Textbook Discussion & Schematic Diagram of the Diagnosis

A. Definition

Cerebrovascular Disease

A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss

of brain function resulting from a disruption of the blood supply to a part of the brain.Cerebrovascular
accident or stroke is the primary cerebrovascular disorder in the United States.A cerebrovascular
accident is a sudden loss of brain functioning resulting from a disruption of the blood supply to a part of
the brain.It is a functional abnormality of the central nervous system.Cryptogenic strokes have no known
cause, and other strokes result from causes such as illicit drug use, coagulopathies, migraine, and
spontaneous dissection of the carotid or vertebral arteries.The result is an interruption in the blood supply to
the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.

Classification

Strokes can be divided into two classifications.

 Ischemic stroke. This is the loss of function in the brain as a result of a disrupted blood supply.
 Hemorrhagic stroke. Hemorrhagic strokes are caused by bleeding into the brain tissue, the
ventricles, or the subarachnoid space.

Prevention

 Healthy lifestyle. Leading a healthy lifestyle which includes not smoking, maintaining a healthy
weight, following a healthy diet, and daily exercise can reduce the risk of having a stroke by about one
half.
 DASH diet. The DASH (Dietary Approaches to Stop Hypertension) diet is high in fruits and
vegetables, moderate in low-fat dairy products, and low in animal protein and can lower the risk of
stroke.
 Stroke risk screenings. Stroke risk screenings are an ideal opportunity to lower stroke risk by
identifying people or groups of people who are at high risk for stroke.
 Education. Patients and the community must be educated about recognition and prevention of stroke.
 Low-dose aspirin. Research findings suggest that low-dose aspirin may lower the risk of stroke in
women who are at risk.

Complications

If cerebral oxygenation is still inadequate; complications may occur.

Tissue ischemia. If cerebral blood flow is inadequate, the amount of oxygen supplied to the brain is
decreased, and tissue ischemia will result.

Cardiac dysrhythmias. The heart compensates for the decreased cerebral blood flow, and with too much
pumping, dysrhythmias may occur.

Assessment and Diagnostic Findings

CT scan. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Demonstrates
structural abnormalities, edema, hematomas, ischemia, and infarctions. Note: May not immediately reveal all
changes, e.g., ischemic infarcts are not evident on CT for 8–12 hr; however, intracerebral hemorrhage is
immediately apparent; therefore, emergency CT is always done before administering tissue plasminogen
activator (t-PA). In addition, patients with TIA commonly have a normal CT scan

PET scan. Provides data on cerebral metabolism and blood flow changes.
MRI. Shows areas of infarction, hemorrhage, AV malformations, and areas of ischemia.

Cerebral angiography. Helps determine specific cause of stroke, e.g., hemorrhage or obstructed artery,
pinpoints site of occlusion or rupture. Digital subtraction angiography evaluates patency of cerebral vessels,
identifies their position in head and neck, and detects/evaluates lesions and vascular abnormalities.

Lumbar puncture. Pressure is usually normal and CSF is clear in cerebral thrombosis, embolism, and TIA.
Pressure elevation and grossly bloody fluid suggest subarachnoid and intracerebral hemorrhage. CSF total
protein level may be elevated in cases of thrombosis because of inflammatory process. LP should be
performed if septic embolism from bacterial endocarditis is suspected.

Transcranial Doppler ultrasonography. Evaluates the velocity of blood flow through major intracranial
vessels; identifies AV disease, e.g., problems with carotid system (blood flow/presence of atherosclerotic
plaques).

EEG. Identifies problems based on reduced electrical activity in specific areas of infarction; and can
differentiate seizure activity from CVA damage.

Skull x-ray. May show a shift of pineal gland to the opposite side from an expanding mass; calcifications of
the internal carotid may be visible in cerebral thrombosis; partial calcification of walls of an aneurysm may be
noted in subarachnoid hemorrhage.

ECG and echocardiography. To rule out cardiac origin as source of embolus (20% of strokes are the result
of blood or vegetative emboli associated with valvular disease, dysrhythmias, or endocarditis).

Laboratory studies to rule out systemic causes: CBC, platelet and clotting studies, VDRL/RPR,
erythrocyte sedimentation rate (ESR), chemistries (glucose, sodium).

B. Signs and symptoms

According to Textbook Manifested by the patient

Numbness or weakness of the face (+)Left side

Change in mental status (+)

Trouble speaking or understanding speech (+)

Visual disturbances (+)

Homonymous hemianopsia (+)

Loss of peripheral vision (+)

Hemiparesis (+)Left side

Hemiplegia (-)

Paralysis (-)

Ataxia (+)

Dysarthria (+)

Paresthesia (+)left side

Expressive aphasia (+)

Receptive aphasia (-)

 Global aphasia (-)

Dysphagia (+)

vomiting (-)

unilateral neglect (+)

altered consciousness (-)

D.Management
Medical Management

Recombinant tissue plasminogen activator would be prescribed unless contraindicated, and there should
be monitoring for bleeding.

Increased ICP. Management of increased ICP includes osmotic diuretics, maintenance of PaCO2 at 30-35
mmHg, and positioning to avoid hypoxia through elevation of the head of the bed.

Endotracheal Tube. There is a possibility of intubation to establish patent airway if necessary.

Hemodynamic monitoring. Continuous hemodynamic monitoring should be implemented to avoid an

increase in blood pressure.

Neurologic assessment to determine if the stroke is evolving and if other acute complications are
developing

Surgical Management

Surgical management may include prevention and relief from increased ICP.

 Carotid endarterectomy. This is the removal of atherosclerotic plaque or thrombus from the carotid
artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.
 Hemicraniectomy. Hemicraniectomy may be performed for increased ICP from brain edema
in severe cases of stroke.

Nursing Management

After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.

Nursing Assessment

During the acute phase, a neurologic flow sheet is maintained to provide data about the following important
measures of the patient’s clinical status:

 Change in level of consciousness or responsiveness.

 Presence or absence of voluntary or involuntary movements of extremities.
 Stiffness or flaccidity of the neck.
 Eye opening, comparative size of pupils, and pupillary reaction to light.
 Color of the face and extremities; temperature and moisture of the skin.
 Ability to speak.
 Presence of bleeding.
 Maintenance of blood pressure.

During the postacute phase, assess the following functions:

 Mental status (memory, attention span, perception, orientation, affect, speech/language).

 Sensation and perception (usually the patient has decreased awareness of pain and temperature).
 Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration
status, skin integrity, activity tolerance, and bowel and bladder function.
 Continue focusing nursing assessment on impairment of function in patient’s daily activities.