Stroke

Presentation

• Weakness
  
• Sudden or gradual loss of movement of extremities on one side
  
• Difficulty forming words
  
• Difficulty swallowing
• Nausea, vomiting
• History of TIAs

Definition

• An interruption in blood flow to the brain that results in the death of brain cells and can have consequences for movement, sensation or emotions

Stroke Types

• Ischemic
  • is the result of an embolism or thrombosis
    
• Hemorrhagic
  • is the rupturing of a cerebral vessel, causing bleeding into the brain tissue

Pathophysiology

• Blood flow reduced or interrupted, which leads to interruption of nerve impulses down corticospinal tract, leading to decreased or absent voluntary movement on one side of the body (fine movements are more affected than coarse movements), leads to later autonomous reflex activity, leading to spasticity and rigidity of muscles

Risk Factors

• hypertension (modifiable)
• prior ischemic episodes (TIA)
• cardiovascular disease/atrial fibrillation
• oral contraceptives
• emotional stress
• family history
• advancing age
• diabetes mellitus
• obesity

Risk

• African American, related to increased rates of hypertension, diabetes mellitus, and sickle cell anemia
  
• Related to higher incidence of smoking and obesity
  
• Native American, Hispanic, and Asian Americans also have a higher incidence than whites

Modifiable Risk Factors

• hypertension
  
• heart disease
  
• excessive ETOH consumption
  
• obesity
  
• sleep apnea
  
• metabolic syndrome
  
• lack of physical exercise
  
• poor diet and drug abuse
  
• smoking
  
• high cholesterol
  
• use of high dose oral contraceptives

Labs

• CBC including platelets
• PTT, aPTT
• electrolytes
• BG, renal and hepatic studies
• lipid profile
• CSF analysis

Diagnoses

• CT w/o contrast
  
• CTA
  
• MRI
  
• MRA

Ischemic Stroke Treatment

• Antiplatelet (Aspirin)
  • within 24-48 hours after the onset of an ischemic stroke
  • Antiplatelet (Toclopidine, Plavix/clopidogrel, dipyridamole (Persantine), Aggrenox)
• Statins
  • simvastatin, lovastatin
• tPA
  • can only be administered within 3-4.5 hours of onset of signs of clinical ischemic stroke
  • need for inserting a catheter, NG tube, multiple IVs before tPA can be administered, monitoring V/S and neuros while tPA administered,
  • BP followed closely up to 24 hours after administration

Airway/Breathing

• maintenance of airway r/t decreased LOC
  
• absent gag/swallow reflex
  
• maintaining adequate oxygenation
  
• avoiding hypoxia and hypercarbia
  
• realize need for O2
  
• intubation
  
• mechanical ventilation might be required