This document discusses cerebrovascular disorders such as stroke. It begins by defining cerebrovascular disorders as any functional abnormality of the central nervous system caused by disrupted blood supply to the brain. Stroke is the primary cerebrovascular disorder. The document then covers the anatomy of the nervous system, definitions of stroke, risk factors, types of stroke (ischemic and hemorrhagic), clinical manifestations, diagnostic findings, and management approaches including medical, surgical, and nursing considerations.

1. CEREBRO VASCULAR DISORDER (CEREBRO
VASCULAR ACCIDENT)
Dr. Jayesh Patidar
www.drjayeshpatidar.blospot.com

2. INTRODUCTION
• Cerebrovascular disorders” is any functional
abnormality of the central nervous system
(CNS) that occurs when the normal blood
supply to the brain is disrupted. Stroke is the
primary Cerebrovascular disorder in the
United States and in the world. stroke is still
the third leading cause of death.
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3. ANATOMY & PHYSIOLOGY OF
NERVOUS SYSTEM
The nervous system is divided into two parts:
• Central nervous system
• Peripheral nervous system
• ARTERIES: Two internal carotid arteries, Two
vertebral arteries
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4. DEFINITION
• A stroke, or Cerebrovascular accident (CVA),
occurs when blood supply to part of the brain
is disrupted, causing brain cells to die.
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5. INCIDENCE
• AGE : The percentage is higher for people age
65 and older. Of those who survive, 50% to
70% will be functioning independent and 15%
to 30% will live with permanent disability.
• SEX : Stroke is more common in men than in
women.
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6. RACE
• African american have a higher incidence of strokes than whites.
• This high incidence may be related to increase rate of hypertension,
diabetes mellitus and sickle cell anemia in african americans.
• African americans also have a higher incidence of smoking and
obesity than white, which are two other risk factors for stroke.
• African american are twice as likely to die from a strokes as white.
COUNTRY :
• An estimated 700,000 person in the united states and 50,000 in
canada suffer a stroke annually.
• Stroke is the third most commen cause of the death in the united
states and canada, behind cancer and heart disease.
• In canada about 16,000 die from stroke each year, while in united
states there are over 160,000 deaths from strokes.
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7. ETIOLOGY
Nonmodifiable risk factors :
• Age : more than 65 yr
• Gender : More in men than women
• Race : African American
• Family history : Heredity
Modifiable risk factors :
• Hypertension
• Heart disease
• Smoking
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8. • Excessive alcohol consumption
• Obesity
• Sleep apnea
• Metabolic syndrome
• Poor diet
• Drug abuse
• Oral contraceptive
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9. Causes
• Vessel wall embolus
• Carotid artery most often the source
• Related to thrombus formation distal to stenosis
• Cardiac source
• Mitral valve stenosis
• Mitral valve prolapsed
• Calcified mitral annulus
• Ventricular aneurysm
• Atrial or ventricular clot
• Valvular vegetation
• Atrial septal defect
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10. vascular sources
• Intracranial artery thrombus (esp. African-
Americans)
• Aortic arch atherosclerotic Plaque
• Transient hypotension with Carotid Stenosis
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11. TYPES OF STROKE
Strokes are classified as ischemic or hemorrhagic
based on the underlying pathophysiologic
findings.
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12. Ischemic stroke
• An ischemic stroke result from inadequate
blood flow to the brain from partial or
complete occlusion of an artery. These
account for approximately 80% of all strokes.
Ischemic stroke are further divided into
thrombotic and embolic.
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13. Thrombotic stroke
• A thrombotic stroke occurs from injury to a blood
vessels wall and formation of a blood clot. The
lumen of the blood vessel becomes narrowed
and if it becomes occluded, infarction occur.
Thrombosis develops readily where
atherosclerotic plaques have already narrowed
blood vessels. Thrombotic stroke, which is the
result of thrombosis or narrowed blood vessel, is
the most common cause of stroke. Two third of
thrombotic strokes are associated with
hypertension or diabetes mellitus
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14. Embolic stroke
• Another type of stroke may occur when a
blood clot or a piece of atherosclerotic plaque
(cholesterol and calcium deposits on the wall
of the inside of the heart or artery) breaks
loose, travels through the bloodstream and
lodges in an artery in the brain. When blood
flow stops, brain cells do not receive the
oxygen and glucose they require to function
and a stroke occurs. This type of stroke is
referred to as an embolic stroke.
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15. CLINICAL MANIFESTATIONS
• Visual Field Deficits :
Homonymous hemianopsia (loss of half of the visual field)
- Unaware of persons or objects on side of visual loss
- Neglect of one side of the body
- Difficulty judging distances
Loss of peripheral vision
-Difficulty seeing at night
- Unaware of objects or the borders of objects
Diplopia
-Double vision
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16. Motor Deficits
Hemiparesis
• Weakness of the face, arm, and leg non the same side (due to a
lesion in the opposite hemisphere)
Hemiplegia
• Paralysis of the face, arm, and leg on the same side (due to a lesion
in the opposite hemisphere)
Ataxia
• Defective muscular co-ordination, unsteady gait Unable to keep
feet together; needs a broad base to stand
Dysarthria
• Difficulty in forming words
Dysphagia
• Difficulty in swallowing
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17. Sensory Deficits
Paresthesia (occurs on the side opposite the
lesion)
• Numbness and tingling of Extremity
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18. Verbal Deficits
Expressive aphasia
• Unable to form words that are understandable;
may be able to speak in single-word responses
Receptive aphasia
• Unable to comprehend the spoken word; can
speak but may not make sense
Global (mixed) aphasia
• Combination of both receptive and expressive
aphasia
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19. Cognitive Deficits
• Short- and long-term memory loss
• Decreased attention span
• Impaired ability to concentrate
• Poor abstract reasoning
• Altered judgment
Emotional Deficits
• Loss of self-control
• Emotional lability
• Decreased tolerance to stressful situations
• Depression
• Withdrawal
• Fear, hostility, and anger
• Feelings of isolation
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20. ASSESSMENT AND DIAGNOSTIC FINDING
HEALTH HISTORY :
• Past health history : Hypertension, previous stroke,
aneurysm, cardiac disease (including recent myocardial
infraction), dysrhythmias, heart failure, valvular disease,
infective endocarditis, hyperlipidemia, polycythemia,
diabetes
• Family history : Hypertension, diabetes, stroke, coronary
artery disease.
• Medications : Use of oral contraceptives, use of
antihypertensive and anticoagulant therapy
• Nutritional history : Anorexia, nausea, vomiting,dysphagia,
altered sensation of taste and smell
• Cognitive perceptual history : Numbness, tingling of one
side of body, loss of memory, altered in speech, pain,
headache, visual disturbance
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21. PHYSICAL ASSESSMENT
• Glasgow coma scale
• NIH stroke scale
• COGNITIVE FUNCTION :-
• Orientation :
Speech :-aphasia & other problems
– Fluent aphasia (motor/Borka’s) – inability to express
self
– Non-fluent aphasia ( sensory / wernicke’s) – inability
to understand the spoken language.
– Global aphasia – inability to speak or understand
spoken language.
– Other aphasia syndromes – amnesia, conduction.
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22. • Other alterations include :
– Confabulation – fluent , nonsensical speech
– Preservation – continuation of thought process
with inability to change rain of though without
direction or repetition.
• MOTOR FUNCTION :
-Voluntary movement
-Reflexive movement : Biceps, Triceps, Patellar,
Achilles, Planter:
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23. DIAGNOSTIC EVALUATION
Diagnosis of stroke, including extent of
involvement
• CT, CTA (computer tomographic angiography)
• MRI, MRA (magnetic resonance angiography)
• SPECT (single photon emission computed tomography)
• PET ( Positron emission tomography )
• MRS (magnetic resonance spectroscopy)
• Xenon CT
• Electroencephalogram
• Cerebral angiography
• Cerebrospinal fluid analysis
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24. CT SCAN
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25. Cerebral blood flow measures
• Cerebral angiography
• Digital subtraction angiography
• Doppler ultrasonography
• Transcranial Doppler
• Carotid duplex
• Carotid angiography
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26. Cardiac assessment
• Electrocardiography
• Chest x-ray
• Cardiac enzymes
• Holter monitor
Additional studies
• Complete blood count
• Prothrombin time, activated partial thromboplastin time
• Electrolytes
• Blood glucose level
• Renal and hepatic studies
• Lipid profile
• Arterial blood gases analysis
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27. MANAGEMENT :
MEDICAL MANAGEMENT :
• Platelet-inhibiting medications : Aspirin, dipyridamole
[Persantine], clopidogrel [Plavix], and ticlopidine [Ticlid]).
Currently the most cost-effective antiplatelet regimen is
aspirin 50 mg/d and dipyridamole 400 mg/d.
• Thrombolytic therapy : Recombinant t-PA is a genetically
engineered form of t PA, a thrombolytic substance made
naturally by the body. The minimum dose is 0.9 mg/kg; the
maximum dose is 90 mg.
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28. Eligibility Criteria for t-PA
Administration
• Age 18 years or older
• Clinical diagnosis of stroke with NIH stroke scale score
under 22
• Time of onset of stroke known and is 3 hours or less
• BP systolic ≤ 185; diastolic ≤ 110
• Not a minor stroke or rapidly resolving stroke
• No seizure at onset of stroke
• Not taking warfarin (Coumadin)
• Prothrombin time ≤ 15 seconds or INR ≤ 1.7
• Not receiving heparin during the past 48 hours with
elevated partial thromboplastin time.
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29. • Platelet count ≥ 100,000
• Blood glucose level between 50 and 400 mg/dL
• No acute myocardial infarction
• No prior intracranial hemorrhage, neoplasm,
arteriovenous, malformation, or aneurysm
• No major surgical procedures within 14 days
• No stroke or serious head injury within 3 months
• No gastrointestinal or urinary bleeding within last
21 days
• Not lactating or postpartum within last 30 days
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30. Surgical management
• Carotid endarterectomy : Removal of an
atherosclerotic plaque or thrombus from the carotid
artery to prevent stroke in patients with occlusive
disease of the extracranial cerebral arteries. This
surgery is indicated for patients with symptoms of
TIA or mild stroke found to be due to severe (70% to
99%) carotid artery stenosis or moderate (50% to
69%) stenosis with other significant risk factors.
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31. NURSING MANAGEMENT
ASSESSMENT
• Assess the level of consciousness or responsiveness as
evidenced by movement, resistance to changes of
position, and response to stimulation; orientation to time,
place, and person
• Presence or absence of voluntary or involuntary
movements of the extremities; muscle tone; body
posture; and position of the head
• Stiffness or flaccidity of the neck
• Eye opening, comparative size of pupils and pupillary
reactions to light, and ocular position
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32. • Color of the face and extremities; temperature and
moisture of the skin
• Quality and rates of pulse and respiration; arterial
blood gas values as indicated, body temperature,
and arterial pressure
• Ability to speak
• Volume of fluids ingested or administered; volume
of urine excreted each 24 hours
• Presence of bleeding
• Maintenance of blood pressure within the desired
parameters
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33. NURSING DIAGNOSES
• Impaired physical mobility related to hemiparesis, loss
of balance and coordination, spasticity, and brain
injury
• Acute pain related to hemiplegia and disuse of
extrimity
• Self-care deficits (hygiene, toileting, grooming, and
feeding) related to stroke
• Disturbed sensory perception related to altered
sensory reception, transmission, and/or integration
• Impaired swallowing
• Incontinence related to flaccid bladder, detrusor
instability, confusion, or difficulty in communicating
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34. • Disturbed thought processes related to brain
damage, confusion, or inability to follow
instructions
• Impaired verbal communication related to
brain damage
• Risk for impaired skin integrity related to
hemiparesis/ hemiplegia, or decreased
mobility
• Interrupted family processes related to
catastrophic illness and caregiving burdens
• Sexual dysfunction related to neurologic
deficits or fear of failure
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35. Hemorrhagic strokes
• Hemorrhagic strokes account for 15% of
cerebrovascular disorders and are primarily
caused by an intracranial or subarachnoid
hemorrhage
• Hemorrhagic strokes are caused by bleeding into
the brain tissue, the ventricles, or the
subarachnoid space. Primary intracerebral
hemorrhage from a spontaneous rupture of small
vessels accounts for approximately 80% of
hemorrhagic strokes and is primarily caused by
uncontrolled hypertension
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36. Pathophysiology
Etiological factors
•
•
presses on nearby cranial nerves or brain tissue
•
•
•
causing subarachnoid hemorrhage
•
•
increase in ICP resulting from the sudden entry of blood into the subarachnoid
space,
•
•
injures brain tissue; or by secondary ischemia of the brain resulting from the
reduced perfusion pressure
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37. TYPE OF HEMORRHAGE
• INTRACEREBRAL HEMORRHAGE
An intracerebral haemorrhage, or bleeding into the brain
substance, is most common in patients with hypertension and
cerebral atherosclerosis because degenerative changes from
these diseases cause rupture of the vessel.
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38. • INTRACRANIAL (CEREBRAL) ANEURYSM
An intracranial (cerebral) aneurysm is a dilation
of the walls of a cerebral artery that develops
as a result of weakness in the arterial wall.
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39. • SUBARACHNOID HEMORRHAGE :
• A subarachnoid hemorrhage (hemorrhage into
the subarachnoid space) may occur as a result
trauma, or hypertension.
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40. CLINICAL MANIFESTATIONS
• Severe headache
• Loss of consciousness
• Rigidity of the back and neck (nuchal rigidity)
• Pain in spine due to meningeal irritation
• Visual disturbance (visual loss, diplopia,
ptosis)
• Dizziness
• Hemiparesis
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41. ASSESSMENT AND DIAGNOSTIC
FINDING :
DIAGNOSTIC EVALUATION :
• CT Scan : To determine the size and location of the
hematoma as well as presence or absence of ventricular
blood.
• Cerebral angiography : To confirm the diagnosis of an
aneurysm or AVM.
• Lumber puncture
PREVENTION:
• Control hypertension.
• Stop smoking.
• Stop to take alcohol.
• Avoid to take high cholesterol diet
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42. SURGICAL MANAGEMENT
• Craniotomy : Many patients with a primary
intracerebral hemorrhage are not treated
surgically. However, surgical evacuation is
strongly recommended for the patient with a
cerebellar hemorrhage if the diameter
exceeds 3 cm. Surgical evacuation is most
frequently accomplished via a craniotomy.
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43. Extracranial-intracranial arterial bypass :
An extracranial-intracranial arterial bypass may be performed to
establish collateral blood supply to allow surgery on the
aneurysm. Alternatively, an extracranial method may be used,
whereby the carotid artery is gradually occluded in the neck
to reduce pressure within the blood vessel.
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44. POST OPERATIVE COMPLICATIONS :
• Intraoperative embolization
• Postoperative internal artery occlusion
• Fluid and electrolyte disturbances
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45. NURSING DIAGNOSIS :
• Ineffective cerebral tissue perfusion related to
bleeding
• Disturbed sensory perception related to
medically imposed restrictions (aneurysm
precautions)
• Anxiety related to illness and/or medically
imposed restrictions (aneurysm precaution)
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46. HOME CARE
• Discuss measures to prevent subsequent strokes.
• Identify signs and symptoms of specific
complications.
• Identify potential complications and discuss
measures to prevent them (blood clots, aspiration,
pneumonia, urinary tract infection, fecal impaction,
skin breakdown, contracture).
• Identify psychosocial consequences of stroke and
appropriate interventions.
• Identify safety measures to prevent falls.
• State names, doses, indications, and side effects of
medications.
•
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47. • Demonstrate adaptive techniques for accomplishing
ADLs.
• Demonstrate swallowing techniques (for patients with
dysphagia).
• Demonstrate care of enteric feeding tube, if applicable.
• Demonstrate home exercises, use of splints or
orthotics, proper positioning, and need for frequent
repositioning.
• Describe procedures for maintaining skin integrity.
• Demonstrate indwelling catheter care, if applicable.
Describe a bowel and bladder elimination program as
appropriate.
• Identify appropriate recreational or diversional
activities, support groups, and community resources.
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48. THANK YOU
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