset

- usually secondary to some other condition or problems such as intoxication,

withdrawal, medical condition, severe stressors

Causes
Delirium may be caused by severe physical or mental illness, or any
process which interferes with the normal metabolism or function of the
brain. For example, fever, pain, poisons (including toxic drug reactions),
brain injury, surgery, traumatic shock, severe lack of food or water or sleep,
and even withdrawal symptoms of certain drug and alcohol dependent states,
are all known to cause delirium.

In addition, there is an interaction between acute and chronic symptoms of

brain dysfunction; delirious states are more easily produced in people
already suffering with underlying chronic brain dysfunction.

A very common cause of delirium in elderly people is a urinary tract

infection, which is easily treatable with antibiotics, reversing the delirium.

A mnemonic for the myriad causes of Delirium is:

- Infections (Pnuemonia, Urinary Tract Infections)

- Withdrawal (Ethanol,opiate)
- Acute Metabolic (acidosis, renal failure, imbalances, alkalosis)
Trauma (acute severe pain)
- Central nervous system pathology (epilepsy, cerebral haemorrhage)
Hypoxia
- Deficiences (vit b12, thiamine)
- Endocriopathies (thyroid, parathyroid, hypopituitarism,
hyper/hypoglycemia, Cushing's)
- Acute vascular (Stroke, MI, PE, heart failure)
- Toxins/drugs (prescribed - Tramadol, recreational)
Heavy metals

Assessment in clients with delirium

- Review MMS exam in text

- Scrutinize the underlying cause

- Orientation to time (1st to go)

- Orientation to place

- Orientation to person (last to go)

- Distractibility

- Ability to converse

- Level of consciousness (alert, drowsy, stupurous)

- Illusions and hallucinations (type, specific, timing)

- Awareness of own deficit

S/SX of clients with delirium

- inability to focus attention, confusion and disorientation

- Memory formation and disturbance

- Abnormalities of awareness and effect

Nursing Intervention for clients with

Delirium

- careful assessment, do what is appropriate to eliminate the cause

- meet physiologic needs: nutrition, hydration, sleep, appropriate level of

stimulation and pain relief
- safety: falls, wandering, IVs NGs pulled out easily, may strike out in fear

- Judicious use of antipsychotic anti-anxiety meds

Communication with clients with delirium

- Short questions, instructions, no “big” words. Be patient

- Check for comprehension, give instructions more than once, not in

condescending manner
- Face to face, normal tone voice, good light

- No sweet and meaningful calling etc.

Reality Orientation with clients with delirium

- Clocks, calendars, cues place prominently. Talk about it

- Names on doors, Big

- Familiar routine, structure and staff

- Verbal reorientation to PPT as a naturation

 THROMBOLYTIC THERAPY
What is thrombolytic therapy?

Thrombolytic therapy is a treatment used to break up dangerous clots inside your

blood vessels. To perform this treatment, your physician injects clot-dissolving
medications into a blood vessel. In some cases, the medications flow through your
bloodstream to the clot. In other cases, your physician guides a long, thin tube,
called a catheter, through your blood vessels to the area of the clot. Depending on
the circumstances, the tip of the catheter may carry special attachments that break
up clots. The catheter then delivers medications or mechanically breaks up the clot.

Thrombolytic therapy commonly is used to treat an ischemic stroke, which is

another name for a clot in blood vessel in your brain. It can also be used to treat
clots in:

• A lung artery, called a pulmonary embolism

• The deep veins of your leg, called deep vein thrombosis (DVT)
• Your heart, which may cause a heart attack
• An artery elsewhere in your body, such as in an arm or leg artery; or
• A bypass graft or dialysis catheter that has become blocked

Your blood is normally a liquid that travels smoothly through your arteries and
veins. Sometimes, however, blood components, called platelets, can form clumps
and, together with other blood components, can cause the blood to gel. This process
is called clotting or, more technically, coagulation. This is a normal process that
protects you from excessive bleeding from even a minor injury. However, in certain
circumstances blood clots can build up inside a blood vessel and block blood flow. At
other times, pieces of these clots can break off, travel through your bloodstream,
lodge in a blood vessel somewhere else in your body and obstruct normal blood flow.
Blood clots in your heart or lungs, for example, can starve the organ and be life
threatening.

Depending upon the situation, your physician may decide to provide thrombolytic
therapy, also called thrombolysis, as an emergency treatment or as a scheduled
procedure to dissolve the blood clots. For example, you may receive emergency
thrombolysis if you are having a stroke. In some circumstances, if you have DVT or
a blocked bypass graft, your physician may schedule thrombolytic therapy for you.

How do I prepare?

First your physician will ask questions about your general health, medical history,
and symptoms. In addition, your physician will conduct a physical examination.
Together these are known as a patient history and exam. As part of your history and
exam, your physician will ask you to list any medications, including vitamins or
dietary supplements, you take. Some of these substances may affect your blood's
clotting ability. Your physician will also want to know when your symptoms occur
and how often.

Next, your physician will order tests to make sure that you are able to receive
thrombolysis safely. For example, he or she will check to see if your blood is clotting
properly and that other factors, such as the mineral salts in your blood, are normal.
The tests you will receive depend on which blood vessel is blocked and your medical
condition. For example, your physician may order an echocardiogram test to find
out whether there is a blood clot in your heart or an electrocardiogram (ECG) to
evaluate your heart rhythm.

Your physician will give you the necessary instructions you need to follow before the
thrombolysis procedure, such as fasting. Usually, your physician will ask you not to
eat or drink anything 12 hours before your procedure. Your physician will also
discuss with you whether to reduce or stop any medications that might increase your
risk of bleeding or other complications.

You will usually undergo a test called angiography either before or as part of
thrombolytic therapy. Angiography creates a picture of your blood vessels (called an
angoigram), and uses a dye, called contrast, which is eventually flushed out through
your kidneys. If you have kidney trouble, or if you have had a test that uses contrast
before and had an allergic reaction to the contrast, you should tell your vascular
surgeon. He or she may prescribe medications designed to minimize the chance of
problems with the contrast material.

Am I a candidate for thrombolytic therapy?

You may be a candidate for thrombolytic therapy if you have symptoms of a stroke,
heart attack, pulmonary embolism, DVT, or a clot in an artery or bypass graft in a
limb. These symptoms may include:

• Chest pain
• Numbness or tingling on one side of the body
• Blurred vision in one eye
• Slurred speech
• Sudden weakness
• Severe swelling of an arm or leg; or
• Pain, numbness, or coldness in a limb

If you have a life-threatening clot, your physician will attempt to establish

thrombolytic therapy as soon as possible after symptoms begin, preferably within 1
to 2 hours.
 If you have severe high blood pressure, active bleeding or
severe blood loss, a stroke from bleeding in the brain (called
hemorrhagic stroke), severe liver disease, or have recently had
surgery you probably are not a good candidate for
thrombolytic therapy because of the increased risk of bleeding
associated with these conditions.

Am I at risk for complications during

thrombolytic therapy?

If you have diabetes or kidney disease, you may have a higher risk of complications
from the contrast agents used in the angiogram. If you have kidney disease,
sometimes your physician can treat you with medications or fluids before you
receive contrast, to protect your kidneys and minimize the risk.

People with blood clotting disorders also may have a higher risk of complications
from thrombolysis. Other factors that may increase the risk for complications
include:

• History of internal bleeding

• Pregnancy
• Endocarditis, an infection in the lining of the heart
• Advanced age
• Recent surgery or injury
• Poorly controlled hypertension; or
• Diabetic retinopathy, a problem in the eyes that results from diabetes

What happens during thrombolytic therapy?

In some hospitals, physicians perform thrombolytic therapy in the intensive care

unit, but in others thrombolysis may be performed in nursing units familiar with the
treatment and potential complications. In either circumstance, your physicians and
nurses will carefully watch your vital signs and be prepared for an emergency
during the procedure, such as bleeding. Initially, you will lie on an x-ray table, and
machines will monitor your vital signs.

Thrombolytic drugs can be delivered in two ways: through a short catheter inserted
in a vein (called an intravenous, or IV, catheter), or through a long catheter that is
guided to the clot through your arteries or veins. In emergencies, vascular surgeons
often choose the IV method because it is quick and safe to perform outside of a
hospital. If your physician chooses to guide the catheter directly to the clot, the end
of the catheter may be placed in the vessels leading to your brain, lung, heart, arm,
or leg depending upon the location of the clot.
 To deliver the thrombolytic therapy, your physician will make a
small puncture over an artery or vein in your groin, your wrist,
or your elbow. This place is called the access site. Before inserting
the catheter through this puncture, he or she will clean your skin
and shave any hair. This reduces your risk of infection. Your
physician then will numb your skin with a local anesthetic and
then sometimes makes a small cut or puncture to reach the blood
vessel below. Although you may be given some mild sedation, you
will usually stay awake during the procedure.

Next, your physician will usually inject contrast through the

catheter to map your blood vessels with angiography and to
locate the clot. You may feel a warm sensation during the
injection, which is normal. As the contrast flows through your
blood vessels, x-rays are taken. The x-rays do not pass through
the contrast, so pictures of your blood vessels appear on a screen.
An indication of the clot location will appear as well.

Once your physician locates the clot, depending on the particular circumstances, he
or she may inject the thrombolytic drugs through an IV catheter. More commonly,
your vascular surgeon will guide a longer catheter through your blood vessels to the
vicinity of the clot and then inject the drugs near or into it. Because you have no
nerve endings in your blood vessels, you will not feel the catheters as they move
through your body.

Currently, the most common thrombolytic agents (“clot-busting" drugs) are:

• Streptokinase
• Urokinase; and
• Tissue plasminogen activator (t-PA)

Other drugs include recombinant, or genetically engineered, t-PA (a newer version

of t-PA) and TNK (Tenecteplase.)

Your physician will periodically monitor the x-ray screen to see the clot breaking up.
However, depending on the size and location of the clot, the drugs your physician
chooses, and other factors, this process can take several hours. Sometimes, if you
have a severe blockage, the treatment could last for several days. Once the clot has
been dissolved or if it cannot be dissolved further, your physician will stop the
medication. When the tests used to monitor your blood's coagulation ability are in a
satisfactory range, your physician will then remove the IV or catheter, and press on
the access site for 10 to 20 minutes to stop any bleeding. During the process, and for
several hours afterwards, your physician will ask you to remain still to minimize the
risk of bleeding from the access site.

The technique for mechanical thrombectomy is similar, except that small devices are
attached to the catheter tip remove the clot or even break it up physically. These
devices include a suction cup, a rotating device, and a high-speed fluid jet.
Mechanical thrombectomy can work faster than thrombolytic drugs in some cases,
and in favorable circumstances the procedure may take as little as 30 minutes. You
physician will advise you if you are a good candidate for mechanical thrombectomy.

What can I expect after thrombolytic therapy?

Usually, you will stay in bed as you recover from thrombolytic therapy. During this
time, your physician and the hospital staff closely watch you for any complications.
You may receive fluids, antibiotics, or painkillers. If your physician inserted the
catheter through an artery in your arm or leg, you may have to hold the limb
straight for several hours. Once any bleeding from the access site stops, and your
vital signs are normal, you may be discharged. Often, however, you will require
further hospitalization for treatment of the underlying reason for the clot, or for
adjustment of anticoagulation doses if needed to prevent clots from reforming.

If you notice any unusual symptoms after or during your procedure, you should tell
your physician immediately. These symptoms may include:

• Arm or leg pain that lingers or gets worse

• A fever
• Shortness of breath
• An arm or a leg that turns blue, develops swelling or feels cold; or
• Problems around your access site, such as bleeding, swelling, pain, or
numbness

Before your discharge, your physician will give you instructions about everyday
tasks to follow after you return home. For example, you should not lift more than
about 10 pounds for the first few days after your procedure. You should drink
plenty of water for 2 days to help flush the contrast dye out of your body. You can
usually shower 24 hours after your procedure, but you should avoid baths for a few
days.

During your recovery, you may experience nausea, vomiting, or coughing. You
should tell your physician if any nausea, back pain or lightheadedness lingers,
because these symptoms could mean you have internal bleeding.

If you received thrombolytic therapy in an emergency, you may receive additional

care for your condition. For example, if you had a stroke, your physician may
prescribe medications, a special diet, or physical therapy. If you had a heart attack,
your physician may need to examine your heart to see if any other arteries are
blocked. If you had a blocked bypass graft, you may need further treatment or
anticoagulation to keep the bypass open.
Are there any complications?

Complications are not unusual with thrombolytic therapy, which is why it should be
carried out under close supervision. However, your physician can manage most of
them, including:

• Bleeding in the access site or elsewhere

• Low blood pressure; or
• Allergy to thrombolytic drugs

Bleeding in the brain leading to stroke, can also occur, but it is rare and affects
fewer than 1 in 100 patients.

Thrombolytic therapy is not always successful. In up to 25 percent of patients, the

treatment is unable to break up the clot. This is especially true if the clot has been
established for a long time. In another 12 out of every 100 patients, the clot or
blockage will re-form in the blood vessel, especially if an underlying reason for the
clot to form in the first place is not found and treated.