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Clients With Cerebrovascular Disease Cerebrovascular Accident (CVA)  Commonly Known

Clients With Cerebrovascular Disease Cerebrovascular Accident (CVA)  Commonly Known

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Published by neil0522

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Published by: neil0522 on Dec 30, 2009
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05/11/2014

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Clients with Cerebrovascular DiseaseCerebrovascular Accident (CVA)
Commonly known as stroke or brain attack
A condition in which
neurologic deficits result from decreased blood flow to localized area of the brain
Neurologic deficits determined by the area of brain involved, size of affected area, length of time blood flow is decreased or stopped
Major loss of blood supply to brain can cause severe disability or death; if short or small area involved client may not be aware
Pathophysiology
Characterized by gradual, rapid onset of neurologic deficits due tocompromised cerebral blood flow
Blood flow and oxygenation of cerebral neurons decreased or interrupted; changes occur in 4 – 5 minutes
Cells swell and cerebral blood vessels swell decreasing blood flow;vasospasm and increased blood viscosity further impede blood flow
Penumbra is a central core of dead or dying cells surrounded byband of minimally perfused cells
Cells of the penumbra receives marginal blood flow and their metabolic activities are impaired
These cells may survive if adequate circulation is re-established
Neurologic deficits occur on opposite side where stroke occurred inbrain:
contralateral deficit 
Causes
Ischemia
Occurs when the blood supply to a part of the brain isinterrupted or totally occluded
Commonly due to thrombosis or embolism
Thrombotic (large vessel) stroke
o
The most common cause of ischemic stroke
o
Atherosclerosis is the primary cause
o
Fatty materials deposit on large vessel walls(especially at arterial bifurcations) andeventually these plaques causes stenosis of theartery
o
Blood swirls around the irregular surface of theplaques causing platelets to adhere and thevessel becomes obstructed
o
These causes infarcts usually affecting thecortex
o
Most common type of stroke in people withdiabetes
 
Lacunar (small vessel) stroke
o
Endothelium of smaller vessel is primarilyaffected due to hypertension
o
Leading to arteriosclerosis and stenosis
o
Infarcts are usually located in the deeper,noncortical parts of the brain or in the brainstem
Embolic stroke
o
Occlusion of a cerebral artery by an embolus or blood clot
o
Embolus forms outside the brain, detaches andtravels through the cerebral circulation where itlodges and causes an obstruction
o
Chronic atrial fibrillation is associated with ahigh incidence
o
Other sources of emboli include tumor, fat,bacteria and air 
o
Usually has a sudden onset with immediatemaximum deficit
Hemorrhage
Results from rupture of a cerebral vessel causing bleedinginto the brain tissues
Bleeding results with edema, compression of the braincontents or spasm of the adjacent blood vessels
Often secondary to hypertension and most common after age50
Other factors includes ruptured intracranial aneurysms,trauma, erosion of blood vessels by tumors, arteriovenousmalformations, anticoagulant therapy, blood disorders
Usually produce extensive residual functional loss andslowest recovery
Risk factors
Hypertension
Diabetes mellitus
Atherosclerosis
Substance abuse including alcohol, nicotine, heroin, amphetamines,cocaine
Obesity, sedentary life-style, hyperlipidemia, atrial fibrillation, cardiacdisease, cigarette smoking, previous transient ischemic attacks
Women: oral contraceptive use, pregnancy, menopause
Clinical manifestations
Stroke manifestations can be correlated with the cause and with thearea of the brain in which perfusion is affected
Manifestations of thrombotic stroke develop over minutes tohours to days (slow onset is related to increasing size of thethrombus)
 
Embolic strokes occur suddenly and without warning
Hemorrhagic stroke occurs rapidly with manifestationsdeveloping over minutes to hours
General findings unrelated to specific vessel sites includesheadache, vomiting, seizures and changes in mental status
Early warnings of impending ischemic stroke includes
Transient hemiparesis
Loss of speech
Hemisensory loss
Specific deficits after stroke
Motor deficits
Affects connections involving motor areas of cerebral cortex,basal ganglia, cerebellum, peripheral nerves
Produce effects in contralateral side ranging from mildweakness to severe limitation
Hemiplegia
(paralysis of half of body)
Hemiparesis
(weakness of half of body)
Apraxia
(inability to perform a previously learned skilled taskin the absence of paralysis)
Able to conceptualize the content of the message tosend to muscles but motor patterns necessary toconvey the impulse cannot be reconstructed
Instructions do not reach the limb from the brain anddesired action cannot happen
E.g. dressing and bathing
Flaccidity (absence of muscle tone or hypotonia)
Spasticity (increased muscle tone usually with some degreeof weakness)
Affected arm and leg are initially flaccid and become spasticin 6 – 8 weeks, causes characteristic body positioning
When voluntary muscle control is lost, strong flexor muscles overbalance the extensors
Imbalance can cause serious contractures
o
Adduction of shoulder 
o
Pronation of forearm
o
Flexion of fingers
o
Extension of hip and knee
o
Foot drop, outward rotation of leg, withdependent edema
Muscles of the thorax and abdomen are usually not affectedbecause they are innervated from both cerebral hemispheres
Communication disorders

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