Nursing Care of Clients with

Cerebrovascular Accident (CVA)

Prepared by: Mr. Erwin U.Imperio, RN
 Anatomy of the Brain
Illustrations of the brain and how it is
affected by stroke.
Contents:
– Major Anatomical Areas of the Brain
– Layers of the Cerebrum
– Control Centers of the Brain
– Cerebellum and Brain Stem
• The manifestations of
stroke depends on
which region and the
extent of brain
affected.
Major Anatomical Areas of the Brain
1. Cerebrum (largest part) - responsible for several higher functions, including higher
intellectual function, speech, emotion, integration of sensory stimuli of all types, initiation of
the final common pathways for movement, and fine control of movement.
a. Consists of two hemispheres:
Left: controls the majority of functions on the right side of the body
Right: controls the majority of functions on the left side of the body
Note: Left hemisphere stroke will be more likely to produce aphasia and
other language deficits
b. Composed of pairs of different lobes:
1. Frontal
2. Parietal
3. Temporal
4. Occipital
2. Cerebellum (second largest) - responsible for maintaining balance and further control of
movement and coordination.
3. Brain Stem (final pathway) - responsible for a variety of autonomic functions
Note:
a. Crossing of nerve fibers takes place in the brain stem, particularly medulla oblongata
b. Strokes in these area can be serious or even fatal, people who survive may left with
severe impairments or remain in a vegetative state
Control Centers of the Brain
 Layers of the Cerebrum
Gray matter ( contains the centers of cognition and personality and the
coordination of complicated movements )

White matter ( a network of fibers that enables regions of the brain to

communicate with each other )
 Blood Vessels of the Brain
The blood vessels of the brain and how they are
affected by stroke.
Contents:
- Major Blood Vessels of the Brain
- Circle of Willis
- Anterior Cerebral Artery
- Middle Cerebral Artery
- Posterior Cerebral Artery
- Lenticulostriate Arteries
Major Blood Vessels
 Major Blood Vessels
• Normal function of the brain's control
centers is dependent upon adequate
supply of oxygen and nutrients through a
dense network of blood vessels.
• Blood is supplied to the brain, face, and
scalp via two major sets of vessels:
a. Right and Left Common Carotid Arteries
b. Right and Left Vertebral Arteries
Major Blood Vessels
Common Carotid Artery Vertebrobasilar Artery
- supplies the posterior two-fifths of the
External cerebrum, part of the cerebellum, and the
brain stem.
Internal
- supply blood to the anterior three-fifths of • Stroke in the vertebrobasilar artery
cerebrum, except for parts of the temporal results in:
and occipital lobes
a. Variable level of consciousness
• Stroke in the internal carotid artery b. Hemiparesis
results in:
c. Quadriplegia (possible depending
a. Contralateral hemiparesis
on collateral flow)
b. Global aphasia (dominant
d. Cranial nerve paralysis (III, VI, VII,
side)
XII)
c. Visual disturbances
e. Ataxia
Note: Symptoms may vary with f. Dysphagia
availability of collateral circulation! f. Mutism (locked in syndrome)
g. Visual disturbances
 Circle of Willis
• At the base of the brain, the carotid
and vertebrobasilar arteries form a
circle of communicating arteries
known as the Circle of Willis.
• From this circle other arteries arise
and travel to all parts of the brain:
1. Anterior Cerebral Artery
(ACA)
2. Middle Cerebral Artery
(MCA)
3. Posterior Cerebral Artery
(PCA)
• Because the carotid and
vertebrobasilar arteries form a circle,
if one of the main arteries is
occluded, the distal smaller arteries
that it supplies can receive blood
from the other arteries (collateral
circulation).
Anterior Cerebral Artery (ACA)
• The anterior cerebral artery
extends upward and forward from
the internal carotid artery. It
supplies the frontal lobes, the parts
of the brain that control logical
thought, personality, and voluntary
movement, especially the legs.
• Stroke in the anterior cerebral
artery results in:
1. Contralateral leg
hemiparesis
2. Contralateral sensory loss in leg
3. Bladder incontinence
4. Expressive aphasia (dominant
hemisphere)
• If both anterior cerebral territories
are affected, profound mental
symptoms may result (akinetic
mutism).
Middle Cerebral Artery (MCA)
• The middle cerebral artery is the
largest branch of the internal
carotid. The artery supplies a
portion of the frontal lobe and the
lateral surface of the temporal and
parietal lobes, including the
primary motor and sensory areas
of the face, throat, hand and arm
and in the dominant hemisphere,
the areas for speech.
• The middle cerebral artery is the
artery most often occluded in
stroke.
• Stroke in the middle cerebral artery
results in:
1. Receptive aphasia (dominant
hemisphere)
2. Contralateral hemiparesis
3. Contralateral sensory loss
Posterior Cerebral Artery (PCA)
• The posterior cerebral arteries stem
in most individuals from the basilar
artery but sometimes originate from
the ipsilateral internal carotid artery.
• The posterior arteries supply the
temporal and occipital lobes of the left
cerebral hemisphere and the right
hemisphere. When infarction occurs
in the territory of the posterior
cerebral artery, it is usually secondary
to embolism from lower segments of
the vertebral basilar system or heart.
• Stroke in the posterior cerebral artery
results in:
1. Contralateral sensory loss
2. Contralateral hemiparesis
3. Contralateral homonymous
hemianopia
4. Ataxia
 Lenticulostriate Artery
• A small, deep penetrating
arteries, branch from the
middle cerebral artery.
• Occlusions of these vessels or
penetrating branches of the
circle of Willis or vertebral or
basilar arteries are referred to
as lacunar strokes.
• Within a few months of the
infarction, the necrotic brains
cells are reabsorbed by
macrophage activity, leaving a
very small cavity a lake or
lacune in French.
 Stroke
Definition:
Most often, stroke occurs when blood flow to the brain stops because it
is blocked by a clot. The brain cells in the immediate area begin to die
because they stop getting the oxygen and nutrients they need to
function.

WHO: "neurological deficit of cerebro- vascular cause that

persists beyond 24 hours or is interrupted by death within
24 hours“

• TIA
• Brain Attack
• Acute Ischemic Cerebrovascular Syndrome
• Acute Coronary Syndrome
 Risk Factors
• Nonmodifiable • Modifiable
a. Increasing age a. Hypertension
b. Being male b. Heart disease
c. Race c. Hyperlipidemia
d. Prior (Stroke)/ d. Diabetes Mellitus
transient ischemic e. Cigarette smoking
attacks f. Excessive alcohol
e. Heredity intake
g. Drug abuse
 Etiology
• Ischemia • Hemorrhage
- occurs when the blood supply is - occurs from rupture of cerebral
interrupted or totally occluded by: vessel, which causes bleeding into
a. thrombus (formation of brain tissue
a blood clot within cerebral a. intracerebral hemorrhage/
arteries damaged by parenchymal (occurs when
atherosclerosis) a diseased artery within the
1. large-vessel brain ruptures, flooding the
2. small-vessel surrounding brain tissue
b. embolus (clot originating with blood)
elsewhere in the circulation) b. subarachnoid hemorrhage
(bleeding into the skull or
cranium that occurs when a
blood vessel on the surface of
the brain ruptures and bleeds
into the meninges)
 Classification of Stroke
• According to:
1. Etiology
a. Ischemic Stroke
a.1. Thrombotic
a.2. Embolic
b. Hemorrhagic
b.1. Parenchymal
b.2. Subarachnoid
2. Onset and Duration
a. Transient Ischemic Attack / TIA (lasts less than 30
seconds but no more than 24 hours with complete
resolution of symptoms)
b. Stroke in evolution (progressive development of stroke over
a period of hours to days)
c. Completed stroke (neurologic deficit remains unchanged for a 2-3
day period)
 Pathogenesis

A. Atherosclerosis and
Thrombus Formation

Pathology →
 Pathogenesis, Cont.

A. Atherosclerosis and

Thrombus Formation

Arterial Wall Injury →

 Pathogenesis, Cont.

A. Atherosclerosis and
Thrombus Formation

Role of Monocytes and

T-Lymphocytes in the
Transformation to
Foam Cells →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Oxidation of LDL-
Cholesterol →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Smooth Muscle Cell

Migration and
Proliferation →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Role of Platelets →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Plaque Fissuring
and Formation →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Thrombus
Formation I --
Platelet Activation
→
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Thrombus
Formation II --
Platelet Activation
and Blood Flow →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Thrombus
Formation III --
Activation of
Coagulation
Cascade →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Physiologic
Subtypes of
Thrombosis-Related
Ischemic Stroke →
 Pathogenesis, Cont.

A. Atherosclerosis
and Thrombus
Formation

Evolution of
Cerebral
Atherothrombosis
→
 Pathogenesis, Cont.

B. Cerebral Embolism

Formation

Formation →
* Cardiac Sources
 Pathogenesis, Cont.

B. Cerebral Embolism

Formation

Hemorrhagic
Conversion →
 Pathophysiology

• Cellular Injury During Ischemia

 Pathophysiology, Cont.

• Cellular Injury
During Ischemia

Neuronal Function:
Importance of
Oxygen and
Glucose →
 Pathophysiology, Cont.

• Cellular Injury
During Ischemia
a. Inadequate Energy
Supply →
b. Deterioration of Ion
Gradients →
c. Consequences of
Calcium Overload
→
 Pathophysiology, Cont.

• Cellular Injury
During Ischemia

The Ischemic
Penumbra →

Cerebral Infarction /
Effects of Edema →