CVA part A

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  1. definition
    • also known as brain attack or stroke
    • change in the normal blood supply to the brain
    • - occulsion or rupture of vessel
    • -permanent damage in minutes
    • - time is tissue
  2. Stats
    • Q yr 700,000 americans experience a new or reccurent CVA
    • - mortality rate is 22%
    • q 3 mins someones dies from a stroke
    • - 3rd leading cause of death in US
    • leading cause of serious long term disablity
    • ischemic- lack of oxygen
  3. Risk factors- non modifiable
    • Age > 65
    • Gender- higher in males but die more bc their symptoms present differently- numbness tingling
    • race/ethnicity- African Americans
    • Fam Hx- HTN, DM, inc chol, afib, arthrosceloric
    • Hx of stroke, TIA (pre stroke), or MI
  4. risk factors- modifable
    • smoking
    • HTN. high chol, and lipids- diet
    • cardiac or carotid disease
    • alchol and drug abuse
    • dm
    • A-fib- abnormal rythm inc risk for clot
    • lack of exercise
    • GOOD- healthy weight, good diet, take care of teeth (peridonal dx), no smoking
  5. Two types of strokes
    • Ischemic stroke:
    • - obstruction in brain vessel, narrow or blocked
    • - most strokes are Emboli/thrombi
    • Hemorrhagic stroke:
    • - blood vessel in brain leaks/rupture
    • -AVM, HTN, Aneurysm
  6. Patho: Ischemic Stroke
    • disruption of cerebral blood flow- ischemic cascade is activated
    • - anaerobic metabolism- lactic acid incr (no O2, no energy)
    • - dec ATP (cells aren't working), dec neuron fx
    • - cerebral vasodilation- edema (inc CO2)
    • - cells dies- end result
    • ischemic area around dead/dying cells called penumbra
    • (decr blood flow to brain due to occulsion from clot)
  7. Penumbra
    • you can save this area before it is too late.
    • time is tissue
    • the area is ischemic- like a brain angina (decrease blood flow to the area)
    • Goal is reestab blood flow
    • DOC < 4 hr TPA- clot buster (lysis) Thrombolytic agent
    • DOC > 4 hrs Aspirin/Plavix (anti-platelet) prevent the platelets from sticking the the plaque
    • both helps to reestab blood flow
  8. Thrombotic Stroke
    • usually 50% of stroke is caused by this
    • Occurs at bifurcations and
    • - internal carotids
    • - vertebral arteries
    • - junction of vertebral and basilar arteries
  9. Thrombotic stroke
    why it happens
    • atherosclerotic blood vessels
    • - plaque- sticky clot forms
    • - clot occludes vessel
    • slow onset, usually worsen over 72 hours- gets bad
    • - progression step wise
    • - s/s: weakness and neuro s/s on one side of the body, speech and visual chx
  10. Embolic stroke
    • dislodge clot from heart?- clot consist of blood, bacteria, cells from the heart
    • lodges into very small blood vessels
    • middle cerebral artery is most commonly involved
    • also: bifurcation
    • sudden and maximum deficit at onset
  11. embolic stroke
    how it works
    • usually emboli from heart or atherosclerotic plaques in carotid artery
    • - afib, mural thrombi, MI, bacterial endocarditis
    • sudden onset- travels until it gets stuck
    • rapid neurological changes
    • - can progress to bleed
    • s/s: paralysis, aphasia
    • embolic stroke
    • - sometimes it resolves
    • - enough collateral circulations that blood can still flow
  12. Transient Ischemic Attacks
    • TIA
    • a transient episode of neuro dysfunction caused by focal ishemic cerebral neurologic deficits
    • no acute infarction of the brain
    • symptoms lasting a few mins to 1 hr
    • s/s: sudden loss of motor, sensory of visual fx
    • - depends on the part of the brain
    • MRI won't show anything
    • PMH- HTN, high chol
    • short term
  13. TIA warning
    • warning sign- brain angina (dec blood flow)
    • multiple TIA's: high stroke risk
    • multiple TIA's: damage brain tissue
    • TX: antiplatelet, f/u, pt education essential
  14. Lacunar Stroke
    • occulusion from small penetrating (deep) artery w/develop of cavity in area of infarct brain tissue
    • commonly occur in basal ganglia, thalamus, internal capsule, brain stem
    • leaves behind small cavaties (lake)
    • dx: MRI and clinical s/s
    • sometimes they have no s/s
    • deep in brain
  15. S/s of ischemic stroke depends on
    • location of artery involved and amt of brain tissue affected
    • the size of inadequate perfusion
    • amt of collateral circulation
  16. clinical manisfestation of ischemic stroke
    • speech deficit
    • visual problems
    • confusion/chx in mental status
    • H/a
    • dizziness/loss of balance
    • sensory loss
    • difficulty walking
    • numbness or weakness of the face, arm, leg especially on one side of the body
    • chx in attention, learning, memory
    • chart in p1975
  17. Hemorrhagic Stroke
    • <10%
    • leading cause: HTN
    • most frequently fatal
    • blood vessels consist of 2 layers so incr rupture
  18. Hemorrhagic stroke
    • bleeding into the brain
    • normal brain metabolism is disrupted
    • incr ICP from Incr blood
    • ischemia from pressure and loss of blood perfusion
    • - Intracerebral (HTN, cerebral atheroscl)
    • - Intracranial (aneurysm)
    • - AVM's
    • dec perfussion
    • incr ICP- brain tissue gives loss brain tissue
  19. Hemorrhagic stroke
    • Risk: HTN, cerebral atherosclerosis, brain tumors, anti-coag, illicit drug use
    • bleed into brain tissue
    • sudden onset- bleed
    • symptoms w/ rapid progression
    • prognosis is poor
    • most common- uncontrolled HTN
    • significant neurological damagae- stupor to comatose
  20. Hemorrhagic stroke
    Intracranial (Cerebral) Aneurysm
    • dilation of cerebral arterial wall d/t weakness
    • cause is unknown
    • predisposing factors: HTN, atheroscerosis, congential defects (born like this), trauma
    • HTN= inc BP leads to incr risk for rupture
  21. hemorrhagic stroke
    aneurysm- what happens
    • aneurysm ruptures
    • - bleeds into subarachnoid (arachnois reabsorbs CSF) space, ventricle, intracerebral tissue
    • vasospasm of cerebral artery (low o2)
    • blood supply decreases distal to bleed
    • rapid s/s: neuro symptoms--- death
  22. Hemorrhagic stroke AVM
    AV malformations
    • abnormally in embryo development
    • lacks capillary bed
    • mass of malformed of thin walled dilated vessels
    • - abnormal communication btw arterial and venous system
    • HTN: cause spike in BP
    • dilates and ruptures
    • asymptomatic
    • young adult to adult
    • born with this and not even know
  23. s/s of hemorrhagic stroke
    • rapid, abrupt onset- bleed- dec blood supple, inc ICP
    • ** Severe h/a, photophobia
    • early chx in LOC- memory, speech, confusion, loss of muscle movement
    • N/v
    • seizures
    • abnormal posturing, fixed dilated pupils (late)
    • s/s similar to ischemic stroke
    • catastrophic event- coma, death
  24. review left vs right
  25. Right Hemisphere CVA
    • R- reduces L visual field, L motor weakness
    • I- impulsive (lack of intution, attention span)
    • G- gone attention span
    • H- humor loss, inhibition low (inapproriate)
    • T- disoriented to time, place, spacial
    • other
    • denial of deficit
    • poor judgement
    • agnosia- sight, touch, hearing
  26. Left Hemisphere CVA
    • L- loss of motor Right and visual right
    • E- expressive global (asphasia)
    • F- feels depressed, anxious
    • T- the pt is slow cautious
    • others
    • worthless, quick to anger/frustration
    • altered reading
    • communication issue
  27. brain stem or cerebellum (balance/coordination) infarcts
    • nystagmus
    • ataxia- w/out gait- not coordinated
    • quadriparesis
    • hemipareisis
    • dysarthia (difficulty forming words), dysphagia
  28. dx test
    • MRI- early
    • CT scan (non constast)
    • angiograpghy. MRA- blood flow study
    • PET scan. SPECT studies- details
    • Echo- EF, how well the blood is perfusing
    • EEG- brain activity
    • Labs: CBC (bleed/infection), PT, PTT, Chem (bs/lytes), cardiac enzymes (r/o cardiac)
    • 12 lead EKG and carotid ultrasound- arrythimia
  29. Is it a stroke?
    condition that mimic a stroke
    • unrecognized seizures
    • metabolic conditions- chx in BS/lytes
    • hypo/hyperglycemia
    • brain tumors
    • syncope, positional vertigo
    • confused state
    • infections- menigitis
Card Set:
CVA part A
2016-03-12 01:45:20

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