INTRODUCTION

Cerebrovascular Accident (CVA)

Strokes, or brain attacks, are a major cause of death and permanent disability. They occur when blood flow to a region of the brain is obstructed and may result in death of brain tissue.

LEFT AND RIGHT HEMISPHERE STROKES FEATURE LANGUAGE LEFT HEMISPHERE Aphasia Agraphia Alexia (word blindness) Possible Deficit RIGHT HEMISPHERE Impaired sense of humor

MEMORY

VISION

BEHAVIOR

Inability to discriminate words and letters Reading problems Deficits in the right visual field Slowness Cautiousness Anxiety when attempting a new task Depression or a catastrophic response to illness Sense of guilt Feeling of worthlessness Worries over future Quick anger and frustration Intellectual impairment No deficit

Disorientation to time, place, and person Inability to recognize faces Visual spatial deficits Neglect of the left visual field Loss of depth perception Impulsiveness Lack of awareness of neurologic deficits Confabulation Euphoria Constant smiling Denial illness Poor judgement Overestimation of abilities (risk for injury) Loss of ability to hear tonal variations

HEARING

DIFFERENTIAL FEATURES OF THE TYPES OF STROKE Ischemic FEATURE EVOLUTION THROMBOTIC Intermittent or stepwise improvement between episodes of worsening Complete stroke Daytime (10am to EMBOLIC Abrupt development of completed stroke Steady progression HEMORRHAGIC Usually abrupt onset

ONSET

Daytime

Daytime

 LEVEL OF CONSCIOUSNESS CONTRIBUTING ASSOCIATED FACTORS PRODROMAL SYMPTOMS NEUROLOGIC DEFICITS

12pm) Gradual (minutes to hours) Preserved (client is awake) Hypertension Atherosclerosis Transient ischemic attack Deficits during the first few weeks Slight headache Speech deficit Visual problems Confusion Normal, possible presence of protein no improvements over weeks to months permanent deficits possible

Sudden

Preserved (client is awake) Cardiac disease

Sudden, may be gradual if caused by hypertension Deepening stupor or coma Hypertension Vessel disorders

Maximal deficit at onset Paralysis Expressive aphasia

Focal deficits Severe, frequent

CEREBROSPINAL FLUID SEIZURES DURATION

Normal no

bloody usually variable permanent neurologic deficits possible

rapid improvements

Risk factors Many factors can increase your risk of a stroke. A number of these factors can also increase your chances of having a heart attack. Stroke risk factors include: Potentially treatable risk factors

High blood pressure risk of stroke begins to increase at blood pressure readings higher than 120/80 millimeters of mercury (mm Hg). Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors.

Cigarette smoking or exposure to second hand smoke. High cholesterol a total cholesterol level above 200 milligrams per deciliter (mg/dL), or 5.2 millimoles per liter (mmol/L).

Diabetes. Being overweight or obese. Physical inactivity. Obstructive sleep apnea (a sleep disorder in which the oxygen level intermittently drops during the night).

Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart rhythm. Use of some birth control pills or hormone therapies that include estrogen.

Heavy or binge drinking. Use of illicit drugs such as cocaine and methamphetamines. Other risk factors

Personal or family history of stroke, heart attack or TIA. Being age 55 or older. Race African-Americans have higher risk of stroke than people of other races. Gender Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they are more likely to die of strokes than men.

TYPES OF STROKE Ischemic Thrombotic Embolic Hemorrhagic Intracerebral Hemorrhage Subarachnoid Hemorrhage Aneurysm Berry or Saccular Pseudoaneurysm Fusiform

Ishemic Stoke Ischemic stroke is more common and occurs when blood flow to a part or parts of the brain is stopped by a blockage in a vessel.

Hemorrhagic stroke is more deadly and occurs when a weakened vessel tears or ruptures, diverting blood flow from its normal course and instead leaking or spilling it into or around the brain itself. There is a third type referred to as transient ischemic attack (TIA) or mini-stroke. While they are not true strokes because the symptoms are temporary, TIAs are usually a warning sign of a stroke to come. Heeding the warning signs of TIAs and treating the underlying risk factors that trigger them can prevent many strokes. Transient Ischemic Attack

Visual Deficits Blurred vision Diplopia (double vision) Blindness in one eye Tunnel vision

Motor Deficits Transient weakness (arm, hand, or leg) Gait disturbance (ataxic)

Sensory Deficits Transient numbness (face, arm or hand) Vertigo

Speech Deficits Aphasia Dysarthria (slurred speech)

A TIA is caused by a brief pause in blood flow to part of the brain the result of a temporary or partial blockage. The symptoms of a TIA resemble those of a stroke but they do not last as long. Most symptoms disappear within an hour, although some may persist for up to 24 hours. Usually, no permanent brain damage occurs as a result of a TIA. According to the National Stroke Association, approximately 5 million Americans have experienced at least one TIA. TIA Symptoms Patients suffering a TIA may describe a veil or window shade partly covering the vision of one eye that clears up spontaneously after several minutes. This represents the temporary blockage (occlusion) of the retinal artery to the eye. There may also be dizziness, imbalance, loss of coordination, confusion, difficulty speaking or understanding, and generalized weakness. There is no way to differentiate the temporary symptoms of a TIA from those of an acute stroke. All patients need medical evaluation urgently. About one-third of those who have a TIA eventually will have an acute stroke. Many strokes can be prevented by heeding TIA warning signs and treating underlying risk factors. The vast majority of strokes approximately 83 percent are ischemic. They are caused by an obstruction of an artery leading to or in the brain, preventing oxygenated blood from reaching parts of the brain that the artery feeds. Ischemic strokes are either thrombotic or embolic, depending on where the obstruction or clot (thrombus or embolism), causing the blockage originated:

Thrombotic Ischemic Stroke Thrombotic stroke is caused by a thrombus (blood clot) that develops in an artery supplying blood to the brain usually because of a repeated buildup of fatty deposits, calcium and clotting factors, such as fibrinogen and cholesterol, carried in the blood. The body perceives the buildup as an injury to the vessel wall and responds the way it would to a small wound it forms blood clots. The blood clots get caught on the plaque on the vessel walls, eventually stopping blood flow. There are two types of thrombotic stroke:

Large vessel thrombosis, the most common form of thrombotic stroke, occurs in the brains larger arteries. The impact and damage tends to be magnified because all the smaller vessels that the artery feeds are deprived of blood. In most cases, large vessel thrombosis is caused by a combination of long-term plaque buildup (atherosclerosis) followed by rapid blood clot formation. High cholesterol is a common risk factor for this type of stroke.

Small vessel disease (lacunar infarction) occurs when blood flow is blocked to a very small arterial vessel. It has been linked to high blood pressure (hypertension) and is an indicator of atherosclerotic disease.

Thrombotic disease accounts for about 60 percent of acute ischemic strokes. Of those, approximately 70 percent are large vessel thrombosis.

Embolic Ischemic Stroke A blood clot that forms in one area of the body and travels through the bloodstream to another where it may lodge is called an embolus. In the case of embolic stroke, the clot forms outside of the brain usually in the heart or large arteries of the upper chest and neck and is transported through the bloodstream to the brain. There it eventually reaches a blood vessel small enough to block its passage. Emboli can be fat globules, air bubbles or, most commonly, bits and pieces of atherosclerotic plaque, such as lipid debris, that have detached from an artery wall. Many emboli are caused by a cardiac condition called atrial fibrillationan abnormal, rapid heartbeat in which the two small upper chambers

of the heart (called the atria) quiver instead of beating. Quivers cause the blood to pool, forming clots that can travel to the brain and cause a stroke. Cardiac sources of embolism account for 80 percent of embolic ischemic strokes. Ischemic Stroke Symptoms The signs of ischemic stroke are similar to those of a TIA, except the damage can be permanent. The most common indicator is sudden weakness of the face, arm or leg, most often on one side of the body. Other warning signs may include:

sudden numbness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; and/or sudden severe headache with no known cause (most common with hemorrhagic stroke).

The symptoms depend on the side of the brain that's affected, the part of the brain, and how severely the brain is injured. Stroke may be associated with a headache, or may be completely painless. Therefore, each person may have different warning signs. HEMORRHAGIC STROKE Hemorrhagic stroke occurs when a vessel in the brain suddenly ruptures and blood begins to leak directly into brain tissue and/or into the clear cerebrospinal fluid that surrounds the brain and fills its central cavities (ventricles). The rupture can be caused by the force of high blood pressure. It can also originate from a weak spot in a blood vessel wall (a cerebral aneurysm) or other blood vessel malformation in or around the brain. Damage can be caused in two ways. As in the case of ischemic stroke, oxygen- and nutrient-rich blood is prevented from reaching the brain cells beyond the point of rupture. In addition, leaked blood can irritate and harm the brain cells in the areas where it accumulates. It is the location of the hemorrhage, rather than the amount of bleeding, that tends to be the bigger factor in influencing the severity of the stroke. For example, bleeds in the brainstem, though relatively tiny, can be quite lethal, whereas the same-sized bleed in the frontal lobe may not even be noticeable. There are two types of hemorrhagic strokes. They are differentiated by where the ruptured artery is located and where the resulting blood leakage occurs.

Intracerebral Hemorrhage (ICH) (also called Intraparenchymal hemorrhage or intracranial hematoma) This type of stroke is caused by the sudden rupture of an artery or blood vessel within the brain. The blood that leaks into the brain results in a sudden increase in pressure that can damage the surrounding brain cells. If the amount of blood increases rapidly, the sudden and extreme build up in pressure can lead to unconsciousness or death. Approximately 10 percent of all strokes are intracerebral hemorrhages. They occur most commonly in the basal ganglia where the vessels can be particularly delicate. High blood pressure (hypertension) is the most common cause of this type of stroke. Less common causes include trauma, infections, tumors, blood clotting deficiencies, and abnormalities in cerebral blood vessels. Blood Vessel Abnormalities: Blood vessel abnormalities in the brain include arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). AVMs and AVFs, also called lesions, are abnormal connections between cerebral arteries (which carry blood to the brain) and veins (which take blood away from the brain). AVMs appear to be acquired prior to birth (congenital) and tend to form near the back of the brain. Although AVFs can be congenital, more often they are caused by a trauma that damages an artery and a vein which are side by side in the brain. These blood vessel abnormalities can cause a host of problems, but the two most common are pressure against the adjacent parts of the brain, causing neurological problems (such as seizures, paralysis or loss of speech), and bleeding (hemorrhage) into surrounding tissues. Hemorrhage from cerebral arteriovenous abnormalities represents from 2 percent to 4 percent of all strokes. Subarachnoid Hemorrhage (SAH) Subarachnoid hemorrhage occurs when bleeding from a damaged vessel causes blood to accumulate between the brain

and the skull, in the subarachnoid space, and press on the surface of the brain instead of dispersing into the tissue. The leaked blood can irritate, damage or destroy surrounding brain cells.

When blood enters the subarachnoid space, it mixes with the cerebrospinal fluid (CSF) that cushions the brain and spinal cord. This can block CSF circulation, which leads to fluid buildup and increased pressure on the brain. The open spaces in the brain (ventricles) may enlarge, resulting in a condition called hydrocephalus. This can make a patient lethargic, confused or incontinent. The large accumulation of blood increases the pressure surrounding the brain, interfering with brain function. The leaked blood also can produce a condition called vasospasm in which the vessels narrow, impeding the flow of blood to the brain. This can result in an ischemic stroke. The condition typically develops five to eight days after the initial hemorrhage. Most often, a subarachnoid hemorrhage occurs because a cerebral aneurysm, an abnormal bulging outward in the wall of an artery, ruptures. SAH also can occur because blood leaks from abnormal blood vessel connections (AVMs and AVFs) near the surface of the brain.

Cerebral Aneurysm: A brain aneurysm is a weak bulging spot on the wall of a brain artery very much like a thin balloon or weak spot on an inner tube. Aneurysms form from wear and tear on the arteries, and sometimes from injury, infection or an inherited tendency.

There are two types of aneurysm:

Saccular This is the most common type. It has a neck and stem and is also known as a berry aneurysm because of its shape. Fusiform This is a less common type of aneurysm. It is an outpouching of the wall on both sides of the artery and does not have a stem. Pseudoaneurysm, also known as a false aneurysm, is a hematoma that forms as the result of a leaking hole in an artery. Note that the hematoma forms outside the arterial wall, so it is contained by the surrounding tissues. Also it must continue to communicate with the artery to be considered a pseudoaneurysm. This must be distinguished from a true aneurysm which is a localised dilatation of an artery including all the layers of the wall. A pseudoaneurysm is also different from an arterial dissection, which is a separation of the layers of the arterial wall, and may be associated with later aneurysm formation. Aneurysms that cause subarachnoid hemorrhage are usually located at the base of the brain in the Circle of Willis. This is an area in which a lot of blood pressure changes occur and where a lot of vessels branch off, which can expose them to weakness. Although it is not possible to predict whether an aneurysm will rupture, an aneurysm is more likely to do so when it has a diameter of 7 millimeters or more. Unruptured brain aneurysms can be medically treated to prevent a possible rupture. Sudden & Severe Symptoms Symptoms of a hemorrhagic stroke appear without warning. The sudden increase in blood volume within the rigid skull (cranium) creates intense intracranial pressure that cannot be released. This, in turn, may trigger a severe (thunderclap) headache, neck pain, double vision, nausea or vomiting, loss of consciousness or even death.

About 17 percent of strokes are hemorrhagic. The average age at which people suffer hemorrhagic stroke tends to be lower than for ischemic stroke. This is because many of the risk factors are related to unhealthy behaviors, such as smoking or drug use, rather than the effects on the body of aging. The fatality rate for hemorrhagic strokes is higher than for ischemic strokes and overall prognosis is poorer. Tests

Physical examination. Your doctor will ask you or a family member what symptoms you've been having, when they started and what you were doing when they began. Your doctor then will evaluate whether these symptoms are still present. Your doctor will want to know what medications you take and whether you have experienced any head injuries. You'll be asked about your personal and family history of heart disease, TIA or stroke

Blood tests. You may have several blood tests, which give your care team important information such as how fast your blood clots, whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection. Your blood's clotting time and levels of sugar and key chemicals must be managed as part of your stroke care.

Computerized tomography (CT) scan. Brain imaging plays a key role in determining if you're having a stroke and what type of stroke you may be experiencing. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. Doctors may inject a dye into your blood vessels to view your blood vessels in your neck and brain in greater detail (computerized tomography angiography).

Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Sometimes your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography).

Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows build up of fatty deposits (plaques) and blood flow in your carotid arteries.

Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin, and guides it through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye into your blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in your brain and neck.

Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke. You sometimes may have a transesophageal echocardiogram. In this test, your doctor inserts a flexible tube with a small device (transducer) attached in your throat and down into your esophagus the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, a transesophageal echocardiogram can create clear, detailed ultrasound images of your heart and any blood clots. Complications A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain suffers a lack of blood flow and which part was affected. Complications may include:

Paralysis or loss of muscle movement. Sometimes a lack of blood flow to the brain can cause you to become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm. This can cause difficulty with several daily activities, including walking, eating and dressing. With physical therapy, you may see improvement in muscle movement or paralysis.

Difficulty talking or swallowing. A stroke may cause you to have less control over the way the muscles in your mouth and throat move, making it difficult for you to talk, swallow or eat. For example, some people may experience slurred speech (dysarthria), due to incoordination of muscles in your mouth. You also may have difficulty with language (aphasia), including speaking or understanding speech, reading or writing. Therapy with a speech and language pathologist may help you improve your skills.

Memory loss or thinking difficulties. Many people who have had strokes experience some memory loss. Others may have difficulty thinking, making judgments, reasoning and understanding concepts. These complications may improve with rehabilitation therapies.

Emotional problems. People who have had strokes may have more difficulty controlling their emotions, or they may develop depression.

Pain. Some people who have had strokes may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. Some people may be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication generally develops several weeks after a stroke, and it may improve over time. But because the pain is caused by a problem in your brain, instead of a physical injury, few medications may treat CPS.

Changes in behavior and self-care. People who have had strokes may become more withdrawn and less social or more impulsive. They may lose the ability to care for themselves and may need a caretaker to help them with their grooming needs and daily chores.

Incidence and Prevalence It is estimated that there are more than 4.7 million stroke survivors in the United States. About 730, 000 strokes occur each year, and more than 150, 000 deaths result. About 25% of strokes occur in people under 65 years of age. The number of strokes occurring in the younger population is increasing as a result of chronic intravenous (IV) drug abuse. Those using crack cocaine experience an increased incidence of stroke resulting from changes in the clotting mechanism caused by the drugs, spasm of cerebral vessels or hemodynamic stress from the sudden increase in systolic blood pressure. Between 5% and 15% of all clients who have strokes have a recurrence within 1 year. By 5 years, about 40% have recurrence, and half of those die from stroke complications (Goldszmidt & Caplan, 2003). Strokes tend to occur more often in the southern United States (stroke belt), which is probably related to the geopgraphic distribution of the older population, an increased use of tobacco, obesity, and a diet in higher fats.

Stroke is the third leading cause of death and the leading cause of disability in the United States. Number One leading cause of disability, 25% with initial stroke die within 1 year, 50-75% will be functionally independent, 25% will live with permanent disability. Approximately 600,000 strokes, or brain attacks, occur in the United States each year and of these, approximately 150,000 (25%) are fatal. The incidence of stroke is higher in African Americans than Caucasians. Stroke occurs at an equal rate in men and women, but women are more likely to die. Ischemic stroke occurs more frequently in people over age 65 and hemorrhagic stroke is more common in younger people.