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127 Cards in this Set
- Front
- Back
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agnosia
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failure to recognize familiar objects perceived by the senses
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aneurysm
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a weakening or bulge in an arterial wall
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aphasia
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inability to express oneself or to understand language
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apraxia
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inability to perform previously learned purposeful motor acts on a voluntary basis
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ataxia
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impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance
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dysarthria
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defects of articulation due to neurologic causes
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expressive aphasia
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inability to express oneself; often associated with damage to the left frontal lobe area
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hemianopsia
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blindness in one falf of the field of vision in one or both eyes
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hemiplegia / hemiparesis
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weakness / paralysis of one side of the body, or part of it, due to an injury to the motor areas of the brain
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infarction
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a zone of tissue deprived of blood supply
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Korsakoff's syndrome
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personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations
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penumbra region
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area of low cerebral blood flow
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receptive aphasia
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inability to understand what someone else is saying; often associated with damage to the temporal lobe area
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top 3 leading causes of death
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1. heart disease
2. cancer 3. cerebrovascular disorders |
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cerebrovascular disorders
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refers to a functional abnormality in the CNS that occurs when the normal blood supply to the brain is disrupted
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incidence of ischemic strokes
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85% of strokes
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short def of ischemic stroke
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a sudden loss of function resulting from disruption of the blood supply to a part of the brain
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incidence of hemorrhagic stroke
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15% of strokes
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what happens in hemorrhagic stroke (short)
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there is extravasation of blood into the brain or subarachnoid space
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what type of treatment should be used early in an ischemic stroke
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thrombolytic therapy, within 3 hours of onset
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5 different types of ischemic strokes
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1. large artery thrombotic strokes
2. small penetrating artery thrombotic strokes 3. cardiogenic embolic strokes 4. cryptogenic strokes 5. other |
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large artery thrombotic strokes
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caused by atherosclerotic plaques in the large blood vessels of the brain thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction
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small penetrating artery thrombotic strokes
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affect one or more vessels
-most common type of ischemic stroke -aka lacunar strokes because of the cavity created after the death of infarcted brain tissue |
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cardiogenic thrombotic strokes
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associated with cardiac dysrhythmias, usually A-fib
-can also be associated with valvular heart disease and thrombi in the left ventricle -emboli originate in the heart and circulate to the cerebral vasculature -may be prevented by the use of anticoagulation therapy in patients with A-fib |
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cryptogenic strokes
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have no known cause
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other causes of strokes
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illicit drug use
coagulopathies migraine sponatneous dissection of the carotid or vertebral arteries |
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ischemic cascade
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1. ischemia
2 energy failure 3. acidosis and ion imbalance 4. depolarization and increase in glutamate and intracellular calcium 5. cell membranes and proteins break down, formation of free radicals, protein production decreased 6. cell injury and death |
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t-PA aka tissue plasminogen activator may revitalize what area
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the penumbra area
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neuroprotectants do what
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protect the brain from secondary injury
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main presenting symptom of ischemic stroke
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numbness or weakness of the face, arm, or leg, especially on one side of the body
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timeline of functional recovery from an ischemic stroke
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usually plateaus at 6 months
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The patient experiencing an ischemic stroke may present with any of the following symptoms...
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-numbness or weakness, especially on one side of the body
-confusion or change in mental status -trouble speaking or understanding speech -visual disturbances -difficulty walking, dizziness, or loss of balance or coordination -sudden severe headache |
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Symptoms of left hemispheric stroke
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paralysis or weakness on right side of body
-right visual field deficit -aphasia (expressive, receptive, or global) -altered intellectual activity -slow, cautious behavior |
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Symptoms of right hemispheric stroke
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paralysis or weakness on left side of body
-left visual field deficit -spatial-perceptual deficits -increased distractibility -impulsive behavior and poor judgment -lack of awareness of deficits |
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neurologic deficits of stroke - manyy
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homonymous hemianopsia
loss of peripheral vision diplopia hemiparesis hemiplegia ataxia dysarthria dysphagia paresthesia aphasia - 3 types short and long term memory loss decreased attention span impaired concentration poor abstract reasoning altered judgment loss of emotional control emotional lability decreased tolerance to stressful situations depression withdrawal fear, hostility, and anger feelings of isolation |
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Stroke is a lesion of what..
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an upper motor neuron lesion and results in loss of voluntary control over motor movements
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Timeline of motor deficits in stroke
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In the early stages - flaccid paralysis and loss of or decrease in the deep tendon reflexes
Usually by 48 hours - the deep tendon reflexes reappear and increased tone is observed along with spasticity (abnormal increase in muscle tone) of the extremities on the affected side |
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When a patient makes verbal substitutions for desired syllables or words, this is an example of
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apraxia (inability to perform a previously learned action)
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TIA - transient ischemic attack
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-a neurologic deficit lasting less than 24 hours, with most episodes resolving within 1 hour
-temporary ischemia to a specific region of the brain -may serve as a warning of impending stroke |
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the initial diagnostic test for a stroke
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noncontrast CT to determine if ischemic or hemorrhagic
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low-dose aspirin may lower the risk of stroke in...
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women
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stroke high-risk groups
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>55 years
male african american |
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modifiable risk factors of stroke
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hypertension
A-fib (treat with warfarin to decrease risk of emboli) hyperlipidemia obesity smoking diabetes mellitus asymptomatic carotid stenosis (treat w/ carotid endarterectomy) valvular heart disease excessive alcohol consumption periodontal disease |
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target INR for warfarin therapy
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INR 2.5
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platelet inhibiting medications
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-aspirin
-extended-release dipyridamole (Persantine) plus aspirin -clopidogrel (Plavix) -ticlpidine (Ticlid) |
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medication for secondary stroke prevention
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-statins, such as simvastatin (Zocor)
-antihypertensives -ACE inhibitors -thiazide diuretics |
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how does t-PA work?
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t-PA works by binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the atherosclerotic lesion
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Why can't thrombolytic therapy be used after 3 hours?
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because revascularization of necrotic tissue (which develops after 3 hours) increases the risk for cerebral edema and hemorrhage.
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Absolute contraindications for t-PA therapy
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onset greater than 3 hours before admission
-prior intracranial hemorrhage, neoplasm, AV malformation, or aneurysm -surgical procedures in last 14 days -stroke, serious head injury, or intracranial surgery in last 3 months -GI or urinary bleeding in last 21 days -a patient who is anticoagulated |
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NIHSS
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National Institutes of Health Stroke Scale
0-normal 42-severe stroke -assessed before receiving t-PA |
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After, t-PA therapy, how long before an anticoagulant can be used?
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24 hours
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Dosage and Administration of t-PA
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Dosage - 0.9 mg/kg, max 90 mg
Admin - 10% of calculated dosage via IV bolus over 1 minutes, then remaining 90% by IV over 1 hour with an infusion pump |
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What is one of the most important vital signs to monitor post-stroke and why?
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BP, with the goal of lowering the risk of intracranial hemorrhage, if on t-PA - should be maintained at SBP <180 and DBP < 105
-if not on t-PA SBP <220 and DBP <120 |
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Standard procedure of monitoring vital signs after a stroke
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for 2 hours - q 15 min
next 6 hours - q 30 min then every hour until 24 h after treatment |
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What is the most common side effect of t-PA?
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bleeding, closely monitor this
-give 24h delay in placement of tubes and catheters if possible |
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Eligibility requirements for t-PA administration
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-age>18
-clinical diagnosis of ischemic stroke -time of onset known and <3h -BP<185/110 -not a minor or rapidly resolving stroke -no seizure at onset -not taking warfarin -not receiving heparin w/in last 48h w. elevated PTT -PT time <15 or INR <1.7 -platelet count >100,000 -no contraindications |
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surgical prevention of ischemic stroke
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cartotid endarterectomy (most common)
carotid stenting under research |
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carotid endarterectomy
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the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries
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when is carotid endarterectomy indicated?
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patients with symptoms of TIA or mild stroke found to be caused by severe or moderate stenosis
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primary complications of carotid endarterectomy
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-stroke
-cranial nerve injuries -infection or hematoma at the incision -carotid artery disruption -HTN - leads to cerebral hemorrhage, edema, hemorrhage at surgical incision, or disruption of the arterial reconstruction -post op hypotension - leads to cerebral ischemia and thrombosis |
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what is given to reduce BP to previous levels post endarterectomy?
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sodium nitroprusside
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What should be reported to the neurosurgeon immediately after an endarterectomy?
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-any neurologic deficit (thrombus at the site is suspected)
-extensive edema and hematoma formation in the neck (will need tracheostomy) (but some edema in neck is normal) |
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hyperperfusion syndrome
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occurs when cerebral vessel autoregulation fails
-arteries accustomed to diminished blood flow may be permanently dilated; increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and intracerebral hemorrhage |
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how to treat postop hypotension
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fludids and low-does phenylephrine infusion
-usually resolves in 24-48h -should have serial ECGs to r/o myocardial infarction |
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sign of hyperperfusion syndrome
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severe unilateral headache improved by sitting upright or standing
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nursing interventions in the recovery period after stroke
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-improve mobility and prevent joint deformities
-prevent shoulder pain -enhance self-care -manage sensory-perceptual difficulties -assist with nutrition -attain bowel and bladder control -improve though processes -improve communication -maintain skin integrity -improve family coping -helping the patient cope with sexual dysfunction -promoting home and community-based care |
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potential complications after stroke
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-decreased cerebral blood flow due to increased ICP
-inadequate oxygen delivery to the brain -pneumonia |
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improving mobility and preventing joint deformities in a stroke patient
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-when control of voluntary muscles is lost, the strong flexor muscles exert control over the extensors
-prevent shoulder adduction -position the hands and fingers -changing positions -establish an exercise program |
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Why should the stroke patient be placed in a prone position for 15-30 min several times a day?
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helps to promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures
-drain bronchial secretions -prevents contractual deformities of the shoulders and knees |
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how often should affected extremities be put through passive ROM? and why
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4-5 times a day
-maintain joint mobility -regain motor control -prevent contractures -prevent further deterioration of the neuromuscular system -enhance circulation -prevent venous stasis, which may predispose the patient to thrombosis and PE |
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At first, the extremities are usually flaccid. If tightness occurs in any area, the ROM ..
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should be performed more frequently
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quadriceps and gluteal muscle setting
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started early to improve the muscle strength needed for walking
-at least 5x daily for 10 min at a time |
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three problems that can occur with should function post-stroke
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1. painful shoulder
2. subluxation of the shoulder 3. shoulder-hand syndrome |
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shoulder-hand syndrome
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painful shoulder and generalized swelling of the hand
-can cause a frozen shoulder and ultimately atrophy of subcutaneous tissues |
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what meds are helpful in the management of post-stroke pain
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amitriptyline hydrochloride (Elavil) - but it can cause cognitive problems, has a sedating effect, and is not effective in all patients
-lamotrigine (Lamictal) - anti seizure - alternative |
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amitriptyline hydrochloride (Elavil)
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used for poststroke pain, but can cause cognitive problems, has a sedating effect, and is not effective in all patients
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FIM -
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Functional Independence Measure - early baseline assessment of functional ability after a stroke
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amorphosynthesis
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in a patient with homonymous hemianopsia, the tendency to turn away from the affected side of the body and to neglect that side and the space on that side
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what should be recommended to help with constipation post stroke
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high-fiber diet
2-3L fluid intake regular time for toileting - usually after breakfast |
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symptoms that may be observed more frequently in patients with acute intracerebral hemorrhage compared with ischemic stroke
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-vomiting
-early sudden change in level of consciousness -focal seizures due to frequent brain stem involvement |
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Hemorrhagic strokes are primarily caused by..
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intracranial or subarachnoid hemorrhage
-bleeding into the brain tissue, the ventricles, or the subarachnoid space |
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Primary intracerebral hemorrhage results from
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a spontaneous rupture of small vessels
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What is the main cause of primary intracerebral hemorrhage?
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uncontrolled hypertension
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Subarachnoid hemorrhage results from...
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a ruptured intracranial aneurysm in about half the cases
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causes of intracerebral hemorrhage
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1. uncontrolled HTN
also -cerebral atherosclerosis -in the elderly - cerbral amyloid angiopathy -AVMs -intracranial aneurysms -intracranial neoplasms -certain meds - anticoagulants, amphetamines, illicit drugs |
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cerebral amyloid angiopathy
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involves damage caused by the deposit of beta-amyloid protein in the small and medium-sized blood vessels of the brain
-a common cause of intracerebral hemorrhage in the elderly |
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mortality rate of intracerebral hemorrhage
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43% after 30 days
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When an aneurysm or AVM ruptures, what happens?
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Subarachnoid hemorrhage
-Normal brain metabolism is disrupted by the brain being exposed to blood -by an increase in ICP resulting from the sudden entry of blood into the subarachnoid space, which compresses and injures brain tissue -secondary ischemia of the brain resulting from the reduced perfusion pressure and vasospasm that frequently accompany subarachnoid hemorrhage |
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intracerebral hemorrhage is bleeding into...
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the brain substance
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if bleeding ruptures the wall of the lateral venricle...
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this causes intraventricular hemorrhage, which is frequently fatal
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an aneurysm may be due to...
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-atherosclerosis, which results in a defect in the vessel wall with subsequent weakness of the wall
-a congenital defect of the wall -hypertensive vascular disease -head trauma -advancing age |
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where do cerebral aneurysms usually occur
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at the bifurcations of the large arteries at the circle of Willis
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Are multiple aneurysms uncommon?
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no
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arteriovenous malformation
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caused by an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed. this leads to dilation of the arteries and veins and eventual rupture
-common cause of hemorrhagic stroke in young people |
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subarachnoid hemorrhage may occur as a result of...
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-an AVM
-intracranial hemorrhage -trauma -HTN |
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Main, most common presenting symptoms of hemorrhagic stroke
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-"exploding headache"
-decreased LOC |
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functional recovery of hemorrhagic stroke
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slower than ischemic, usually plateaus at about 18 months
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In addition to the neurologic deficits seen with an ischemic stroke, the patient with an intracranial aneurysm or AVM can also show s/s such as...
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-sudden, unusually severe HA
-loss of consciousness for a variable time -nuchal and spinal rigidity and pain due to meningeal irritation -visual disturbances - loss, diplopia, ptosis (if aneurysm adjacent to the oculomotor nerve -tinnitus, dizziness, hemiparesis |
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at times an aneurysm or AVM leaks blood, leading to the formation of a clot that seals the site of rupture. (little neurologic deficit)
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true
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if severe bleeding of an aneurysm or AVM...
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cerebral damage, followed rapidly by coma and death
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mortality of subarachnoid hemorrhage
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very high
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diagnostic tests
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1. CT scan
2. CT scan plus cerebral angiography to confirm 3. lumbar puncture if no evidence of ICP, CT scan is negative, and subarachnoid hemorrhage must be confirmed |
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Hunt-Hess classification system
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guides the physician in diagnosing the severity of subarachnoid hemorrhage after an aneurysmal bleed
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Risk factors for hemorrhagic stroke
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HTN #1
increased age male excessive alcohol intake PPA usage |
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PPA - phenylpropanolamine
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risk factor for hemorrhagic stroke
-ingredient found in appetite suppressants as well as cold and cough agents |
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acute hydrocephalus results when...
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free blood obstructs the reabsorption of CSF by the arachnoid villi
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potential complications of hemorrhagic stroke
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-rebleeding
-cerebral vasospasm resulting in cerebral ischemia -acute hydrocephalus -seizures |
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interventions for cerebral hypoxia and decreased blow flow post hemorrhagic stroke
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provide adequate oxygenation
-maintain HgB and Hct -maintain BP, CO and integrity of blood vells -adequate hydration to reduce viscosity and improve cerebral blood flow -prevent or promptly treat seizure activity |
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the development of cerebral vasospasm after surviving the initial cranial bleed accounts for what percent of morbitity
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40-50%
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vasospasm def
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narrowing of the lumen of the involved cranial blood vessel
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vasospasm is associated with...
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increasing amounts of blood in the subarachnoid cisterns and cerebral fissures, as visualized by CT scan
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vasospasm leads to ...
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increased vascular resistance, which impedes cerebral blood flow and causes brain ischemia and infarction
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s/s of vasospasm may include
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-a worsening headache
-decrease in LOC -new focal deficit - aphasia, hemipareses |
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timeline of vasospasm
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4-14 days after initial hemorrhage, when the clot undergoes lysis (dissolution) and increases the chances of rebleeding
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what may help prevent the development of vasospasm in the period in which it may occur?
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nimodipine (Nimotop) - calcium channel clockers - others include verapamil (Isoptin) and nifedipine (Procardia)
"H therapy" |
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H therapy
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a therapy for vasospasm
1. fluid volume expanders (hypervolemia 2. incduced arterial hypertension 3. hemodilution |
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if a patient is on mannitol post stroke, monitor for..
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signs of dehydration
rebound elevation of ICP |
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increased ICP almost always follows...
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a subarachnoid hemorrhage
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antihypertensive meds include...
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-labetalol (Normodyne)
-necardipine (Cardene) -nitroprusside (Nitropress) |
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What kind of therapy can be used to prevent sudden systemic HTN after an intracranial hemorrhage and eep SBP below 150 mmHg to prevent hematoma enlargement?
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antihypertensive meds
antiseizure med (to prevent seizures, which would raise BP) stool softeners (to prevent straining) |
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postoperative complications of surgery that treats a primary intracerebral hemorrhage
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psychological symptoms
-disorientation, amnesia, Korsakoff's syndrome, personality changes intraoperative embolization postop internal artery occlusion fluid and electrolyte disturbances (from disruption of the neurohypophyseal system) GI bleeding |
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should enemas be used if the patient has increased ICP
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NOOOOOOOO, enemas increase ICP
but you can use stool softeners or mild laxatives |
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after subarachnoid hemorrhage, hyponatremia is found in ...
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10-40 % patients
is less than 135 |
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notify the doctor of hyponatremia if...
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it has persisted for 24h below 135
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cerebral salt-wasting phenomenon
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occurs when the kidneys are unable to conserve sodium
-treatment - hypertonic 3% saline |
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aneurysm precautions
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nonstimulating environment
prevent increases in ICP prevent further bleeding |
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detailed aneurysm precautions
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absolute bed rest
visitors except family restricted HOB 15-30 degrees (or possibly flat, depending on neurosurgeon preference) no activities that increase ICP no smoking no activity requiring exertion no enemas yes stool softeners and mild laxatives exhale during voiding or defacation dim lighting for photophobia no caffeine elastic compression stocking nurse administers all personal care no external stimuli - tv, radio, reading sign on door explain purpose of restrictions |
