Assessment and Care of the Stroke Patient

Megan McHugh, MS, RN, CCRN, CNRN

Stroke Coordinator

MedStar Georgetown University Hospital

Goals:

• What is Stroke?

• Stroke Statistics

• Types of stroke

• Imaging Basics

• Cerebrovascular correlations

• Common deficits

• Hyperacute stroke care/tPA

• Acute stroke care

• Deficits

What is Stroke?

Abrupt and dramatic development of a focal neurologic deficit caused by an occlusion or

hemorrhage of a vessel feeding the brain

Stroke Statistics

• Incidence • 795,000 new cases annually in the United States

• 610,000 are first strokes

• 185,000 are recurrent strokes

• 4th leading cause of death

• Prevalance • Symptomatic Stroke

• Men – 2.7% >= 18 years, 3.8% of black men

• Women – 2.5% >= 18 years have had a stroke

• Silent Stroke increases with age

• Age 55-64 11%

• Age 85+ 43%

Stroke Statistics

• Mortality • 5.5% of all deaths in the US.

• 12.6% off all stroke patients die within 30 days

• 8.1% of ischemic stroke patients

• 44.6% of hemorrhagic stroke patients

• Disability • Survivors:

• 15-30% totally disabled

• 20% institutionalized at 3 months

• Only 50-70% regain functional independence

• Expense • Direct medical cost of stroke in 2007 was $25 billion

• Direct and indirect cost in 2007 $41 billion

• Individual lifetime cost $140,000

Transient Ischemic Attack

(TIA) Definition

• Acute, neurological event that reduces blood flow to a portion of the brain

• Symptoms correlate with the region of the brain affected

• Two definitions: Time vs. Tissue • Time: Temporary weakness/numbness or visual

changes caused by vascular disease that resolves within 24 hours

• Tissue: No permanent damage, e.g. resolved symptoms with normal MRI

• One third of patients whose symptoms resolve have MRI scans positive for an acute stroke!!!

TIA Statistics

• 15% of all strokes heralded by TIA

• Risk of stroke

• Within 2 days: 3-10%

• Within 90 days: 9-17% (one study showed 20%)

• Death within one year: 12-13%

Classification of Strokes

Stroke

Ischemic 87%

Thrombotic

Large vessel 20%

Small vessel (lacunar) 25% Embolic

20%

Cryptogenic 30%

Hemorrhagic 13%

ICH 10%

SAH 3%

Stroke Recognition

• Sudden:

• Weakness or numbness

• Trouble speaking or understanding

• Trouble seeing in one or both eyes

• Trouble walking, loss of balance or coordination

• Severe headache

Ischemic Stroke

How a clot forms

Courtesy Genetech

Infarct versus Penumbra

Penumbra

Infarct

Stages of Infarction (R MCA)

Lacunar stroke

Hemorrhagic Stroke

• 15-20%

• Intracerebral

Within the brain

parenchyma

• Subarachnoid

• Aneurysm

• Vascular malformations

Subarachnoid Hemorrhage

Types of Stroke: Summary

• Clots can form in an artery or travel from someplace else

• Blood vessels that burst inside the brain tissue cause intracerebral hemorrhages

• Blood vessels that burst in the subarachnoid space cause subarachoid hemorrhage

• Clots in the venous drainage system can lead to either type of stroke

Anatomy: Lobes of the Brain

Anatomy: Homunculus

Imaging 101

• MRI and CT are looking from the bottom up

• The left side of the image is the right side of the brain

• The right side of the image is the left side of the brain

Imaging basics: CT

• Best for showing acute blood

• Normal for 12-24 hours post stroke

• Important: CT read as “negative for acute stroke” that was done less than 24 hours after last normal does NOT mean they didn’t have a stroke!

Imaging Basics: MRI

• DWI (Diffusion weighted image) positive in seconds, stays positive for about two weeks.

• Areas of restricted diffusion, e.g. ischemia are bright (“light-bulb”)

• Flair (Fluid Attenuated Inversion Recovery) is positive in 6-12 hours, lasts forever

• Ischemia is bright, fluid is dark.

Imaging Basics: Illustration

CT Day 1 CT day 5 MRI diffusion day 1

Blood Supply of the Brain

Arterial supply

Blood Supply of the Brain

• Three come in: Basilar (Vertebrobasilar) formed from L and R vertebral

L & R Internal carotids

• Circle of Willis (the “beltway”)

• Six go out (three per side): ACA – anterior cerebral artery

MCA – middle cerebral artery

PCA – posterior cerebral artery

Incoming

B

C C

Circle of Willis

Outgoing

M M

ACOM

PCOM PCOM

95 North

270

Rt. 66

95 South

Rt. 4

Rt. 50

Complete

M M

ACOM

PCOM PCOM

C C

B

Circle of Willis

Cerebrovascular Anatomy

PCA PCA

MCA MCA

ACA ACA

PCOM PCOM

ACOM

Vascular Territories

ACA

PCA

MCA MCA

Examples

•Occlusion: •ACA

•collateral circulation •MCA •PCA •Carotid •Basilar

•PICA

ACA Occlusion

M M

ACOM

PCOM PCOM

C C

B

270

66

ACA Occlusion

Symptoms, by Vessel Insufficiency: ACA

• Personality change

• Confusion

• Incontinence

• Leg weakness greater than arm weakness

• Difficulty tracking

• Motor/sensory changes on opposite side of body

MCA Occlusion

M M

ACOM

PCOM PCOM

C C

B

Right MCA occlusion

MRI Day 2

L MCA Completed Infarct

CT Day 1 CT Day 5

Symptoms, by Vessel Insufficiency: MCA

• Middle cerebral artery

Motor/sensory changes on opposite side of body

Arm weakness greater than leg weakness

Same side visual changes

Left—speech

Right—knowing where body parts are

PCA Occlusion

M M

ACOM

PCOM PCOM

C C

B

PCA Occlusion

Symptoms, by Vessel Insufficiency: PCA

Opposite-side sensory loss

Same-side vision loss

Left—communication

Right—knowing where body parts are

Graying of vision

R Carotid Occlusion

M M

ACOM

PCOM PCOM

C C

B

R Carotid Occlusion

MRI

Symptoms, by Vessel Insufficiency

• Carotid artery

Opposite motor/sensory loss

Amaurosis fugax (fleeting blindness)

Right—knowing where body parts are

Left—speech

R Basilar Occlusion

M M

ACOM

PCOM PCOM

C C

B

PICA Occlusion

• Largest branch off vertebral

• One of the three main arterial supplies for the cerebellum

• Other two are SCA and AICA

QuickTime™ and a decompressor

are needed to see this picture.

Quic kTime™ and a decompress or

are needed to see th is p ic ture.

Dizziness

Nausea and vomiting

Ataxia

Dysarthria

Dysphagia

Eye movement

Facial weakness

Hearing loss

Symptoms, by Vessel Insufficiency: Vertebrobasilar

Clinical Presentation: Summary

• Determined by region of vascular insufficiency

Clinical Presentation: Right Hemisphere

Neglect—body part or loss of function not acknowledged

Flat or bland affect

Apraxia—partial or complete inability to execute purposeful movement

Left hemiplegia/hemisensory loss

Speech changes—expressive, receptive, global aphasia

Right hemiplegia/hemisensory loss

Clinical Presentation: Left Hemisphere

• Brain stem

Hemiplegia/quadriparesis

Loss of sensory in ½ of body or all four limbs

Dysarthria

Dysphagia

Ataxia

Nausea and vomiting

Cranial nerve changes

Clinical Presentation: Brain Stem

Stroke Treatments: Ischemic

•Geared towards the cause:

•Ischemic: •Dissolve the clot (tPA) • <3 hours (FDA)

• <4.5 hours (ECASS 3 trial, AHA)

•Retrieve the clot

•Manipulate blood pressure

•Remove the clot/plaque surgically (CEA)

•HOB flat, SBP up to 220 mmHg • to increase perfusion to penumbra

• SBP < 185 mmHg for tPA

Stroke Treatment: Hemorrhagic

• Intracerebral hemorrhage

• Subarachnoid hemorrhage

• Main differences

• BP parameters

• HOB flat or elevated

• No antithrombotics or anticoagulation

• Coagulopathy

Stroke Treatments

• Blood pressure manipulation • Can be elevated to keep vessels open

• Can be lowered to prevent more bleeding

• Brain perfusion manipulation • HOB flat increases perfusion

• HOB elevated increases drainage and lowers ICP

Signs and symptoms reveal location:

• Sudden weakness or numbness

• Sudden loss of vision

• Sudden difficulty speaking or understanding

• Sudden dizziness or loss of balance

• Sudden severe headache

“Sudden” is the key!

Common Deficits

• Aphasia

Expressive aphasia – can understand what you are saying but cannot get the right words out, speaking gibberish, or mute

Receptive aphasia – cannot understand what is being said to them; likened to being in a foreign country where you don’t know the language

Can have both expressive and receptive aphasia

Give pt time to try to communicate – remember they may be very frustrated

Common Deficits

• Swallowing difficulties

May silently aspirate, without even a cough

Common cause of increased mortality

Swallow screen by the nurse and full evaluation help identify these patients so that we can feed safely and reduce risk.

Well-meaning family need education about aspiration pneumonia so they understand why we may delay starting feedings

Aspiration precautions for all: Sit up 90 degrees to feed, small spoonfuls, correct consistency, don’t rush, stop if coughing

Common Deficits

• Hemiplegia

Most often one side of the face/arm/leg weak or flaccid

Can easily dislocate a shoulder if you pull on it repositioning the patient; often develop shoulder pain even without overt injury

Prop weak arm up on a pillow, hand above heart to reduce dependent edema

Common Deficits

• Neglect

Pt may be unaware of the weak side of the body

May not look towards that side, may not see that side

May not know that there is a problem, so they try to get out of bed and fall

Pay attention to the patient – try to feed them and address them from the bad side to help in recuperation

Care goals:

• Prevent secondary injury/ infections • Prevent pressure ulcers by frequent

repositioning • Prevent edema by elevating flaccid

extremities on pillows • Prevent aspiration pneumonia by swallow

screens, aspiration precautions • Prevent contracture by doing range of motion

exercise every shift in weak limbs • Prevent falls: patients with symptoms of

neglect/ visual cuts are at very high risk

Remember the Basics

• Infection

• DVT

• Pneumonia

• Bowel/bladder care

• Constipation

• Incontinence

Remember the Basics

• Mobility

• Falls

• contractures

• Skin care

• Avoid breakdown

• Detect dysphagia

• Swallow assessment

• Nutritional compromise

Complications of Stroke

Summary

• Care is the KEY to RECOVERY

• Symptoms determined by vessel(s) affected

• In-hospital care is only the beginning

• Rehab and improvement continue for many months

References Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the Brain Attack Coalition (2010). Stroke (41) 2402-2448. Retrieved from http://stroke.ahajournals.org

Heart Disease and Stroke Statistics 2011 Update: A Report from the American Heart Association. Retrieved from http://circ.ahajournals.org

Expansion of the Time Window for Treatment of Acute Ischemic stroke with Intraveious Tissue Plasminogen Activator: A science advisory from the American Heart Association/ American Stroke Association (2009)

Comprehensive Overview of Nursingand Interdisciplinary Care of the Acute Ischemic Stroke Patient: A scientific statement from the American Heart Association (2009)