cerebralvascularaccident.ppt

8/9/2019 CerebralVascularAccident.ppt

1/70

Cerebral VascularCerebral Vascular

AccidentAccidentSTROKESTROKE


2/70


3/70

RISK FACTORS FOR STROKESRISK FACTORS FOR STROKES

NonmodifableNonmodifable Age- incidenceAge- incidence

it! age until ageit! age until age

"#$"#$ Race- !ig!er inRace- !ig!er in

A%rican AmericansA%rican Americans

&ender- !ig!er in&ender- !ig!er in

menmen 'eredit(- %amil('eredit(- %amil(

!istor( increases ris)!istor( increases ris)

*otentiall( +odifable*otentiall

( +odifable ,i%est(le- ecessi.e,i%est(le- ecessi.e

alco!ol/ cigarettealco!ol/ cigarette

smo)ing/ obesit(/ !ig!smo)ing/ obesit(/ !ig!

%at diet/ drug abuse$%at diet/ drug abuse$

*at!ologic conditions-*at!ologic conditions-

cardiac disease/ 0+/cardiac disease/ 0+/

'TN/ migraine'TN/ migraine

!eadac!es/!eadac!es/!(1ercoagulabilit(!(1ercoagulabilit(

states$states$


4/70


5/70

ETIO,O&2 AN0 *AT'OETIO,O&2 AN0 *AT'O

Etra-cranial %actors- related to t!eEtra-cranial %actors- related to t!e

circulator( s(stem$circulator( s(stem$

S(stemic blood 1ressure- 3"4 and 5674S(stemic blood 1ressure- 3"4 and 5674

cardiac out1ut- !en reduced b( 849cardiac out1ut- !en reduced b( 849

cerebral blood :o is reduced$cerebral blood :o is reduced$

;lood .iscosit(- anemia increases cerebral;lood .iscosit(- anemia increases cerebral

blood :o and 1ol(c(t!emia reduces it$blood :o and 1ol(c(t!emia reduces it$


6/70

INTRACRANIA, FACTORSINTRACRANIA, FACTORS

A$ +etabolic %actorsA$ +etabolic %actors

Increased CO< and lo O< results inIncreased CO< and lo O< results in

.asodilation to restore blood :o to.asodilation to restore blood :o to

normal$normal$

CO< is t!e most 1otent regulator o%CO< is t!e most 1otent regulator o%

cerebral blood :o$cerebral blood :o$

Increased '(drogen ion concentrationIncreased '(drogen ion concentrationincreases cerebral blood :o$increases cerebral blood :o$


7/70

Intracranial %actors/ cont=dIntracranial %actors/ cont=d

;$ ;lood .essels;$ ;lood .esselsT!e condition o% t!e blood .esselsT!e condition o% t!e blood .essels

su11l(ing t!e brain is im1ortant>>>su11l(ing t!e brain is im1ortant>>>*otential 1roblems- congenital anomalies*otential 1roblems- congenital anomalies

?tortuosit(/ coiling/ )in)ing/ and AV?tortuosit(/ coiling/ )in)ing/ and AV

mal%ormations@$mal%ormations@$

T!e mal%ormations inter%ere it! cerebral bloodT!e mal%ormations inter%ere it! cerebral blood

:o and contribute to at!erosclerotic disease:o and contribute to at!erosclerotic diseaseCollateral circulation de.elo1sCollateral circulation de.elo1s

Circle o% illisCircle o% illis


8/70

Intracranial %actors/ cont=dIntracranial %actors/ cont=d

C$ Intracranial 1ressureC$ Intracranial 1ressure

IC* increases it! an assault to brain$IC* increases it! an assault to brain$

Causes o% IC*B stro)e/ neo1lasms/Causes o% IC*B stro)e/ neo1lasms/

in:ammation/ trauma/ and !(droce1!alus$in:ammation/ trauma/ and !(droce1!alus$

IC* com1resses t!e brain and reducesIC* com1resses t!e brain and reduces

cerebral blood :o/ !ic! ma( lead tocerebral blood :o/ !ic! ma( lead to

in%arct$in%arct$ ;ot! etracranial and intracranial %actors;ot! etracranial and intracranial %actors

ma( lead to stro)ema( lead to stro)e


9/70

At!erosclerosisAt!erosclerosis

An abnormal accumulation and infltration o%An abnormal accumulation and infltration o%

in t!e intima o% t!e arteries$in t!e intima o% t!e arteries$

*laues de.elo1 in an area o% !ig! turbulenceD*laues de.elo1 in an area o% !ig! turbulenceD

!ic! ma( later damage t!e 1laue$!ic! ma( later damage t!e 1laue$ *latelets and fbrin aggregate or collect on t!e*latelets and fbrin aggregate or collect on t!e

sur%ace o% t!e 1laue$sur%ace o% t!e 1laue$

*arts o% t!e 1laue brea)s o and tra.el to a*arts o% t!e 1laue brea)s o and tra.el to a

narroer distal arter(narroer distal arter(

Cerebral in%arct occurs$Cerebral in%arct occurs$


10/70


11/70


12/70


13/70

T2*ES OF STROKET2*ES OF STROKE

Isc!emicB +ost common t(1e o% stro)e>Isc!emicB +ost common t(1e o% stro)e> Occurs due to decreased blood :o to anOccurs due to decreased blood :o to an

area o% t!e brain due to 1artial or com1letearea o% t!e brain due to 1artial or com1lete

occlusion o% and arter( due to t!rombosis$occlusion o% and arter( due to t!rombosis$T!is lac) o% blood/ o(gen and nutrients toT!is lac) o% blood/ o(gen and nutrients to

an area o% t!e brain causes necrosis o%an area o% t!e brain causes necrosis o%

cerebral tissue$cerebral tissue$

To t(1esB t!rombotic and embolicTo t(1esB t!rombotic and embolic

See ,eis/ 1age 67GD table ##-6$See ,eis/ 1age 67GD table ##-6$


14/70


15/70


16/70

T!rombotic Stro)eT!rombotic Stro)e

T!rombotic stro)es are usuall(T!rombotic stro)es are usuall(1roceeded b( 1rodromal e1isodes1roceeded b( 1rodromal e1isodes?arnings@ called TIA=s ?transient?arnings@ called TIA=s ?transient

isc!emic attac)s@$isc!emic attac)s@$TIA=s last %rom # to 84 minutes$TIA=s last %rom # to 84 minutes$

Include- 1aresis or decreased strengt! andInclude- 1aresis or decreased strengt! andmotion o% an etremit($motion o% an etremit($

A1!asia or disturbance o% language %unction/A1!asia or disturbance o% language %unction/ *aral(sis/ mental con%usion/ or .isual*aral(sis/ mental con%usion/ or .isual

disturbances$disturbances$


17/70

T!rombotic stro)eT!rombotic stro)e

T!e etent o% t!e sto)e de1ends on ra1idit( o%T!e etent o% t!e sto)e de1ends on ra1idit( o%

onset/ sie o% lesion/ and 1resence collateralonset/ sie o% lesion/ and 1resence collateral

circulation$circulation$

T!ere is a 1attern to t!rombotic stro)e>T!ere is a 1attern to t!rombotic stro)e> 6$ single attac)D s(m1toms occur o.er se.eral !ours6$ single attac)D s(m1toms occur o.er se.eral !ours


18/70

T!rombotic stro)eT!rombotic stro)e

S(m1toms at "< !ours are usuall( dueS(m1toms at "< !ours are usuall( due

to resulting edema to tissuesDto resulting edema to tissuesD

s(m1toms im1ro.e a%ter edemas(m1toms im1ro.e a%ter edema

subsides ?J < ee)s@$subsides ?J < ee)s@$

T!is t(1e o% stro)e occurs during orT!is t(1e o% stro)e occurs during or

a%ter stro)e$a%ter stro)e$


19/70


20/70


21/70

E+;O,IC STROKEE+;O,IC STROKE

Cerebral embolism results %rom occlusionCerebral embolism results %rom occlusion

o% cerebral arter( b( an embolus$o% cerebral arter( b( an embolus$

Necrosis and cerebral edema results$Necrosis and cerebral edema results$

Embolus is t!e second most commonEmbolus is t!e second most common

cause o% stro)e$cause o% stro)e$

+ost emboli originate in t!e+ost emboli originate in t!e

endocardium it! 1laues or tissueendocardium it! 1laues or tissuebrea)ing o and entering circulation$brea)ing o and entering circulation$


22/70


23/70

Embolic Stro)eEmbolic Stro)e

Emboli are associated it! !eartEmboli are associated it! !eart

conditions suc! asDconditions suc! asD

A fbA fb

+I+I

In%ecti.e endocarditisIn%ecti.e endocarditis

R!eumatic !eart diseaseR!eumatic !eart disease

Val.ular 1rost!esesVal.ular 1rost!eses

AS0AS0


24/70

Embolic stro)eEmbolic stro)e

,ess common causes o% emboliB,ess common causes o% emboliB

AirAir

Fat %rom long bone %ractureFat %rom long bone %racture

Amniotic :uid 1ost1artumAmniotic :uid 1ost1artum

tumorstumors


25/70

Embolic stro)eEmbolic stro)e

*rodromal arning less li)el(D single*rodromal arning less li)el(D single

e.entse.ents

sudden onsetsudden onset

+ost commonl( related to !ead+ost commonl( related to !ead

traumatrauma

'ig! rate o% re-occurrence i% cause is'ig! rate o% re-occurrence i% cause isnot treated$not treated$


26/70

'emorr!agic stro)e'emorr!agic stro)e

Intracerebral !emorr!ageIntracerebral !emorr!ageis bleedingis bleeding

it!in t!e brain caused b( ru1ture o% ait!in t!e brain caused b( ru1ture o% a

blood .essel t!at lasts %rom minutes toblood .essel t!at lasts %rom minutes to

da(s$da(s$

+ost commonl( caused b( 'TN+ost commonl( caused b( 'TN

+a( be caused b( brain tumors/+a( be caused b( brain tumors/

trauma/ t!rombol(tic drugs/ andtrauma/ t!rombol(tic drugs/ and

ru1tured aneur(sms$ru1tured aneur(sms$


27/70

'emorr!agic stro)e'emorr!agic stro)e

;lood it!in t!e closed area o% t!e;lood it!in t!e closed area o% t!e

brain im1oses 1ressure on t!e brainbrain im1oses 1ressure on t!e brain

tissue and dis1laces brain tissue andtissue and dis1laces brain tissue and

decreases blood :o to brain$decreases blood :o to brain$

Clinical mani%estations de1ends on t!eClinical mani%estations de1ends on t!e

site and amount o% !emorr!age andsite and amount o% !emorr!age and

resultant damage$resultant damage$*oor 1rognosisD "49 die*oor 1rognosisD "49 die


28/70


29/70

Subarac!noid stro)eSubarac!noid stro)e

Caused b( aneur(sms/ AV mal%ormations/Caused b( aneur(sms/ AV mal%ormations/

trauma/ and 'TN$trauma/ and 'TN$

+a( !a.e 1rodromal s(m1toms i%+a( !a.e 1rodromal s(m1toms i%

ballooning or dilation a11lies 1ressure toballooning or dilation a11lies 1ressure tobrain tissue$brain tissue$

+a( suddenl( ru1ture/ causing neuro+a( suddenl( ru1ture/ causing neuro

c!angesc!anges+aorit( o% aneur(sms are in t!e+aorit( o% aneur(sms are in t!e Circle ofCircle of

WillisWillis


30/70

Subarac!noid !emorr!age/Subarac!noid !emorr!age/

cont=dcont=d I% aneur(sm lea)s/ 1t ma( !a.e a !eadac!e>I% aneur(sm lea)s/ 1t ma( !a.e a !eadac!e>

Ru1ture o% aneur(sm causes 1ressure inRu1ture o% aneur(sm causes 1ressure in

subarac!noid s1ace due to bleeding$ Clinicalsubarac!noid s1ace due to bleeding$ Clinical

mani%estationsBmani%estationsB 'eadac!e/ let!arg(/ con%usion/ nausea/ .omiting/'eadac!e/ let!arg(/ con%usion/ nausea/ .omiting/

%e.er/ nec) 1ain/ and bac)ac!es/ 1aral(sis/ coma and%e.er/ nec) 1ain/ and bac)ac!es/ 1aral(sis/ coma and

deat!$deat!$

+assi.e !emorr!age is defnes as 84 to #4 ml o% blood$+assi.e !emorr!age is defnes as 84 to #4 ml o% blood$

atc! %or re-bleeding !en clot starts to dissol.e$atc! %or re-bleeding !en clot starts to dissol.e$

?usuall( it!in frst < ee)s 1ost ru1ture@$ Reduce?usuall( it!in frst < ee)s 1ost ru1ture@$ Reduce

acti.it( and 1re.ent straining$acti.it( and 1re.ent straining$


31/70

Tem1oral 0e.elo1ment o%Tem1oral 0e.elo1ment o%

CVACVATransient Isc!emic Attac)s ?TIA=s@-Transient Isc!emic Attac)s ?TIA=s@-

;rie% e1isodes o% neuro mani%estations;rie% e1isodes o% neuro mani%estations

?less t!an


32/70

TIA=sTIA=s

sHs .ar( de1ending on t!e 1art o% brainsHs .ar( de1ending on t!e 1art o% brainaected$aected$

TreatmentBTreatmentB +edications suc! as as1irin/ *ersantine+edications suc! as as1irin/ *ersantine

?di1(ridamole@/ Ticlid/ and anticoagulant?di1(ridamole@/ Ticlid/ and anticoagulantmedication$medication$

,ong term t!era1( 1ost TIA,ong term t!era1( 1ost TIA

Surgical treatment- carotid endartarectom(/Surgical treatment- carotid endartarectom(/etra-cranial- intracranial b(1ass ?EC-ICetra-cranial- intracranial b(1ass ?EC-ICb(1ass@/ and transiluminal angio1last($b(1ass@/ and transiluminal angio1last($


33/70

Re.ersible isc!emic NeurologicRe.ersible isc!emic Neurologic

0efcit0efcit

A neuro defcit !ic! remains


34/70

Stro)e LIn- E.olutionStro)e LIn- E.olution

A 1rogressi.e stro)e !ic! de.elo1sA 1rogressi.e stro)e !ic! de.elo1s

o.er !ours or da(s$o.er !ours or da(s$

C!aracteristic o% an enlarging intra-C!aracteristic o% an enlarging intra-

arterial t!rombus$arterial t!rombus$

A ste1ise or intermittent 1rogression o%A ste1ise or intermittent 1rogression o%

deterioration o% neurological s(m1toms$deterioration o% neurological s(m1toms$

+ani%estations do not resol.e and lea.e+ani%estations do not resol.e and lea.eresidual damage$residual damage$


35/70

Com1leted Stro)eCom1leted Stro)e

Neuro de%ects unc!anged o.er < to 8Neuro de%ects unc!anged o.er < to 8

da(s$da(s$

Msuall( embolic in natureMsuall( embolic in nature

Also called stable stro)e$Also called stable stro)e$

Signals readiness %or aggressi.e re!abSignals readiness %or aggressi.e re!ab

t!era1($ ?unless an aneur(sm ist!era1($ ?unless an aneur(sm isin.ol.ed@$in.ol.ed@$


36/70

Clinical +ani%estationsClinical +ani%estations

All defcits are directl( related to areaAll defcits are directl( related to area

o% brain t!at is in.ol.ed$o% brain t!at is in.ol.ed$

See ,eis/ 1age 67#4/ Table ##-


37/70

Neuromotor FunctionNeuromotor Function

0estruction o% motor neurons in t!e0estruction o% motor neurons in t!e

1(ramidal 1at!a( causesB1(ramidal 1at!a( causesB

+obilit(+obilit(

Res1irator( %unctionRes1irator( %unction

Salloing and s1eec!Salloing and s1eec!

&ag re:e&ag re:e

Sel%-care abilitiesSel%-care abilities


38/70


39/70

*atterns o% defcits*atterns o% defcits

Contralateral defcitsContralateral defcits A lesion on one side o% t!e brain aects t!eA lesion on one side o% t!e brain aects t!e

motor %unction on t!e ot!er side o% t!e brain$motor %unction on t!e ot!er side o% t!e brain$

T!e arms and legs on t!e aected side ma(T!e arms and legs on t!e aected side ma(

be ea) or 1aral(ed to dierent degreesbe ea) or 1aral(ed to dierent degrees

de1ending t!e degree o% cerebral circulationde1ending t!e degree o% cerebral circulation

com1romised$com1romised$

See ,eis/ *age 67#6D Table ##-#See ,eis/ *age 67#6D Table ##-#


40/70

T!e aected s!oulder tends to rotateT!e aected s!oulder tends to rotateinternall(D t!e !i1 rotates eternall($internall(D t!e !i1 rotates eternall($

T!e aected %oot is 1lantar :eed andT!e aected %oot is 1lantar :eed and

in.erted$in.erted$An initial 1eriod o% :accidit( ma( lastsAn initial 1eriod o% :accidit( ma( lasts

%or se.eral da(s to ee)s$%or se.eral da(s to ee)s$

S1asticit( o% muscles %ollos t!eS1asticit( o% muscles %ollos t!e:accid stage and is related to:accid stage and is related tointerru1tion o% u11er neuron in:uence$interru1tion o% u11er neuron in:uence$


41/70

CommunicationCommunication

A1!asia- total loss o% com1re!ension andA1!asia- total loss o% com1re!ension and

use o% language due to damage to t!euse o% language due to damage to t!e

dominant !emis1!ere ?le%t !emis1!ere@$dominant !emis1!ere ?le%t !emis1!ere@$

0(s1!asia-d(s%unction related to0(s1!asia-d(s%unction related tocom1re!ension or use o% language due tocom1re!ension or use o% language due to

1artial disru1tion or loss$1artial disru1tion or loss$ Non-:uent ?minimal s1eec! acti.it( it! sloNon-:uent ?minimal s1eec! acti.it( it! slo

s1eec! t!at reuires ob.ious eort@s1eec! t!at reuires ob.ious eort@ Fluent- ?s1eec! is 1resent/ but contains littleFluent- ?s1eec! is 1resent/ but contains little

meaning%ul communication@$meaning%ul communication@$


42/70

CommunicationCommunication

Conducti.e a1!asia- miture o% bot!Conducti.e a1!asia- miture o% bot!

e1ressi.e and rece1ti.e a1!asiae1ressi.e and rece1ti.e a1!asia

&lobal a1!asia- results %rom a massi.e&lobal a1!asia- results %rom a massi.e

lesion and t!ere is .irtual loss o% alllesion and t!ere is .irtual loss o% all

language abilit($language abilit($


43/70

Communication/ cont=dCommunication/ cont=d

ernic)e=s area damageernic)e=s area damage Rece1ti.e a1!asia !ere neit!er t!e sound orRece1ti.e a1!asia !ere neit!er t!e sound or

s1eec! or its meaning can be understood$s1eec! or its meaning can be understood$

Im1aired com1re!ension o% bot! s1o)en andIm1aired com1re!ension o% bot! s1o)en and

ritten language$ritten language$

;oca=s area damage;oca=s area damage

E1ressi.e a1!asia ?diPcult( s1ea)ing and [email protected] a1!asia ?diPcult( s1ea)ing and riting@

0(sart!ria- disturbance in muscular control o%0(sart!ria- disturbance in muscular control o%s1eec!$ ?1ronunciation/ articulation/ 1!onation@s1eec!$ ?1ronunciation/ articulation/ 1!onation@

0OES NOT EFFECT CO+*RE'ENSION OF0OES NOT EFFECT CO+*RE'ENSION OF

,AN&MA&E$,AN&MA&E$


44/70


45/70

AectAect

+a( be unable to control emotions+a( be unable to control emotions

+a( be de1ressed RT bod( image and+a( be de1ressed RT bod( image and

loss o% %unctionloss o% %unction

+a( be %rustrated RT immobilit( and+a( be %rustrated RT immobilit( and

communication issuescommunication issues


46/70

Intellectual FunctionIntellectual Function

+emor( and udgment ma( be+emor( and udgment ma( be

im1airedim1aired

,e%t-sided stro)e 1atients are more,e%t-sided stro)e 1atients are more

cautious in udgment and mo.ement$cautious in udgment and mo.ement$

Rig!t-sided stro)e 1atients moreRig!t-sided stro)e 1atients more

im1ulsi.e and mo.e uic)er$im1ulsi.e and mo.e uic)er$


47/70

S1atial-*erce1tual AlterationsS1atial-*erce1tual Alterations

Rig!t sided stro)e 1atient !as moreRig!t sided stro)e 1atient !as mores1atial-1erce1tual orientation issuesBs1atial-1erce1tual orientation issuesB Erroneous 1erce1tion o% sel% and illnessErroneous 1erce1tion o% sel% and illness

?ma( den( illness or bod( 1arts@$?ma( den( illness or bod( 1arts@$ Erroneous 1erce1tion o% sel% in s1ace ?ma(Erroneous 1erce1tion o% sel% in s1ace ?ma(

ignore aected sideD can=t udge distances@ignore aected sideD can=t udge distances@

Agnosia or inabilit( to recognie an obectAgnosia or inabilit( to recognie an obect

b( sig!t/ touc! or !earing$b( sig!t/ touc! or !earing$ A1raia or t!e inabilit( to carr( out learnedA1raia or t!e inabilit( to carr( out learned

seuential mo.ements on command$seuential mo.ements on command$


48/70

EliminationElimination

+ost occur initiall( and are transient$+ost occur initiall( and are transient$

Freuent consti1ation 0T immobilit(/Freuent consti1ation 0T immobilit(/

ea) abdominal muscles/ de!(dration/ea) abdominal muscles/ de!(dration/

and diminis!ed de%ecation re:ees$and diminis!ed de%ecation re:ees$

Mrinar( and boel elimination ma( beMrinar( and boel elimination ma( be

0T %unctional inabilities to e1ress0T %unctional inabilities to e1ress

needs and manage clot!ing$needs and manage clot!ing$


49/70

0iagnostic Studies0iagnostic Studies

CT Scan-CT Scan-indicate sie and location o%indicate sie and location o%

lesion/ dierentiates beteen in%arctlesion/ dierentiates beteen in%arct

and !emorr!age/ eecti.eness o%and !emorr!age/ eecti.eness o%

treatment/ and e.aluate t!e course o%treatment/ and e.aluate t!e course o%!ealing$!ealing$

+RI- considered best met!od to+RI- considered best met!od to

dierentiate beteen !emorr!age anddierentiate beteen !emorr!age andin%arct$in%arct$


50/70

0iagnostics0iagnostics

*ET*ET s!os c!emical acti.it( and de1ictss!os c!emical acti.it( and de1ictsetent i% tissue damage$etent i% tissue damage$

00SASA- IV or arterial inection o% contrast- IV or arterial inection o% contrast

material to .isualie blood .essels$material to .isualie blood .essels$T0A-T0A- transcranial do11ler measurestranscranial do11ler measures

.elocit( o% cerebral blood :o in t!e.elocit( o% cerebral blood :o in t!earteries/ also detects micro-emboli$arteries/ also detects micro-emboli$

,* ma( be done to detect blood or ;C=s,* ma( be done to detect blood or ;C=s?not done i% increased IC* is sus1ected@?not done i% increased IC* is sus1ected@


51/70


52/70

Collaborati.e careCollaborati.e care

*REVENTION*REVENTION

'ealt!( diet'ealt!( diet

eig!t controleig!t control

Regular eerciseRegular eercise

No S+OKIN&No S+OKIN&

,imiting alco!ol,imiting alco!ol

Routine !ealt! assessmentRoutine !ealt! assessment


53/70

0RM& T'ERA*20RM& T'ERA*2

*ro1!(lactic lo dose as1irin/ dail($*ro1!(lactic lo dose as1irin/ dail($

*ersantine #4 mg 8 Q da( decreases*ersantine #4 mg 8 Q da( decreases

1latelet aggregation !ic! !el1s to1latelet aggregation !ic! !el1s to

decrease ris) o% t!rombus anddecrease ris) o% t!rombus and

embolus %ormation$embolus %ormation$

TIC,I0 or *,AVIQ- 1latelet aggregationTIC,I0 or *,AVIQ- 1latelet aggregation

in!ibitorsin!ibitors


54/70

Surgical T!era1(Surgical T!era1(

Carotid endarterectom( ?CEA@- t!eCarotid endarterectom( ?CEA@- t!e

at!eromatous lesion is remo.ed %romat!eromatous lesion is remo.ed %rom

t!e carotid arter( to im1ro.e bloodt!e carotid arter( to im1ro.e blood

:o:o 0ecreases stro)e and deat! in 1atient0ecreases stro)e and deat! in 1atient

it! TIA=s$it! TIA=s$

0one on 1atient it! "4-9 occlusion0one on 1atient it! "4-9 occlusion


55/70

Transluminal Angio1last(Transluminal Angio1last(

Insertion o% balloon to o1en stenosedInsertion o% balloon to o1en stenosed

arter( to 1ermit blood :o$arter( to 1ermit blood :o$

*atient it! s(m1tomatic stenosis o%*atient it! s(m1tomatic stenosis o%

.ertebrobasilar or carotid arteries.ertebrobasilar or carotid arteries Ris) o% dislodging emboliRis) o% dislodging emboli


56/70

EC-IC ;2*ASSEC-IC ;2*ASS

Etracranial-intracranial b(1assEtracranial-intracranial b(1ass

Msed !en obstruction cannot beMsed !en obstruction cannot be

remo.ed directl(remo.ed directl(

A branc! o% etracranial arter( isA branc! o% etracranial arter( isanastomosed to a branc! o% intracranialanastomosed to a branc! o% intracranial

arter( ust be(ond t!e area o% obstruction$arter( ust be(ond t!e area o% obstruction$

*atients at !ig! ris) %or stro)e and reuire*atients at !ig! ris) %or stro)e and reuireclose-long term assessment andclose-long term assessment and

management$management$

ACMTE CAREACMTE CARE


57/70

ACMTE CAREACMTE CARE

Table ##-#D ,eis 1age 67#$Table ##-#D ,eis 1age 67#$

Initiall(Initiall(

Ensure 1atent aira( 0T altered le.el o%Ensure 1atent aira( 0T altered le.el o%

consciousness$consciousness$Remo.e denturesRemo.e dentures

Administer o(gen .ia nasal cannula orAdminister o(gen .ia nasal cannula or

non-rebreat!er mas) 0T res1irator(non-rebreat!er mas) 0T res1irator(distressdistress


58/70

Acute CareAcute Care

Establis! IV access it! normal salineEstablis! IV access it! normal saline

to maintain ;*to maintain ;*

Remo.e clot!ingRemo.e clot!ing

Obtain immediate CT ScanObtain immediate CT Scan

+onitor VS/ ,OC/ O< sats/ cardiac+onitor VS/ ,OC/ O< sats/ cardiac

r!(t!ms/ &lasgo Coma Scale/ 1u1ilr!(t!ms/ &lasgo Coma Scale/ 1u1il

sie and reacti.it($sie and reacti.it($



59/70


+aintain 1atient armt!+aintain 1atient armt!

Reassure 1atient and %amil(Reassure 1atient and %amil(

Isc!emic CascadeIsc!emic Cascade


60/70

Isc!emic CascadeIsc!emic Cascade

Series o% e.ents in res1onse toSeries o% e.ents in res1onse tot!rombotic and embolic stro)es$t!rombotic and embolic stro)es$ Isc!emic area becomes discolored andIsc!emic area becomes discolored and

so%t/ initiall($ 'oe.er/ around t!e borderso%t/ initiall($ 'oe.er/ around t!e bordert!ere is an area o% 1er%usion called t!et!ere is an area o% 1er%usion called t!eischemic penumbraischemic penumbrat!at maintainst!at maintains1er%usion %or 8 to 7 !ours 1ost stro)e$1er%usion %or 8 to 7 !ours 1ost stro)e$

I% adeuate blood :o is reinitiated duringI% adeuate blood :o is reinitiated duringt!is 1eriod/ less neuro damage resultst!is 1eriod/ less neuro damage results

TreatmentTreatment


61/70

TreatmentTreatment

Control :uid and electrol(te balanceControl :uid and electrol(te balance

Adeuate !(dration 1romotes 1er%usion toAdeuate !(dration 1romotes 1er%usion to

t!e brainD !oe.er o.er !(dration ma(t!e brainD !oe.er o.er !(dration ma(

increase cerebral edema>increase cerebral edema>Total inta)e ?oral/ tube %eedings/ IV etc$/Total inta)e ?oral/ tube %eedings/ IV etc$/

6#44-


62/70

TreatmentTreatment

IV solutions it! glucose and ater areIV solutions it! glucose and ater are

a.oided$ ?!(1ertonic solutions ma(a.oided$ ?!(1ertonic solutions ma(

increase cerebral edema@increase cerebral edema@

Increased IC* %rom cerebral edemaIncreased IC* %rom cerebral edema

1ea)s in "< !ours and ma( cause1ea)s in "< !ours and ma( cause

brain !erniation$brain !erniation$

'o to manage IC*'o to manage IC*


63/70

'o to manage IC*'o to manage IC*

En!ance .enous drainage b(BEn!ance .enous drainage b(B

Ele.ating 'O;Ele.ating 'O;

+aintain !ead and nec) in alignment+aintain !ead and nec) in alignment

A.oidance o% !i1 :eionA.oidance o% !i1 :eion

,imit cerebral tissue metabolism and,imit cerebral tissue metabolism and

.asodilation b(B.asodilation b(B

a.oiding !(1ert!ermia/ a.oidinga.oiding !(1ert!ermia/ a.oiding!(1er.olemia/ manage consti1ation!(1er.olemia/ manage consti1ation

+edications+edications


64/70

+edications+edications

0iuretics ?decrease cerebral edema@0iuretics ?decrease cerebral edema@

+annitol ?Osmitrol@+annitol ?Osmitrol@

,asi/ ?Furosemide@,asi/ ?Furosemide@

0eamet!asone %or 1atients it!0eamet!asone %or 1atients it!

.asogenic edema.asogenic edema

0rug T!era1(0rug T!era1(


65/70

0rug T!era1(0rug T!era1(

T!rombol(tic t!era1(T!rombol(tic t!era1( Recombinant tissue 1lasminogen acti.atorRecombinant tissue 1lasminogen acti.ator

?t-*A@- to re-establis! blood :o and 1re.ent?t-*A@- to re-establis! blood :o and 1re.entcell deat! %or 1atients it! isc!emic stro)es$cell deat! %or 1atients it! isc!emic stro)es$

*atients !o recei.e t-*A it!in 8 !ours*atients !o recei.e t-*A it!in 8 !oursa%ter a stro)e more li)el( to !a.e 8


66/70

t-*At-*A

Clot s1ecifcClot s1ecifc

,ess li)el( to cause !emorr!age as,ess li)el( to cause !emorr!age as

com1ared to stre1to)inase orcom1ared to stre1to)inase or

uro)inase$uro)inase$

Single most im1ortant %actor isSingle most im1ortant %actor is

timing>>>timing>>>

t *At-*A


67/70

t-*At-*A

*atients are screened %or coagulation*atients are screened %or coagulation

disorders/ &I bleeding/ and !emorr!agicdisorders/ &I bleeding/ and !emorr!agic

stro)e be%ore initiation o% treatment$stro)e be%ore initiation o% treatment$

+aor side eect is cerebral !emorr!age$+aor side eect is cerebral !emorr!age$+onitor VS during treatmentH control ;*+onitor VS during treatmentH control ;*

O anticoagulants or anti1latelet drug %orO anticoagulants or anti1latelet drug %or


68/70

H gH gt!era1(t!era1(

'e1arin/ coumadin/ as1irin/ ticli1idine'e1arin/ coumadin/ as1irin/ ticli1idine

?Ticlid@/ clo1idrogel ?*la.i@/?Ticlid@/ clo1idrogel ?*la.i@/

di1(ridamole ?*ersantine@$di1(ridamole ?*ersantine@$

Contraindicated %or 1atients it!Contraindicated %or 1atients it!!emorr!agic stro)es!emorr!agic stro)es

+onitor *TH *TT+onitor *TH *TT

+onitor 1atient %or bleeding+onitor 1atient %or bleeding

0rug t!era1(0rug t!era1(


69/70


Calcium c!annel bloc)ers are gi.en %orCalcium c!annel bloc)ers are gi.en %or1atients it! !emorr!agic stro)es$1atients it! !emorr!agic stro)es$

Ecess intracellular calcium ma( beEcess intracellular calcium ma( be

!arm%ul to brain tissue$!arm%ul to brain tissue$Nimodi1ine ?Nimoto1@ decreasesNimodi1ine ?Nimoto1@ decreases

eects o% .asos1asm and minimieseects o% .asos1asm and minimies

tissue damage$tissue damage$As1irin decreases 1latelet aggregationAs1irin decreases 1latelet aggregation

at site o% 1laue$at site o% 1laue$


70/70


T(lenol treats !(1ert!ermiaT(lenol treats !(1ert!ermia

0ilantin ma( be gi.en %or seiures0ilantin ma( be gi.en %or seiures

cerebralvascularaccident.ppt

Documents