Cerebrovascular Accident (CVA)

>Commonly known as stroke or brain attack

>A condition in which neurologic deficits result from decreased blood flow to localized area of the
brain
>Neurologic deficits determined by the area of brain involved, size of affected area, length of time
blood flow is decreased or stopped
>Major loss of blood supply to brain can cause severe disability or death; if short or small area involved
client may not be aware

Causes
Ischemia
 Occurs when the blood supply to a part of the brain is interrupted or totally occluded
 Commonly due to thrombosis or embolism

Thrombotic (large vessel) stroke

>The most common cause of ischemic stroke
>Atherosclerosis is the primary cause
>Fatty materials deposit on large vessel walls (especially at arterial bifurcations) and eventually
these plaques causes stenosis of the artery
>Blood swirls around the irregular surface of the plaques causing platelets to adhere and the vessel
becomes obstructed
>These causes infarcts usually affecting the cortex
>Most common type of stroke in people with diabetes

Lacunar (small vessel) stroke

>Endothelium of smaller vessel is primarily affected due to hypertension
>Leading to arteriosclerosis and stenosis
>Infarcts are usually located in the deeper, noncortical parts of the brain or in the brainstem

Embolic stroke
 >Occlusion of a cerebral artery by an embolus or blood clot
>Embolus forms outside the brain, detaches and travels through the cerebral circulation where it
lodges and causes an obstruction
>Chronic atrial fibrillation is associated with a high incidence
>Other sources of emboli include tumor, fat, bacteria and air
>Usually has a sudden onset with immediate maximum deficit

Hemorrhage
 Results from rupture of a cerebral vessel causing bleeding into the brain tissues
 Bleeding results with edema, compression of the brain contents or spasm of the adjacent
blood vessels
 Often secondary to hypertension and most common after age 50
 Other factors includes ruptured intracranial aneurysms, trauma, erosion of blood vessels by
tumors, arteriovenous malformations, anticoagulant therapy, blood disorders
 Usually produce extensive residual functional loss and slowest recovery

Risk factors
 Hypertension
 Diabetes mellitus
 Atherosclerosis
 Substance abuse including alcohol, nicotine, heroin, amphetamines, cocaine
 Obesity, sedentary life-style, hyperlipidemia, atrial fibrillation, cardiac disease, cigarette
smoking, previous transient ischemic attacks
 Women: oral contraceptive use, pregnancy, menopause

Clinical manifestations
 Stroke manifestations can be correlated with the cause and with the area of the brain in
which perfusion is affected
 Manifestations of thrombotic stroke develop over minutes to hours to days (slow
onset is related to increasing size of the thrombus)
 Embolic strokes occur suddenly and without warning
 Hemorrhagic stroke occurs rapidly with manifestations developing over minutes
to hours
 General findings unrelated to specific vessel sites includes headache, vomiting, seizures
and changes in mental status
 Early warnings of impending ischemic stroke includes
 Transient hemiparesis
 Loss of speech
 Hemisensory loss

Pathophysiology
 Characterized by gradual, rapid onset of neurologic deficits due to compromised
cerebral blood flow
 Blood flow and oxygenation of cerebral neurons decreased or interrupted; changes occur
in 4 – 5 minutes
 Cells swell and cerebral blood vessels swell decreasing blood flow; vasospasm and
increased blood viscosity further impede blood flow
 Penumbra is a central core of dead or dying cells surrounded by band of minimally
perfused cells
 Cells of the penumbra receives marginal blood flow and their metabolic
activities are impaired
 These cells may survive if adequate circulation is re-established
 Neurologic deficits occur on opposite side where stroke occurred in brain: contralateral
deficit
Signs and Symptoms of CVA
Signs

>Sudden weakness, numbness, or paralysis of the face, arm or leg, on one or both sides of the body.
>Sudden blurred vision or blindness in one or both eyes.
>Sudden difficulty speaking, slurring of speech or difficulty understanding.
>Sudden severe headache with sudden onset that occurs without apparent reasons.
>Sudden loss of balance, dizziness, or falling without any apparent reason.

Symptoms

Symptoms Depends on what side of the brain is affected.

Feature Left Hemisphere Right Hemisphere

Language Aphasia Impaired sense of humor
 Wernicke's aphasia
 Broca's aphasia
 Global aphasia
Agraphia
Alexia (word blindness)
Memory Possible deficit Disorientation to time, place, and
person.
Inability to recognize faces.
Vision Inability to discriminate wordsVisual spatial deficits
and letters. Neglect of the left visual field.
Reading problems Loss of depth perception.
Deficit in the right visual field.
Behavior Slowness Impulsive
Cautiousness Lack of awareness of neurologic
Anxiety when attempting a newdeficits.
task. Confabulation
Depression or a catastrophicEuphoria
response to illness. Constant smiling
Sense of guilt Denial of illness
Feeling of worthlessness. Poor judgment
Worries over future. Overestimation of abilities (risk
Quick anger and frustration. for injuries)
Intellectual impairment.
Hearing No deficit Loss of ability to hear tonal
variations.

Diagnostic Procedures
>Blood Tests - including a complete blood count, blood sugar, cholesterol, fat levels, clotting levels, and
a check of other elements in the blood

>Electrocardiogram (EKG) – to measure heart rhythm and check for an irregular heart beat

>Ultrasound– a test that uses sound waves to help determine if there are blockages in the arteries
supplying the brain
>MRI Scan – a test that uses magnetic waves to make pictures of structures inside the head

>CT Scan – a type of x-ray that uses a computer to make pictures of structures inside the head

>Magnetic Resonance Angiography – performed prior to carotid artery surgery to determine how
much the artery has narrowed. Gadolinium, a type of dye, may be injected into your vein for this test.

>Arteriogram - during a conventional arteriogram, a contrast dye is injected and x-ray images are
produced to precisely locate the blockage and to determine how much of the artery is blocked. This test
is usually only done to confirm the need for surgery.

>Echocardiogram - an ultrasound test that looks for blood clots and valve abnormalities within the
heart

>Electroencephalogram (EEG) - a test that can detect seizures by measuring brain waves (used only if
a seizure is suspected)

Surgical Management
>Endarterectomy – purpose is to remove the atherosclerotic plaque from the inner lining of the carotid
artery.
>Extracranial-Incracranial Bypass – bypasses the blocked artery by making a graft or a bypass from
the first artery to the second artery.
>Management Of Anteriovenous Malformation - is an interventional therapy to occlude abnormal
arteries or veins and prevent bleeding from the vascular lesions. Whenever possible the affected vessels
are totally removed. The surgeon ligates the vessels and removes the defect.
>Management of Cerebral Aneurism – Aneurysm may be repaired via craniotomy. Less invasive
procedure is interventional Radiology
>Management of Intracranial Bleeding – Blood clots are removed via craniotomy.

Other Medical Management:

Medical Management
a. Steroids/corticosteroids given in full stomach with antacid or H2 receptor antagonists
b. Vitamin B complex – promote restitution of function of neurons which have reversible damage.
c. Cerebral activator/stimulants – stimulate CNS function.
• nootrophil- PIRACETAM
• encephabol- PYRITINOL HCl
• hydergine- CODERGOCRIN
d. Drugs if it is due to thrombus, give ANTI-COAGULANT

• heparin- HEPARIN SODIUM

• coamadin- WARFARIN SODIUM

e. Drugs if it due to hemorrhage with large hematoma

Nursing Managements
A. Initial nursing objective is to support life and prevent complications.
B. Maintain patient airway and ventilation--- elevate head of bed 20 degrees unless shock is present.

C. Monitor clinical status to prevent complications.

1. Neurological
a. Include assessment of recurrent CVA, increased intracranial pressure,
hyperthermia.
b. Continued coma--- negative prognostic’ sign
2. Cardiovascular--- shock and arrhythmias, hypertension.
3. Lungs--- Pulmonary emboli.

D. Maintain optimal positioning.

1. During acute stages, quiet environment and minimal handling to prevent further bleeding.
2. Upper motor lesion--- spastic paralysis, flexion deformities, external rotation of hip.
3. Position schedule--- 2hours on unaffected side, 20minutes on affected side.
4. Complications common with hemiplegia--- frozen shoulder, footdrop.

E. Maintain skin integrity: turn and provide skin care.

F. Maintain personal hygiene: encourage self-help.

G. Promote adequate nutrition, fluid, and electrolyte balance.

1. Encourage self-feeding.
2. Food should be placed in unparalyzed side of mouth.
3. Tube feedings or gastrostomy feeding may be necessary.

H. Administer tube feedings.

I. Promote elimination.
1. Bladder control may be regained within three to five days.
2. Retention catheter may not be part of treatment regimen.
3. Offer urinal or bedpan every two hours day and night.

J. Provide emotional support.

1. Behavior changes as consciousness is regained--- loss of memory, emotional liability,
confusion, language disorders.
2. Reorient, reassure, and establish means of communication.

K. Promote rehabilitation to maximal functioning.

1. Comprehensive program--- begins during acute phase and follows through convalescence.
2. Guidelines to assist client with lesion left hemisphere.
a. Do not underestimate ability to learn.
b. Assess ability to understand speech.
c. Act out, pantomime communication; use client’s term to communicate; speak in
normal tone of voice.
d. Divide tasks into simple terms; give frequent feedback.
e.
3. Guidelines to assist client with lesion right hemisphere.
a. Do not overestimate abilities.
b. Use verbal cues as demonstrations; pantomimes may confuse.
c. Use slow, minimal movements and avoid clutter around client.
d. Divide tasks into simple steps; elicit return demonstration of skills.
e. Promote awareness of body and environment on affected side.