Cerebrovascular Accident (Stroke)

What is a cerebrovascular accident?

an acute neurological deficit lasting more than 24 hours

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What are the 4 types of CVA?

1. ischaemic
2. haemorrhagic
3. transient ischaemic attack
4. cryptogenic

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In simple terms, explain what causes an ischaemic stroke?

Caused by a vascular total occlusion (usually a thrombus or thromboembolism)

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In simple terms, explain what causes a haemorrhagic stroke?

Caused by a vascular rupture, resulting in a brain bleed

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In simple terms, explain what is a transient ischaemic attack (TIA)?

A transient (comes and goes) episode of neurological dysfunction lasting less than 24 hours,

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In simple terms, explain what is a cryptogenic stroke?

A stroke with unknown cause

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In more detail, explain the process of an ischaemic stroke

Cholesterol plaque builds up in the artery, and a blood clot forms. The blood clot (or thrombus) blocks the blood flow through the artery, cutting off blood and oxygen supply to the cerebum

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What type of ward should an ischaemic stroke patient be transferred to?

A hyper-acute stroke ward

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In more detail, explain the process of a haemorrhagic stroke

A rupture occurs in the blood vessel lining or an aneurysm occurs (a weakening in the vessel wall), which eventually tears and blood leaks out into the brain

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Which type of ward should a haemorrhagic stroke patient be transferred to pre and post treatment?

A neurosurgical ward or neurological ICU pre-treatment, then a neurological ward post-treatment

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In more detail, explain the process of a transient ischaemic attack?

Plaque or blood clot forms in the artery, and for a small amount of time it occludes the blood flow (causing symptoms), but eventually it breaks off and goes elsewhere (symptoms go away)

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Why are TIAs a reason for concern?

They are a warning sign for future TIAs and ischaemic strokes =
this plaque can continue to build-up and eventually lead to an ischaemic stroke

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What technical intervention is required for a TIA?

Regular cranial dopplers = ultrasound of vessel to ensure there are no blockages that could cause future ischaemic stroke

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What is the Circle of Willis?

The collateral blood supply to the brain

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Which arteries supply the Circle of Willis?

The two internal carotid arteries, and the basilar artery

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The Circle of Willis supplies blood flow to which arteries, which then supply blood flow to the cerebrum?

The anterior, middle and posterior cerebral arteries

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How does the Circled of Willis "protect" against ischaemia?

In the event of vessel damage or blockage in one area, blood flow can go the other way (it is a circle)

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Strokes can be referred to as the area affect.
Give an example of this

An MCA Infart -
a thrombus/emoblism in the middle cerebral artery blocks blood flow to the cerebrum

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What is emotional lability in stroke?

When the temporal lobe is affected, causing uncontrolled emotions and reactions, such as: inappropriate laughing and crying

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Ischaemic strokes are caused by blockages of the artery. What is thrombosis?

Formation of a solid mass (clot) formed at the site and has not moved anywhere. It can be life-saving (injury) but also life-threatening. It is the consequence of appropriate activation of the process of normal haemostatis.

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What is it called when a thrombus develops in the artery?

Arterial thrombosis

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What is an embolism?

A foreign body that blocks an artery, which has TRAVELLED to the area

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Give an example of an emboli?

Air bubble, fat, bone fragment

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What is a thromboembolism?

A blood clot that has formed somewhere and has travelled to block an artery

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In general terms, what is Virchow's Triad?

3 reasons why we get thrombosis

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Explain the first reason in Virchow's Triad?

1. Vessel wall injury = damage to the endothelial lining wall, causing atherosclerotic plaque build-up, causing inappropriate thrombosis
- caused by irritation or inflammation

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What lifestyle factors cause irritation or inflammation that cause vessel wall injury?

Alcohol, smoking, drugs, diabetes

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Explain the second reason in Virchow's Triad?

Hypercoagulability of blood = common in patients with AF
- caused by cancer, inflammatory disease, AF, etc.

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What drugs can be given for hypercoagulability of blood?

Warfarin and antiplatelets

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Explain the third final reason in Virchow's Triad?

Stasis of blood = anything that makes blood become static
- caused by immobility, varicosed veins, AF

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Explain the pathophysiology of Atrial Fibrillation (a major risk for stroke)

Heart pumps blood from the atria into the ventricles. However, in AF there is an atrial quiver and blood is unable to pumped out of the atria properly/at a slower rate. Blood pools back down

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How is Atrial Fibrillation a risk of thrombosis and subsequent ischaemic stroke?

When blood pools back, most commonly into the left atrial appendage, stasis takes place, and a thromboembolism forms. This then travels to the brain, blocking arteries, and causing strokes

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When undertaking an ABCDE assessment, what might you notice in a patient with AF?

- patient appears fatigued, dizzy and "not feeling themselves"
- when taking manual pulse, it will feel irregular
- when undertaking an ECG, there will be no P wave

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Name some lifestyle and genetic factors and why they cause strokes (pt.1)

- over 55 years old = due to longer exposure to build-up of atherosclerosis
- female = due to the female lifespan, ie: pre-eclampsia, gestational diabetes, oral contraceptives causing hypertension
- family history under 65 years old
- CADASIL gene
- Afric

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Name some lifestyle and genetic factors and why they cause strokes (pt.2)

- AF
- Hypertension = damages endothelial lining of blood vessel, thrombus forms
- Smoking = damages endothelial lining of blood vessel, plaque builds up
- Type 2 diabetes = same again
- Hyperlipidaemia = high amounts of lipids (fat cells) in the blood, c

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Name some lifestyle and genetic factors and why they cause strokes (pt.3)

- hypercholesterolaemia = same again
- sickle cell disease = cells clump together easily, causing a thrombosis
- drug and alcohol use = damages endothelial lining of blood vessel wall, and causes plaque build-up

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What are the signs and symptoms of ischaemic stroke?

- weakness in one side (hemiplegia)
- facial droop
- numbness and tingling
- language disturbances
- visual disturbances
- poor balance

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What are the signs and symptoms of haemorrhagic stroke?

- explosive headache
- visual disturbances
- nausea and vomitting
- neck pain
- sensitivity to light
- hemiplegia

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During a CVA, when blood flow to the brain is restricted, what happens?

Some degree of permanent neurological damage lasting more than 24 hours

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What is a thrombotic ischaemic stroke?

Damaged areas of an atherosclerotic plaque can cause a blood clot to form, which blocks blood flow in the arteries

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What is an embolic ischaemic stroke?

Blood clot (thrombus) or debris (emboli) from elsewhere in the body, typically the heart values (left atrial appendage in AF), travel through the circulatory system and block/narrow arteries

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During a stroke, blood flow is so drastically reduced that cells cannot recover. What happens to these cells?

They undergo cellular death

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What is an ischaemic penumbra?

Area around the initial damage = chance for blood flow to be restored and reduce effects

part of the brain in an ischaemic stroke that is at risk of progressing to infarction but is still salvageable if re-perfused

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What is an ischaemic cascade?

the actual brain injury caused by a stroke

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Explain the ischaemic cascade

After a CVA, there is an impeded blood supply to the cerebrum. This means that the brain does not receive oxygen or glucose. Cells then convert to anaerobic metabolism and lactate acid is produced. ATP becomes exhausted and depleted. Cell membrane becomes

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Explain the ischaemic cascade (pt.2)

When calcium becomes too high, glutamate is released, which stimulates receptors and more calcium is produced. This causes excitotoxicity = when proteases, lipase, and free radicals are released, and break down the cell membrane. Toxins enter cells and br

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Explain the ischaemic cascade (pt.3)

Cells experience apoptosis. Cells die through necrosis, glutamate and toxins are released into surrounding environment, which poison nearby neurons. This breaks down the blood barrier and causes cerebral oedema = which results in secondary progression of

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What is the 3 aspects of the secondary progression of the brain injury?

1. affected area softens
2. cerebral swelling
3. oedema subsides

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What are the clinical manifestations of ischaemic stroke during nursing assessment?

- high blood pressure
- high blood glucose (due to high cortisol levels)
- varying states of ACVPU
- sensory problems = numbness, tingling, decreased sensation on affected side of body
- weakness = paresis, unable to generate force and control same during

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What are the clinical manifestations of ischaemic stroke during nursing assessment? (pt.2)

- motor = initial acute stroke phase when limbs become flaccid and then develop hyperreflexia
- altered coordination
- control and balance disruptions
- visual changes (hemianopia) and speech changes
- dysphasia (swallow) = in patients with bilateral cere

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What are the goals of stroke nursing care?

- limit effect of the stroke = salvaging ischaemic penumbrae
- prevent complications
- identify stroke cause to prevent re-stroke
- long-term secondary prevention
- patient and family education
- discharge planning

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List the nursing assessments undertaken if a patient had symptoms of a stroke

- ABCDE = find out time of onset
- blood glucose
- GCS-P
- CT head/brain = excludes haemorrhagic stroke
- swallow assessment = NIL until complete
- IV access and bloods
- ROSIER
- NIHSS

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What bloods might the medical team require?

- Hba1c
- FBC
- U&E
- lipid profile
- CRP
- INR (if on warfarin or anticoagulant drugs)
- coagulation screen

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What is the ROSIER assessment?

Recognition Of Stroke In the Emergency Room

- assessment to rule out stroke mimics
- allows suitable referrals to stroke team

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What should you do before undertaking the ROSIER assessment?

Take a blood glucose

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What is the National Institute of Health Stroke Scale assessment?

systematic neurological assessment completed by medical team/specialist stroke nurses

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What is the Bamford stroke classification system?

Used to classify ischaemic strokes = categorises stroke based on initial presenting symptoms and clinical signs

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What is important to remember about CT brain scan results?

You typically won't see an ischaemic stroke on CT that quickly, but you would see a haemorrhagic bleed = rules out haemorrhagic stroke

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Explain the nursing management of an ischameic stroke patient

- query eligibility for thrombolysis or thrombectomy
- aspirin/clopidogrel treatment
- take patient weight for drug prescription
- bloods
- x-ray (chest, may be extra fluid)
- transfer to stroke unit
- neurological monitoring
- ECG to rule out AF
- post-t

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What is thrombolysis treatment?

An injection of an alteplase agent (clot-busting drug) which goes in and dissolves clot. It must be given within 4-4.5 hours of symptom onset, and is only given if patient is likely to survive.

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What are the aims and important factors of thrombolysis treatment?

- reduces impact of stroke
- must be completed within 4.5 hours of symptom onset

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What is the post-thrombolysis nursing care?

- monitor site
- neurological assessment using GCS (compare to baseline)
- monitor for complications (pain, bleeding, etc.)
- neurovascular obs = touch assessment, includes assessment of pulses, capillary refill time, skin colour, temperature, sensation,

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What is a thrombectomy treatment?

- aka: mechanical clot retrieval = surgical removal of a clot within an artery
- significantly reduces affect of stroke and improves recovery
- only 2 clinicians trained in NI

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Explain aspirin/clopidogrel prescription post-treatment

- repeat CT brain = if no bleed or further damage, prescribed 300mg aspirin and clopidogrel for 14 days, then long-term maintenance dose of 75mg. Inhibits platelet aggregation and decreases events of recurrent ischaemic attacks

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What are the nursing considerations for hyper acute stroke?

- clinical assessment
- observe for deterioration/complications/re-stroke
- ensure adequate hydration and nutrition
- IV access
- communication strategies

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What is post-stroke care?

- rehabilitation
- damaged neuroplasticity of damaged brain rehabilitation = fundamental
- prevention of complications
- re-learning skills lost from stroke
- new techniques to deal with disability
- re-gaining independence

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What are the key areas of post-stroke rehabilitation?

- promote independence
- improve mobility
- provide information and education
- monitor nutrition and hydration
- support mood and wellbeing
- help with ADLs
- pain management
- fatigue management

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Why are stroke patients at risk of aspiration pneumonia?

Stroke causes dysphasia. Dysphagic patients have impaired oral movements, resulting in debris and secretions not being swallowed properly. This can cause aspiration into the lungs, resulting in pneumonia

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What are some post-stroke complications nurses should look out for?

- mobility problems
- limb contractures
- pain
- falls
- urinary problems
- aspiration pneumonia
- malnutrition
- seizures
- cognitive difficulties
- brain stem death

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What is apraxia?

inability to perform skilled movement

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What is aphasia?

loss of the power of speech

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What is anosognosia?

deficit of self-awareness

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What is hemiplegia?

loss of the power in one side of the body

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What is ataxia?

problems affecting coordination, balance and speech

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What is dysarthria?

imperfect articulation of speech, due to disruption of muscle control

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What is dysphagia?

Difficulty swallowing

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What is hemianopia?

Partial blindess/loss of one part of visual field

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What is the brain stem?

part of the brain that controls our breathing and regulates body functions

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What is a brain stem stroke?

either ischaemic or haemorrhagic, when blood supply is reduced due to either a blockage/bleed, it has a low survival and recovery rate, and can lead to "locked-in syndrome"

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What is locked-in syndrome?

inability to make ANY movements, only able to move eyes left and right

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What is the main stroke treatment aim?

restoring blood flow in the affected area so that another area doesn't become blocked as well (circle of willis)

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What is important if you suspect stroke but aren't sure?

THINK STROKE until proven otherwise

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What is an infarct or infarction?

tissue death or necrosis due to inadequate blood supply to the affected area

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Briefly explain plaque and thrombus formation

- cholesterol and other plaque can build up in the arteries, until it causes narrowing or blockages (atherosclerosis)
- plaque can rupture, cause damage and a blood clot forms
- this begins the clotting cascade

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Briefly explain the clotting cascade

- constriction of blood vessel/artery
- formation of a temporary 'platelet plug'
- release of clotting factors (ie: fibrin which turns into fibrinogen)
- formation of a 'fibrin plug' or final clot

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What does the FAST assessment stand for and how would you explain results?

Face, Arms, Speech, Time

Patient will either be FAST + or FAST -

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What is the best and worst score of a GCS?

15 is the best, 3 is the worst

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Why is it important when assessing a patient to know if they have had any seizure activity?

If seizures are present at the onset of symptoms, it is likely not a stroke. However, they can occur later as a result, ie: intracranial haemorrhage (not a stroke)

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What is syncope?

a loss of consciousness for a period of time, aka: fainting

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If a CT scan comes back normal but stroke is still highly suspected, what would we need?

an MRI scan

= highlights areas of infarction, haemorrhage and ischaemia

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What is the most common artery involved in acute stroke?

middle cerebral artery

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Why is important to identify if a stroke is haemorrhgaic or ischaemic before giving thrombolysis treatment?

It dissolves clots, which means it thins the blood and can cause major bleeds/haemorrhages. It can only be given to ischaemic patients. If given to haemorrhagic, it can kill the patient and cause further bleeding

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What other condition should be ruled out before giving thrombolysis treatment?

Intracranial haemorrhage

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What blood test results and scans are essential before thrombolysis treatment?

platelet count and coagulation screen

CT brain = rule out haemorrhagic stroke

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What should nurses monitor for post-thrombolysis?

bleeds/haemorrhages

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If a patient had thrombolysis and then went into cardiac arrest, what do you think could be the cause?

cardiac tamponade

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What scans will need done after thrombolysis to monitor bleeding?

CT brain scan

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Can thrombectomies be performed on haemorrhagic strokes?

No - there is no clot to surgically remove

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How long can a patient have a thrombectomy for?

up to 24 hours from onset of symptoms, but should really be completed within 6 hours

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What is a third treatment option?

Combination of thrombolysis and thrombectomy

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What is the nursing care post-thrombectomy?

- observations and IV access
- focus on blood pressure (high = risk of another stroke. low = sign of bleeding accompanied by tachycardia)
- supplemental oxygen therapy
- monitor blood glucose (4-11mmols)
- monitor for complications
- SALT referral for swa

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If seizures develop, what might be prescribed?

anti-seizure medications

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What multidisciplinary referrals might you consider for stroke patients? (pt.1)

- OT = assess severity of physical damage/any weaknesses which might impact ADLs
- SALT = one-sided weakness or problems with speech and swallow, risk of choking/aspirating, and may need modified diet
- dietician = if losing weight, may need supplements

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What multidisciplinary referrals might you consider for stroke patients? (pt.2)

- physiotherapy = assess extent of physical damage and any significant weakness (localised in limbs, ability to move/walk?), rehabilitation
- smoking cessation = health promotion and decrease risk of re-stroke
- counselling = huge life change and patient

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What should you consider for a safe discharge in stroke patients? (pt.1)

- medically fit for discharge
- package of care in place (if needed)
- transportation booked
- physiotherapy assessment and discharge completed (ie: correct equipment in use)
- possible referral to community physio
- OT assessment and discharge completed

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What should you consider for a safe discharge in stroke patients? (pt.2)

- pharmacy discussion = new medications discussed, blister packs insitu, carers available to give medications
- discharge letter and letter to GP = explanation of what happened, new medications, plan of treatments (by F1/F2)
- social work financial assess

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What should you consider for a safe discharge in stroke patients? (pt.3)

- aware of stroke symptoms, advise DVLA about driving liscence
- organise follow-up appointments as outpatient in outpatient clinic
- ensure family support at home (wife able to manage at home)

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Cerebrovascular Accident (Stroke)

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