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An umbrella term refers to a functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted.
CVA
Stroke
Is the primary cerebrovascular disorders in the united states and in the world.
2 types of strokes
An ischemic stroke, cerebrovascular accident (CVA), or brain attack is a sudden loss of function resulting from disruption of the blood supply toa part of the brain.
Large artery thrombotic strokes- cause by atherosclerotic plaques in the large blood vessels of the brain.
Small penetrating artery thrombotic strokes- also called lacunar strokes because of the cavity that is created after the death of the infracted brain tissue.
Cardiogenic embolic strokes- associated with cardiac dysrythmias, usually atrial fibriliation. Also associated with valvular heart disease and thomboli in the left ventricle. Emboli originates from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting a stroke.
Cryptogenic strokes- no know cause and strokes from other cause, such as illicit drug use,coagulopathies,migraine, and spontaneous dissection of the carotid or vertebral arteries.
Risk Factors
Hemorrhagic strokes are caused by arteriovenous
malformations (AVMs), aneurysm ruptures, certain drugs, uncontrolled hypertension, hemangioblastomas, and trauma. These strokes can occur in epidural, subarachnoid, or intracerebral hemorrhage.
General cerebral ischemia may be caused by excessive or prolonged drop in blood pressure.
Drug abuse (cocaine) can cause stroke, particularly in adolescents and young adults. Alcohol consumption may also be a risk factor
Pathopysiology
ISCHEMIA Energy failure
ACIDOSIS
ION IMBALANCE
GLUTAMATE
DEPOLARIZATION
CELL MEMBRANES AND PROTEINS BREAKDOWN FORMATION OF FREE RADICALS PROTEIN PRODUCTION DECREASED
Clinical Manifestation
Visual disturbances
Hemiplegia paralysis of one side of the body Hemiparesis weakness of one side of the body
Dysarthria difficulty in speaking Dysphasia or Aphasia impaired speech or loss of speech Apraxia inability to perform a previously learned action
Loss of proprioception inability to perceive the position and motion of body parts
Agnosia deficits in ability to recognize previously familiar objects
Frontal lobe damage; learning capacity, memory or other higher cortical intellectual functions may be impaired. Depression, other psychological problems: emotional lability, frustration , hostility , resentment , and lack of cooperation
Bladder Dysfunction
Persistent urinary incontinence or urinary retention ( may be symptomatic of bilateral brain damage )
Continuing bladder and bowel incontinence ( may reflect extensive neurologic damage )
History and complete physical and neurologic examination Noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) scan, transthoracic or transesophageal echocardiogram Carotid ultrasonography Cerebral angiography Transcranial Doppler flow studies Electrocardiography
Medical Management
Thrombolytic Therapy
Thrombolytic agents or t-PA, used to threat ischemic stroke by dissolving the blood clot that is blocking the blood flow to the brain.
Nursing Management
For complications of carotid endarterectomy are stroke, cranial nerve injuries, infection or hematoma, carotid artery disruption.
It is important to:
Maintain adequate blood pressure level in the immediate post operative period , avoid hypotension to prevent cerebral ischemia and thrombosis. Close cardiac monitoring is necessary, because patient have a high incidence of coronary artery disease. After carotid endarterectomy monitor and document assessment parameters for all body systems with particular attention to neurologic status. Formation of thrombus at the site of endarterectomy when there is increase in neurologic deficits. The patient should be prepared for repeat endarterectomy. Assessment of the following: cranial nerves; facial (VII), vagus (X), accessory (XI) and hypoglossal (XII). Edema on neck after surgery is expected, however extensive edema and hematoma formation can obstruct the airway supplies, including those needed for tracheostomy, must be available
Hyperperfusion Syndrome, occurs when cerebral vessel autoregulation fails. Observe for severe unilateral headache improved by sitting upright or standing.
Intracerebral hemorrhage, occurs infrequently, but is often fatal and results in serious neurologic impairment.
WARNINGS!!!
An increase in cerebral edema the consequences may be deadly if not treated early is indicated by any change or decrease in the level of consciousness, a rapid increase in the systolic blood pressure with no change in the diastolic called a widened pulse pressure, bradycardia, & a change from a slow to rapid irregular breathing pattern.
Accounts for 15 % of cerebrovascular disorder and are primarily caused by an intracranial or subarachnoid hemorrhage.
Patients generally have more severe deficits and a longer recovery time compared to those with ischemic stroke. Caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space Primary cerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% or hemorrhagic strokes and its primarily caused by uncontrolled hypertension Secondary intracerebral hemorrhage is associated with arteriovenous malformations (AVM), intracranial aneurysms, or certain medications
Pathophysiology
A.Intraccerebral Hemorrhage
Also known as bleeding into the brain substance
Most common in pt. with HPN and cerebral atherosclerosis because degenerative changes from disease cause rupture of the vessels. They also may be due to certain types of arterial pathology, brain tumor, and use of medications ( oral anticoagulants, amphetamines, and illicit drugs such as crack and cocaine).
The bleeding is usually arterial and occurs most commonly in the cerebral lobes, basal ganglia, thalamus, brain stem (mostly the pons), and cerebellum.
The bleeding ruptured the wall of the lateral ventricles and causes intraventricular hemorrhages which is frequently fatal.
Intracerebral hemorrhage.
Aneurysm is the dilatation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. A cause of aneurysm is unknown.
May be due to atherosclerosis, resulting in the defect in the vessel wall with subsequent weakness of the wall, congenital defect of the vessel wall, hypertensive vascular disease and head trauma.
Artery in the brain can be the site of cerebral aneurysm. The cerebral arteries most affected by an aneurysm are the internal carotid artery (ICA), anterior cerebral artery (ACA), ante communicating artery (ACoA), posterior communicating artery (PCoa), posterior cerebral artery (PCA), and middle cerebral artery (MCA)
C. Arteriovenous Malformations
AVM is due to an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed. And leads to dilatation of the arteries and veins and rupture.
Common cause of hemorrhagic stroke in young people.
Arteriovenous Malformation
D. Subarachnoid Hemorrhage
Clinical
Manifestations
Tinnitus
Dizziness
Hemiparesis
Visual
There
may be pain and rigidity of the back of the neck (NUNCHAL RIGIDITY)
CT scanning- To determine the size and location of the hematoma as well as the presence or absence of ventricular blood and hydrocephalus.
Medical Management
To allow the brain to recover from the initial result (bleeding). To prevent or minimize the risk for rebleeding and to prevent or to treat complications. Bed rest with sedation to prevent agitation and stress. Management of vasospasm and surgical or medical treatment to prevent rebleeding. Analgesics (Codeine, Acetaminophen) may be prescribed for head and neck pain. The patient is fitted with elastic compression stockings to prevent deep vein thrombosis.
Nursing Management
END
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