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Ischemic ▪85 – 90% of strokes ▪Can be subdivided into embolic or thrombotic Hemorrhagic ▪10-15% of strokes

Thrombotic

1. atherosclerotic plaque formation

2. occludes cerebral vessels

3. ischemia and infarction of tissues

supplied by vessels

Embolic

1. formation of a thrombus

2. most often originate in heart

Weakened vessel ruptures and bleeds into surrounding brain tissue

Two types

1. intracerebral

2. subarachnoid

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Smoking

Hypertension

Diabetes

Atrial fibrillation

Age

Gender

Ethnicity

Heredity

Abuse of amphetamines, cocaine

Inactivity

Previous TIA or stroke

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Sudden numbness or weakness of the face, arm or leg

Sudden confusion or trouble speaking or understanding speech

Sudden trouble seeing from one or both eyes

Sudden trouble walking, dizziness or loss of balance or coordination

Sudden severe headache with no known cause

If you notice any of these signs and

symptoms, call 911

Make note of the time the signs and

symptoms began

ACT F - A - S - T

Rapid recognition of the signs and symptoms of stroke

Rapid activation of EMS

Rapid EMS transport and notifying the hospital ahead of time

Rapid start of pre-hospital care during EMS transport

Rapid diagnosis and treatment at the hospital

Right Gaze Preference

Left Hemiparesis

Left Hemisensory Loss

Left Hemi-inattention (Neglect)

Left Visual Field Deficit

Due to pathology

– if right

hemisphere

stroke (left

muscles become

paralyzed)– so

only muscles

working are the

right.

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Aphasia

Left Gaze Preference

Right Hemiparesis

Right Hemisensory Loss

Right Visual Field Deficit

Hemiparesis: weakness or partial paralysis

Hemiplegia: paralysis

Due to pathology

– if left

hemisphere

stroke (right

muscles become

paralyzed)– so

only muscles

working are the

left.

Cerebellar strokes cause unilateral or bilateral upper or lower extremity incoordination May be accompanied by dizziness and nausea Brainstem strokes cause generalized weakness, disconjugate eye movements,dizziness, nausea and vomiting

Ipsilateral (same side) Limb Ataxia (dyscoordination)

Truncal or Gait

Ataxia (imbalance) Tremors, or Limb Ataxia, result from

lack of coordination of opposing muscle groups

(flexors vs. extensors), causing the muscle groups to

fight each other

Quadriparesis

Sensory Loss in

All 4 Limbs

“Locked In

Syndrome”

Cranial Nerve

Signs

Crossed Signs

(1 side of face and

contralateral body)

Hemiparesis

Hemisensory Loss

Oropharyngeal Weakness:

Dysarthria (speaking), Dysphagia (swallowing)

Eye Movement Abnormalities:

Diplopia

Dysconjugate Gaze

Gaze Palsy (horizontal gaze deficit or gaze

preference)

Decreased LOC

Nausea, Vomiting

Hiccups, Abnormal Respirations

Vertigo, Tinnitus

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Assessment of airway, breathing and circulation is a priority

Focused neuro assessment including the NIHSS

Time last known well Brief medical history/physical

assessment Diagnostic testing such as CT scan or

MRI Treatment with fibrinolytic therapy, if

eligible

Conscious cranial nerve assessment 11 item exam – perform in 7 minutes Focused on focal/neuro deficits Valid, reliable tool. Standardized training Moves from easy to most difficult Score is based on first attempt Easy to communicate to other clinicians

Level of Consciousness (1a, 1b, 1c) Visual (2, 3) Motor (4, 5a, 5b, 6a, 6b) Cerebellar (7) Language (9, 10) Inattention (neglect) (11)

Bonus Cranial Nerves – Optic (II), Oculomotor (III), Abducens (VI), Facial (VII)

Limited ability to assess the posterior circulation

Limited cognitive measurement

Left hemisphere infarcts are over-scored due to language deficits

0 = normal exam, no neurological deficits

>15-20 = indicates a more severe stroke

42 = maximum score, the higher the score the more severe the stroke

Level of consciousness

a. alert, drowsy, stuporous, coma

b. 2 questions – age, month

c. 2 commands

Best Gaze – eyeballs must cross midline

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Visual Fields

▪4 fields in each eye

▪No visual loss, partial hemianopia,

complete or bilateral hemianopia

Facial palsy

▪tests the mouth, teeth and eyebrows for

symmetrical movement

Motor Arm

Checks both arms for drift and effort

Motor Leg

▪extends leg to test for strength,

effort against gravity, in supine

position

Ataxia

▪finger to nose, heel to shin for any

presence of ataxia

Sensory

▪checking for the presence of

sensations on body parts (sharp

and dull)

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Best Language

1.checking for fluency, recall, and

reading ability using a picture

2.identifying objects in picture

3.reading sentences

Dysarthria

1.articulation of speech

2.repeating words

Best Language

–You know how. –Down to earth.

–I got home from work.

–Near the table in the dining room.

–They heard him speak on the radio last

night

Dysarthria

–Mama –Tip-Top

–Fifty-Fifty –Thanks

–Huckleberry –Baseball Player

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Extinction and Inattention

▪neglect, not understanding or

realizing body part or system does

not work

Restore blood flow to the brain by:

removing the clot

dissolving the clot

disrupting the blockage that is occurring in one or more vessels in the brain

Clot-dissolving medications Anticoagulants

Antiplatelet medications

Endovascular treatment recommended for some patients with ischemic stroke

Endovascular surgery- minimally invasive method of treating disease by accessing the blood vessels of the brain and other areas of the body.

Several methods are available including MERCI retriever and Penumbra System

First interventional device cleared by FDA for acute ischemic stroke patients – 8/2004

Performed in over 500 U.S. hospitals

Over 9,000 patients have been treated world-wide

Used in the larger vessels of the brain

Tiny corkscrew-shaped device

Works by wrapping around clot and trapping it

Clot is then retrieved and removed from the body

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MERCI Retriever

FDA Approval in 2007

Breaks up the clot and aspirates the fragments

Designed to remove thrombus or emboli within a large vessel

3 Parts : reperfusion catheter, separator and thrombus-removal ring

FDA Approved 2008

Medical treatment

▪treatment depends on cause of

bleeding

Surgical treatment

▪surgical clipping

▪endovascular coiling

May be used when caused by ruptured aneurysm in the subarachnoid space

Also used to keep aneurysms from rupturing

Must be done with craniotomy

Blood flow to aneurysm is blocked by applying a metal clip to the base where it connects to the blood vessel

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Newer, much less invasive technique

Used to treat certain types of aneurysms

Involves catheter being inserted in femoral artery and navigated through vascular system into the head and into the aneurysm

Tiny platinum coil is threaded through the catheter and deployed into the aneurysm

Keep HOB elevated 30 degrees to reduce ICP

Assess for swallowing dysfunction

Avoid hyperglycemia in all stroke patients

Early mobilization

Skin care

VTE prophylaxis

Definition: neoplasms associated with neural, neuroglial, meningeal or vascular tissue in the brain

Classification

1. primary vs. metastic

2. intra-axial vs. extra-axial

3. malignant vs. benign

Clinical manifestations

1. headache

2. weakness

3. clumsiness

4. difficulty walking

5. seizures

6. alterations in sensation/motor

function

Acquired autoimmune disease

Characterized by weakness of

skeletal muscles and fatigability

Two peaks of onset

1. early : 20-30 years, women more

than men

2. late : after age 50, men more than

women

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Clinical manifestations

1. muscle weakness

a. increase with sustained muscle

contraction

b. least in morning, worst in evening and after exertion

c. usually greater in upper than lower limbs

Progressive degenerative disease

Commonly characterized by relapses and remissions

Affects more than 400,000 people in

the U.S. in early to middle adulthood

Women twice as often as men

Diagnostic methods

1. Neurologic exam

2. MRI

3. MTI

4. VEP

5. cerebrospinal fluid analysis

6. EEG

Treatment

1. Corticosteroids

2. Use of disease-modifying

treatments to reduce progression

a. interferons

3. Regular exercise

Progressive, degenerative disease

Eventually fatal because of respiratory

muscle weakness

Slightly more common in men than

women

Can be familial or sporadic

Goals of treatment: supportive; no

known cure

Potential complications include:

1. pneumonia/respiratory failure

2. urosepsis

3. immobility-related problems

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Syndrome involving degeneration of

dopamine neurons in midbrain

One of most common neurologic

disorders

Average age of onset: 60 years

1.5 times more common in men

Believed to be caused by combination

of genetic and environmental factors

4 cardinal signs

1. tremor

2. muscle rigidity

3. dyskinesia

4. postural instability

Other clinical manifestations include mood disturbances, fatigue, sleep

disturbances, dementia in 15-30%

Acquired, chronic, progressive,

degenerative disease of CNS

Results in profound cognitive,

intellectual and behavioral impairment

Affects 1 in 8 individuals over age 65

Every 70 seconds in the U.S., someone

develops the disease

Can be classified into 2 types

1. familial (early onset)

2. sporadic (late onset)

3 stages

1. early stage

2. intermediate stage

3. late stage

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