cerebrovascular accidents cme 2007
TRANSCRIPT
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Types of CVA’s
IschemicSubarachnoid hemorrhageIntracerebral Hemorrhage
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Ischemic CVA
Thrombotic – clot forms in diseased or damaged artery
Embolic- clot travels from distant location, often the heart with atrial fibrillation
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Brain Ischemia
Blood flow to a portion of brain is interrupted and can result in tissue death.
Area of damage often localized with specific pattern of symptoms.
Cerebral edema can result from iscemia and increase ICP.
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Intracerebral Hemorrhage
Diseased blood vessel bursts and bleeding occurs into brain tissue
Increasing pressure causes damage to surrounding tissue
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Subarachnoid Hemorrhage
“Berry” aneurysm bursts, bleeding occurs between brain surface and cranium
Rapid build up of pressure can cause unconsciousness or death
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Risk Factors
Atrial fibrillation Anticoagulants
HypertensionHigh cholesterolDiabetesAlcohol abuseSmokingRaceFamily history
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Signs & Symptoms
It can be difficult to clinically determine the type of stroke.
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Signs and symptoms can include
Confusion
Loss of consciousness
Aphasia
Dizziness or loss of balance
Signs are related to part of brain that is affected and can vary with each patient
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Signs can be unilateral
Weakness or paralysis
Numbness Unequal pupils Facial droop
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Eyes often provide clues
Unequal pupils
Impaired vision
Extraocular movements
Pinpoint pupils
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Signs that may indicate a bleed
Headache
Nausea/vomiting
Progressive onset
Hypertension
Pt takes anticoagulants
History of recent stroke
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Signs that favor a clot
Sudden onsetComplaints localized to one limbHistory of Atrial FibrillationHistory of TIA
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It is important to recognize the signs of a stroke
And to note the time of their onset.
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It is important to know the time of onset of stroke symptoms because
If treatment for embolic strokes using a thrombolytic (clot breaking) medication is appropriate it must be started within three hours.
The sooner these are given, the better.Patients should be transported to a Stroke
Center immediately.
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Other diagnostic tools
MRI – can provide more detailed image Cerebral angiography-used to image the
blood vessels of the brain
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Don’t forget the “basics”
AirwayBreathingCirculation (blood pressure and pulse)
Blood glucose (hypoglycemia can often appear like a stroke)
Drugs and alcohol can too.
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CPP=MAP - ICPIf the intercranial pressure is high
a high blood pressure is necessary to perfuse the brain.
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History and physical key points
carotid bruits Sensation and motor
function in each extremity (grasp, flexor, extensor)
Pupils and ocular movement
Gait (if possible) Mental status
EKG SpO2 ABG’s ICP monitor Glucose I/O Labs: INR, CBC, Plt
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Treatment considerations
Dilantin Vitamin K / FFP Blood pressure
control
Heparin Aspirin?
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Diagnostics
The cause of a CVA is usually determined by head CT
Note the positive “arrow” sign
Hypoperfused region is dark
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Thrombolytics
Treatment for embolic strokestPA tissue plasminogen activator dissolves
fibrin clotsHas potential to prevent permanent brain
iscemiaCan cause catastrophic hemorrhage in
some patients
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Thrombolytic check list
INCLUSION criteria (must all be
YES) Age 18 years or older ___ Time of onset well established to be
less than 3 hours ___ Clinical diagnosis of ischemic stroke
causing a ___ measurable neurological deficit CT without hemorrhage ___ Risks/benefits: Discussed and
documented in chart ___ EXCLUSION criteria (must all be
NO) SBP>185 or DBP>110 despite simple
measures ___ Symptoms rapidly improving or minor
symptoms (NIHSS = 0) ___
Coma or severe obtundation ___ Seizure at onset ___ Symptoms of subarachnoid hemorrhage
___ Stroke or head trauma within 3 months
___ Major surgery within 14 days ___ History of intracranial hemorrhage ___ GI hemorrhage or urinary tract
hemorrhage within 21 days ___ Arterial puncture at a noncompressible
site or LP within 7 days ___ Recent MI complicated by pericarditis
___ Patients receiving heparin within 48hrs
and with an elevated PTT ___ PT greater than 15 (»INR > 1.7) ___ Platelet count < 100,000 ___ Glucose below 50 or above 400 ___ Pregnant (Note: menstruation is NOT a
contraindication) ___
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Treatment for hemorrhagic strokes
Surgically clipping a berry aneurysm
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Coil placed in aneurysm
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Stent placed in
Vertebral artery.
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