Cerebrovascular Accident (Stroke, Brain Attack)

Cerebrovascular Accident
(Stroke, Brain Attack)
 Sudden onset of focal neurologic deficit

resulting from infarction or hemorrhage
within the brain
 85% nonhemorrhagic
 15% hemorrhagic
1
Transient Ischemic Attack
(TIA)
 Sudden & temporary loss of motor, sensory,
or visual dysfunction (< 6 hrs.)
 S/S:
*amaurosis fugax (loss of vision),
contralateral weakness, or aphasia
*vertigo, diplopia, numbness or
paresthesias, dysphagia, ataxia
2
Management of TIA
 Medical:
Anticoagulants
Aspirin
Tx. hypertension, diabetes
 Surgical:
Carotid endarterectomy, stenting
Angioplasty
3
Incidence of CVA
 3rd leading cause of death

 730,000 strokes/year
 160,000 deaths/year
 2x higher in African-Americans
 4,000,000 stroke survivors in U.S.
4
Signs/Symptoms of Brain Attack
 Dysphagia, dysarthria
 Global aphasia, expressive &

receptive aphasia
 Hemiparesis or hemiplegia of face,

arm, and leg on same side
5
 Paresthesia--numbness, difficulty with
proprioception
 Ataxia, dizziness
 Apraxia
 Visual deficits--homonymous hemianopsia,

loss of peripheral vision, diplopia, loss of
depth perception
6
 Sudden, severe headache
 Disoriented time, place, person.

Unaware of neuro deficits
 Memory loss
 Quick anger, frustration

7
Right & Left Hemisphere CVA
feature left right
language *aphasia *impaired sense

of humor
memory *deficit *disoriented
8
Right & Left Hemisphere CVA
feature left right
vision *deficit right *spatial deficits

visual field *neglect left
visual field
*problem *loss of depth
reading perception
behavior *slow *impulsive

*cautious *euphoric
9
Risk Factors for CVA
 Hypertension
 Diabetes mellitus, hypothyroidism
 Heart disease
 Nonvalvular atrial fibrillation
 Prosthetic heart valve
 Smoking
 Substance abuse
10
 Obesity
 Sedentary lifestyle
 Family history
 High stress levels
 Previous CVA or TIA
 Elevated cholesterol
 Heavy alcohol use
11
 Oral contraceptives
 Dehydration
 Polycythemia
 Carotid atherosclerosis
 Arterio-venous malformation
 Aneurysms
 Sickle cell anemia
12
Diagnostic Tests for CVA
 Carotid ultrasonography
 Cerebral angiography
 Positron Emission Tomography (PET)
 Magnetic Resonance Angiography
 Digital subtraction angiography
 ECG, Holter monitor
 EEG
13
Diagnostic Tests for CVA
 Echocardiogram
 CT scan
 Magnetic Resonance Imaging
 Functional MRI
 Diffusion/Perfusion MRI
 Noninvasive carotid studies
 Labs--PT, PTT, antiphospholipid
antibodies, glucose, lytes, CBC, ABGs
14
Computerized Axial Tomography--CT
Imaging
Scans successive layers of brain tissue
with x-ray beams
 Ischemic--hypo density is gray to

black
vs
 Hemorrhagic--high density lesion
is white
15
Ischemic Brain Attack Management
 Maintain airway--oxygenate
 Neuro assessment
 Treat with tPA (tissue plasminogen

activator) within 3 hours
16
 Correct hypoglycemia, watch for
hyperglycemia
 No free water IV fluids
 Raise serum osmolality to 310

mOs/L
17
Treat hypertension if > 180/100
Control seizures--diazepam, lorazepam,
phenytoin
Neuro protective agents--nimodipine
Maintain normal ICP & CPP
Anticoagulants
Antiplatelets
Carotid Endarterectomy
18
Treatment with tPA for Ischemic
Brain Attack
 Administer tissue plasminogen activator (tPA)
within 3 hours.
 Must do diagnostic CT first
 Determine eligibility
 Calculate dose: 0.9 mg./kg. Up to 90 mg. Loading

dose 10% over 1 min. Remainder over next hour.
19
Hemorrhagic Brain Attack
Management
 Interventions as with ischemic stroke

except for anticoagulation
 Neuro assessment
 Manage increased ICP & CPP
 Monitor VS carefully, esp. controlling
hypertension--danger of further bleed
20
Prevention of Stroke
Prevention of strokes caused by blood
clots:
Use warfarin (Coumadin) to thin blood
Aspirin
Plavix
Ticlid
Carotid endarterectomy
21
Acute Stroke Research
(UCLA Stroke Center)
 Use multiple clot-dissolving regimens
 Use of neuroprotective agents--drugs

that may protect brain cells against
toxic molecules release by necrotic
tissue
 Use of neuroperfusion trials--reverses

blood flow through cerebral veins
22
(UCLA & MGH)
Plan to enhance vessel

recanalization and patient
outcome by delivering tPA through
IV and intra-arterial lines
23
(UCLA)
 Interventional Neuroradiology Techniques:
Dr. Guglielmi developed GDC (Guglielmi

detachable coil)--used in treatment of
brain aneurysms.
This is used as alternative or supplement

to neurosurgery
24
(UCLA Stroke Center)
 1st center in randomized, controlled

trial of carotid & vertebral artery
angioplasty
 Planned angioplasty & stent procedure

(1999)
25
(University of Pittsburgh)
 Human nerve cell transplantation
*Patient is awake
*Inject neurons into damaged areas of
brain
*Takes few minutes to inject
*Map with computer
*4 patients done in 1998
26
Treatment Goals for Brain
Attack--2000
 Decrease to 5th leading cause of death
 Public call 911 within 15 minutes of

warning signs
 Neuroprotective drugs given in

ambulance
 In ED within 30 minutes of signs
27
Treatment Goals for Brain Attack--
2000
 Brain imaging to locate precise

blockage site
 Thrombolytics administered
directly to site of occlusion
28
Treatment Goals for Brain Attack--
2000
 Additional neuroprotective
medications given
 Computer imaging monitors

dissolving clot with arterial
reperfusion measurements
29

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Cerebrovascular Accident (Stroke, Brain Attack)

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Cerebrovascular Accident

(Stroke, Brain Attack)

 Sudden onset of focal neurologic deficit

 3rd leading cause of death

 Global aphasia, expressive &

 Hemiparesis or hemiplegia of face,

 Visual deficits--homonymous hemianopsia,

 Disoriented time, place, person.

 Quick anger, frustration

language *aphasia *impaired sense

memory *deficit *disoriented

vision *deficit right *spatial deficits

behavior *slow *impulsive

 Ischemic--hypo density is gray to

 Treat with tPA (tissue plasminogen

 No free water IV fluids

 Raise serum osmolality to 310

 Must do diagnostic CT first

 Calculate dose: 0.9 mg./kg. Up to 90 mg. Loading

 Interventions as with ischemic stroke

Use warfarin (Coumadin) to thin blood

 Use of neuroprotective agents--drugs

 Use of neuroperfusion trials--reverses

Plan to enhance vessel

 Interventional Neuroradiology Techniques:

Dr. Guglielmi developed GDC (Guglielmi

This is used as alternative or supplement

 1st center in randomized, controlled

 Planned angioplasty & stent procedure

 Human nerve cell transplantation

 Public call 911 within 15 minutes of

 Neuroprotective drugs given in

 In ED within 30 minutes of signs

 Brain imaging to locate precise

 Computer imaging monitors

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