Ischemic Stroke  Trouble speaking or understanding speech

 Visual disturbances
 An ischemic stroke is formerly known as  Difficulty walking, dizziness, or loss of balance or
cerebrovascular disease (stroke) or brain attack  a coordination
sudden loss of function resulting from disruption of  Sudden severe headache
the blood supply to part of the brain.
 It is divided by 5 different types based on the cause: Motor Loss
large artery thrombotic strokes (20%), small
penetrating artery thrombotic strokes (25%),  The most common motor dysfunction is hemiplegia
cardiogenic embolic strokes (20%), cryptogenic (paralysis of one side of the body, or part of it) caused
strokes (30%), and other (5%) by a lesion of the opposite side of the brain.
 Hemiparesis, or weakness of one side of the body, or
Etiology part of it, is another sign

 a blocked artery Communication Loss

Pathophysiology Stroke is the most common cause of aphasia (inability to

express oneself or to understand language). The following are
In an ischemic brain attack, there is disruption of the cerebral dysfunctions of language and communication:
blood flow due to obstruction of a blood vessel. This disruption
in blood flow initiates a complex series of cellular metabolic  Dysarthria (difficulty in speaking) or dysphasia
events referred to as the ischemic cascade (impaired speech), caused by paralysis of the
muscles responsible for producing speech
 Aphasia, which can be expressive aphasia (inability to
express oneself), receptive aphasia (inability to
understand language), or global (mixed) aphasia
 Apraxia (inability to perform a previously learned
action), as may be seen when a patient makes verbal
substitutions for desired syllables or words

Perceptual Disturbances

Visual–perceptual dysfunctions are caused by disturbances of

the primary sensory pathways between the eye and visual
cortex.

Homonymous hemianopsia (blindness in half of the visual field

in one or both eyes) may occur from stroke and may be
temporary or permanent. The affected side of vision
corresponds to the paralyzed side of the body

Sensory Loss

An agnosia is the loss of the ability to recognize objects

Clinical Manifestations through a particular sensory system; it may be visual, auditory,
or tactile.
The patient may present with any of the following signs or
symptoms: Cognitive Impairment and Psychological Effects

 Numbness or weakness of the face, arm, or leg,

especially on one side of the body
 Confusion or change in mental status
  If damage has occurred to the frontal lobe, learning educating patients and the community about
capacity, memory, or other higher cortical intellectual recognition and prevention of stroke.
functions may be impaired. Such dysfunction may be
reflected in a limited attention span. Medical Management
 Depression is common and may be exaggerated by Anticoagulants
the patient’s natural response to this catastrophic
event. Emotional lability, hostility, frustration,  dabigatran (Pradaxa), apixaban (Eliquis), edoxaban
resentment, lack of cooperation, and other (Savaysa), or rivaroxaban (Xarelto)
psychological problems may occur.
Platelet-inhibiting medications
Assessment and Diagnostic Findings
 aspirin, extended-release dipyridamole plus aspirin
Patients may present to the acute care facility with temporary (Aggrenox), and clopidogrel decrease the incidence
neurologic symptoms. of cerebral infarction in patients who have
experienced TIAs and stroke from suspected embolic
A transient ischemic attack (TIA) is a neurologic deficit typically or thrombotic causes
lasting 1 to 2 hours.
Thrombolytic Therapy
 A TIA is manifested by a sudden loss of motor,
sensory, or visual function. The symptoms result from  Thrombolytic agents are used to treat ischemic stroke
temporary ischemia (impairment of blood flow) to a by dissolving the blood clot that is blocking blood flow
specific region of the brain to the brain Intra-arterial delivery of t-PA is an
 The initial diagnostic test for a stroke is usually a alternative to IV administration.
noncontrast computed tomography (CT) scan  This type of administration can allow for higher
 A 12-lead electrocardiogram (ECG) and a carotid concentrations of the drug to be given directly to the
ultrasound are standard tests clot, and the time window for treatment may be
 Other studies may include CT angiography or CT extended up to 6 hours
perfusion; magnetic resonance imaging (MRI) and
magnetic resonance angiography of the brain and neck Endovascular Therapy
vessels; Enhancing Prompt Diagnosis
 transcranial Doppler flow studies; transthoracic or
transesophageal echocardiography; xenon-enhanced CT  Initial management requires the definitive diagnosis of
scan; and single-photon emission CT scan. an ischemic stroke by brain imaging and a careful
history to determine whether the patient meets the
Prevention criteria for t-PA therapy
 A healthy lifestyle including not smoking, engaging in Dosage and Administration
physical activity (at least 40 minutes a day, 3 to 4
days a week),  The patient is weighed to determine the dose of t-PA
 maintaining a healthy weight, and following a healthy  The dosage for t-PA is 0.9 mg/kg, with a maximum
diet (including modest alcohol consumption), can dose of 90 mg. Ten percent of the calculated dose is
reduce the risk of having a stroke given as an IV bolus over 1 minute. The remaining
 Dietary Approaches to Stop Hypertension (DASH) dose (90%) is given IV over 1 hour via an infusion
diet (high in fruits and vegetables, moderate in lowfat pump
dairy products, and low in animal protein), the
Mediterranean diet (supplemented with nuts), and Side Effects
overall diets that are rich in fruits and vegetables
 Once it is determined that the patient is a candidate
 Stroke risk screenings are an ideal opportunity to for t-PA therapy, no anticoagulant agents are given
lower stroke risk by identifying people or groups of for the next 24 hours
people who are at high risk for stroke and by
  Bleeding is the most common side effect of t-PA patients with occlusive disease of the extracranial
administration, and the patient is closely monitored for cerebral arteries
any bleeding  Carotid artery stenting (CAS), with or without
angioplasty, is a less invasive procedure that is used
Therapy for Patients with Ischemic Stroke Not for treatment of carotid stenosis
Receiving Tissue Plasminogen Activator
Management
 Not all patients are candidates for t-PA therapy
 Careful maintenance of cerebral hemodynamics to  It is important to maintain adequate blood pressure
maintain cerebral perfusion is extremely important levels in the immediate postoperative period
after a stroke  Close cardiac monitoring is necessary, because these
patients frequently have concomitant coronary artery
Other treatment measures include the following: disease.
 The nurse focuses on assessment of the following
 Providing supplemental oxygen if oxygen saturation is
cranial nerves: facial (VII), vagus (X), spinal
below 95%
accessory (XI), and hypoglossal (XII).
 Elevation of the head of the bed to 30 degrees to
 Management after carotid stenting also requires
assist the patient in handling oral secretions and
monitoring of neurologic status and evaluation for
decrease ICP
hematoma formation
 Possible hemicraniectomy for increased ICP from
 Cardiac monitoring is necessary with assessment for
brain edema in a very large stroke
bilateral pulses distal to the catheterization site
 Intubation with an endotracheal tube to establish a
patent airway, if necessary Hemorrhagic Stroke
 Continuous hemodynamic monitoring (the goals for
blood pressure remain controversial for a patient who They're caused by a weakened vessel that ruptures and
has not received thrombolytic therapy; bleeds into the surrounding brain. The blood accumulates and
antihypertensive treatment may be withheld unless compresses the surrounding brain tissue.
the systolic blood pressure exceeds 220 mm Hg or
the diastolic blood pressure exceeds 120 mm Hg.) The two types of hemorrhagic strokes are intracerebral (within
the brain) hemorrhage or subarachnoid hemorrhage.
 Frequent neurologic assessments to determine if the
stroke is evolving and if other acute complications are A hemorrhagic stroke occurs when a weakened blood vessel
developing (such complications may include seizures, ruptures. Two types of weakened blood vessels usually cause
bleeding from anticoagulation, or medication-induced hemorrhagic stroke: aneurysms and arteriovenous
bradycardia, which can result in hypotension and malformations (AVMs).
subsequent decreases in cardiac output and cerebral
perfusion pressure).  Another common cause of primary intracerebral
hemorrhage in the older adult is cerebral amyloid
Managing Potential Complications angiopathy (CAA), which involves damage caused by
the deposit of beta-amyloid protein in the small- and
 If cerebral blood flow is inadequate, the amount of
mediumsized blood vessels of the brain
oxygen supplied to the brain will decrease, and tissue
ischemia will result.  Secondary intracerebral hemorrhage is associated
with arteriovenous malformations (AVMs), intracranial
 The importance of adequate gas exchange in these
aneurysms,intracranial neoplasms, or certain
patients cannot be overemphasized, because many
medications
patients are at risk for aspiration pneumonia.

Surgical Prevention of Ischemic Stroke Pathophysiology

 A CEA is the removal of an atherosclerotic plaque or  Symptoms are produced when a primary
thrombus from the carotid artery to prevent stroke in hemorrhage, aneurysm, or AVM presses on nearby
cranial nerves or brain tissue or, more dramatically,
 when an aneurysm or AVM ruptures, causing  AVM is a common cause of hemorrhagic stroke in
subarachnoid hemorrhage (hemorrhage into the young people
cranial subarachnoid space).
 Normal brain metabolism is disrupted by the brain’s
exposure to blood;
 by an increase in ICP resulting from the sudden entry
of blood into the subarachnoid space, which Subarachnoid Hemorrhage
compresses and injures brain tissue; or by secondary
ischemia of the brain resulting from the reduced A subarachnoid hemorrhage (hemorrhage into the
perfusion pressure and vasospasm that frequently subarachnoid space) may occur as a result of an AVM,
accompany subarachnoid hemorrhage. intracranial aneurysm, trauma, or hypertension. The most
common causes are a leaking aneurysm in the area of the
Intracerebral Hemorrhage circle of Willis and a congenital AVM of the brain.

 An intracerebral hemorrhage, or bleeding into the Clinical Manifestations

brain tissue, is most ncommon in patients with
hypertension and cerebral atherosclerosis, because  The conscious patient most commonly reports a
degenerative changes from these diseases cause severe headache
rupture of the blood vessel.  Rupture of an aneurysm or AVM usually produces a
 may also result from certain types of arterial sudden, unusually severe headache and often loss of
pathology, brain tumors, and the use of medications consciousness for a variable period of time
(e.g.,oral anticoagulants, amphetamines, and illicit  There may be pain and rigidity of the back of the neck
drug use) (nuchal rigidity) and spine due to meningeal irritation.
 Bleeding in the outer cerebral lobes (lobar  Visual disturbances (visual loss, diplopia, ptosis)
hemorrhages) in those 75 or older can be related to occur if the aneurysm is adjacent to the oculomotor
CAA. Bleeding from CAA frequently is in the frontal nerve
and parietal lobes. Occasionally, the bleeding  Dizziness, and hemiparesis may also occur.
ruptures the wall of the lateral ventricle and causes  At times, an aneurysm or AVM leaks blood, leading to
intraventricular hemorrhage, which is associated with the formation of a clot that seals the site of rupture
poor outcomes and death  severe bleeding occurs, resulting in cerebral damage,
followed rapidly by coma and death.
Intracranial (Cerebral) Aneurysm
Assessment and Diagnostic Findings
 An intracranial (cerebral) aneurysm is a dilation of the
walls of a cerebral artery that develops as a result of  Any patient with suspected stroke should undergo a
weakness in the arterial wall. CT scan or MRI scan to determine the type of stroke,
 An aneurysm may be due to atherosclerosis, which the size and location of the hematoma, and the
results in a defect in the vessel wall with subsequent presence or absence of ventricular blood and
weakness of the wall; a congenital defect of the hydrocephalus
vessel wall; hypertensive vascular disease; head  Because hemorrhagic stroke is an emergency, CT
trauma; or advancing age scan is usually obtained first because it can be done
rapidly.
Arteriovenous Malformations  Cerebral angiography using the conventional method
or CT (CTA) confirms the diagnosis of an intracranial
 Most AVMs are caused by an abnormality in
aneurysm or AVM.
embryonal development that leads to a tangle of
 Lumbar puncture may be performed if there is no
arteries and veins in the brain that lacks a capillary
bed. evidence of increased ICP, the CT scan results are
negative, and subarachnoid hemorrhage must be
 The absence of a capillary bed leads to dilation of the
confirmed.
arteries and veins and eventual rupture.
Prevention transcranial Doppler ultrasonography or follow-up cerebral
angiography
 Control of hypertension can reduce the risk of
hemorrhagic stroke.  Vasospasm most frequently occurs 7 to 10 days after
 Additional risk factors are increased age, male initial hemorrhage when the clot undergoes lysis
gender, certain ethnicities (Latino, African American, (dissolution), and the chance of rebleeding is
and Japanese) and moderate or excessive alcohol increased.
intake.  It leads to increased vascular resistance, which
 Stroke risk screenings provide an ideal opportunity to impedes cerebral blood flow and causes brain
lower hemorrhagic stroke risk by identifying ischemia (delayed cerebral ischemia) and infarction.
individuals or groups at high risk and educating
patients and the community about recognition and The signs and symptoms reflect the areas of the brain
prevention. involved. Vasospasm is often heralded by a worsening
headache, a decrease in level of consciousness (confusion,
Complications lethargy, and disorientation), or a new focal neurologic deficit
(aphasia, hemiparesis).
Potential complications of hemorrhagic stroke include
rebleeding or hematoma expansion; cerebral vasospasm Management of vasospasm remains difficult and controversial.
resulting in cerebral ischemia; acute hydrocephalus, which It is believed that early surgery to clip the aneurysm prevents
results when free blood obstructs the reabsorption of re-bleeding and that removal of blood from the basal cisterns
cerebrospinal fluid (CSF) by the arachnoid villi; and seizures. around the major cerebral arteries may prevent vasospasm.

Cerebral Hypoxia and Decreased Blood Flow Medication may be effective in the treatment and prevention of
vasospasm. Based on the theory that vasospasm is caused by
 Providing adequate oxygenation of blood to the brain an increased influx of calcium into the cell, medication therapy
minimizes cerebral hypoxia. Brain function depends may be used either to or antagonize this action, or to prevent
on delivery of oxygen to the tissues. or reverse the action of vasospasm if already present.
 Administering supplemental oxygen and maintaining Nimodipine is the most studied calcium channel blocker for
the hemoglobin and hematocrit at acceptable levels prevention of vasospasm in subarachnoid hemorrhage.
will assist in maintaining tissue oxygenation.
 Cerebral blood flow depends on the blood pressure, Another therapy for vasospasm and the resulting delayed
cardiac output, and integrity of cerebral blood vessels. cerebral ischemia, referred to as triple-H therapy, is aimed at
 Adequate hydration (IV fluids) must be ensured to minimizing the deleterious effects of the associated cerebral
reduce blood viscosity and improve cerebral blood ischemia and includes
flow.
1. fluid volume expanders (hypervolemia),
 Extremes of hypertension or hypotension need to be 2. induced arterial hypertension, and
avoided to prevent changes in cerebral blood flow 3. hemodilution.
and the potential for extending the area of injury.
 A seizure can also compromise cerebral blood flow, However, current research and guidelines now endorse
resulting in further injury to the brain. euvolemia to prevent delayed cerebral ischemia and induced
 Observing for seizure activity and initiating arterial hypertension for treatment of delayed cerebral
appropriate treatment are important components of ischemia
care after a hemorrhagic stroke.
Increased Intracranial Pressure
Vasospasm
An increase in ICP can occur after either an ischemic or a
Of those with cerebral vasospasm, The mechanism hemorrhagic stroke but almost always follows a subarachnoid
responsible for vasospasm is not clear, but it is associated with hemorrhage, usually because of disturbed circulation of CSF
increasing amounts of blood in the subarachnoid cisterns and caused by blood in the basal cisterns.
cerebral fissures, as visualized by CT scan. Monitoring for
vasospasm may be performed through the use of bedside
Neurologic assessments are performed frequently, and if there The goals of medical treatment for hemorrhagic stroke are to
is evidence of deterioration from increased ICP (due to allow the brain to recover from the initial insult (bleeding), to
cerebral edema, herniation, hydrocephalus, or vasospasm), prevent or minimize the risk of re-bleeding, and to prevent or
CSF drainage may be instituted by ventricular catheter treat complications.
drainage
Management may consist of bed rest with sedation to prevent
Mannitol may be given to reduce ICP. When mannitol is used agitation and stress, management of vasospasm, and surgical
as a long-term measure to control ICP, dehydration and or medical treatment to prevent rebleeding.
disturbances in electrolyte balance (hyponatremia or
hypernatremia; hypokalemia or hyperkalemia) may occur.  If the bleeding is caused by anticoagulation with
warfarin, the INR may be corrected with fresh-frozen
Mannitol pulls water out of the brain tissue by osmosis and plasma and vitamin K.
reduces total body water through diuresis. The patient’s fluid  Reversing the anticoagulation effect of the new oral
balance is monitored continuously and is assessed for signs of anticoagulants is more complicated.
dehydration and for rebound elevation of ICP.  Protocols may include hemodialysis, the use of oral
activated charcoal, administration of prothrombin
 Other interventions may include elevating the head of
complex concentrates, or administration of
the bed to 30 degrees, avoidance of hyperglycemia
recombinant activated factor VII
and hypoglycemia, sedation, and use of hypertonic
 Idarucizumab (Praxbind) is a medication that was
saline in a variety of concentrations
recently approved for reversing dabigatran (Pradaxa).
Hypertension If seizures occur, they are treated with anticonvulsant
drugs such as phenytoin (Dilantin).
Hypertension is the most common cause of intracerebral  Hyperglycemia should also be treated, and
hemorrhage, and its treatment is critical. hypoglycemia is avoided.

Specific goals for blood pressure management, which are Intermittent pneumatic compression devices should be used
individualized for each patient, remain controversial. starting on the first day of the hospital admission to prevent
DVT.
 Blood pressure goals may depend on the presence of
increased ICP.  If the patient is not mobile after 1 to 4 days from the
 Recently published guidelines for management of onset of the hemorrhage and there is documentation
intracerebral hemorrhage recommend early blood of the bleeding ceasing, then DVT prevention
pressure lowering (if the systolic blood pressure is medications
between 150 and 220 mm Hg) to a goal systolic of  (low–molecular-weight heparin or unfractionated heparin)
140 mm Hg, and report that lowering blood pressure may be prescribed. Analgesic agents may be prescribed
can be effective for improving patient outcomes. for head and neck pain.
 If systolic blood pressure is above 220 mm Hg, IV  Fever should be treated with acetaminophen (Tylenol),
continuous infusions of antihypertensives may be iced saline boluses, and devices such as cooling blankets.
prescribed Nicardipine (Cardene) is one agent that After discharge, most patients will require antihypertensive
may be used as a continuous IV infusion. medications to decrease their risk of another intracerebral
hemorrhage.
Labetalol (Trandate) and hydralazine (Apresoline) are other
examples of medications that may be given as an IV bolus. Surgical Management
During the administration of antihypertensive agents,
hemodynamic monitoring is important to detect and avoid a In many cases, a primary intracerebral hemorrhage is not
precipitous drop in blood pressure, which can produce brain treated surgically. However, if the patient is showing signs of
ischemia. Stool softeners are used to prevent straining, which worsening neurologic examination, increased ICP, or signs of
can elevate the blood pressure. brainstem compression, then surgical evacuation is
recommended for the patient with a cerebellar hemorrhage
Medical Management
The patient with an intracranial aneurysm is prepared for
surgical intervention as soon as their condition is considered
stable.

Surgical treatment of the patient with an unruptured aneurysm

is an option.

 The goal of surgery is to prevent bleeding in an

unruptured aneurysm or further bleeding in an already
ruptured aneurysm.
 This objective is accomplished by isolating the
aneurysm from its circulation or by strengthening the
arterial wall. An aneurysm may be excluded from the
cerebral circulation by means of a ligature or a clip
across its neck.
 If this is not anatomically possible, the aneurysm can
be reinforced by wrapping it with some substance to
provide support and induce scarring.
 Advances in technology have led to the introduction
of interventional neuroradiology for the treatment of
aneurysms.
 These techniques are now being used more
frequently.
 Endovascular techniques may be used in selected
patients to occlude the blood flow from the artery that
feeds the aneurysm with coils, liquid embolic agents,
or other techniques to occlude the aneurysm itself.
 If the aneurysm is very large or very wide at its neck,
a stent-like device made of a very fine mesh may be
used to divert the blood flow away from the
aneurysm.
 The determination of which technique should be used
is based on many factors (characteristics of the
patient and aneurysm) and is made by experienced
endovascular specialists

Postoperative complications are rare but can occur. Potential

complications include psychological symptoms (disorientation,
amnesia, Korsakoff syndrome [disorder characterized by psychosis,
disorientation, delirium, insomnia, hallucinations, personality
changes]), intraoperative embolization or artery rupture,
postoperative artery occlusion, fluid and electrolyte disturbances
(from dysfunction of the neurohypophyseal system), and
gastrointestinal bleeding.