2554

2554

**

Neuroanatomy and Function of Intracranial and Extracranial vessels

..
risk factor
80%
infarction 20% (Hemorrhage)
( 1/3 40 )

130,000 / /
85%
42.5%

physiotheraphy

42.5%

*
2554 25 29 2554
3
**

hemorrhage
170/110 mmHg ( 170 mmHg
110 mmHg)
Intracranial
hernia medulla oblongata
3 emergency case

1. (Frontal lobe) :


2. (Parietal lobe) :

3
3. (Occipital lobe) :

4. (Cerebellum) :


5. (Temporal lobe) :

1. (brain)
1.1 (Forebrain)
(cerebrum)
, speech, thinking, skill, taste

1.2 (Midbrain)

(visual reflex) (auditory reflex)

4
1.3 (Hindbrain)
(medulla oblongata)
(cerebellum)
(pons)




2. (brain stem)
3. (nerve)
(Sympathetic)
(Parasympathetic)
(exercise)
( exercise)
()
HDL HDL

rTPA ()
0 3 ()
(blood clot)
4.5 6 () criteria
*** rTPA ()
4.5
*** 4.5 rTPA
()

5
Management of Ischemic stroke

..
70 80%
(stroke) (Ischemic Stroke)
Stroke Unit, rTPA ()

clinical Dx. :
1. (Sudden onset)
2. (focal deficit)
function

(speech difficulty)
1 (dysathria)

2 (aphasia)
3. (risk factors)
: 10 (old age)
2
(Hypertension)
(smoking)
(DM)


4. (Head injury)
(Dx. )
Brain imaging
CT Scan
MRI
Cardiac test
X-rays, EKG

6
Blood test
blood sugar, BUN, Cr, electrolytes
*** ( Stroke)
- Blood sugar 30 mg/dl
- ( push glucose

General supportive care

Airway, Breathing, Circulation
Fever
> 37.5 C
Blood glucose
stroke blood sugar stroke stress
Acidosis
Hypertension
220/110 mmHg rest
maintain 10%
captopril ( Adalat sublingual )
IV fluid
Treatment of underlying disease

captopril oral Nifedipine sublingual
Aspirin in first 48
2 oral
Stroke Unit
care map
ward stroke
Craniectomy

rTPA ()
Infusion 0.9 mg/kg (max 90 mg) over 1 hr.
10% bolus dose over 1 minute

7
stroke unit
comprehensive stroke unit
rehabilitation stroke unit
anticoagulant

stroke
heparin

warfarin

treatment of neurological complication

(cerebral edema) 1 2

20 30
jugular vein
. mannitol vein
glycerol vein
secondary prevention
stroke
secondary prevention treatment
secondary prevention
stroke
1) cardio embolic stroke ()

anticoagulant warfarin oral

2) / ()
first choice / baseline
Aspirin 50 325 mg oral OD

Clopidogrel 75 mg oral OD
Aspirin 25 mg + dipyridamole 200 mg oral twice daily
Cilostazol 100 mg oral twice daily
Ticlopidine 250 mg oral twice daily
Trifusal 600 900 mg / day

8
3) anticoagulant : warfarin
/
7 ( /
7 7 / )



/
stroke ()
4) (carotid endarterectomy)
70%
stroke (
)

9
Medical Management of Stroke

..
stroke 24 TIA (Transient Ischemic Attack)
24 ,

1. , (Ischemic stroke)
2. (Hemorrhage)

1. (Ischemic stroke)
1.1 (atherothrombosis)


1.2

2. (Hemorrhage)
2.1 (intracerebral hemorrhage)

2.2 (amyloid
angiopathy)

2.3 (ruptured aneurysm)

(subarachnoid hemorrhage)
2.4 (arteriovenous malformation)
(subarachnoid
hemorrhage)
2.5


!!!!!

10

FAST
F = Face ,
A = Arms ,
S = Speech ,
T = Time

cholesterol

11

rTPA () vein acute ischemic stroke
3
(intracranial hemorrhage)
Aspirin

(Antiplatelet)
stroke ,
aspirin 48 (
24 rTPA)
Aspirin Aspent M 81 mg

Aspirin :
: DHF
:

Clopidogrel

(Antiplatelet)
stroke ,
plavix 75 mg oral OD

12

Ticlopidine

(Antiplatelet)
stroke ,
Ticlid 250 mg oral OD, Viladil 250 mg oral OD
platelet

Dipyridamole

(Antiplatelet)
stroke ,
Aggrenox 1 tab oral bid

Anticoagulant

Warfarin (Orfarin)

stroke ,
(bleeding)

vit k Antidote

Heparin

stroke ,
(bleeding)

13

Nadroparin

stroke ,
Fraxiparine

Thrombolytics

Thrombolytics Fibrinolytics
plasminogen
plasmin
protease fibrin

Alteplase (rTPA)

Actilyse
40,000 / 1 dose
stroke acute
rTPA check list
check list yes
O.K.
check list no
case
(bleeding)

14

rTPA :
24

:

: NG tube

24
:
30
:
SBP < 185 mmHg, DBP < 110 mmHg

ACEI
z (Angiotensin Converting Enzyme Inhibitor)

Enaril, Captopril, Ramipril

Angiotensin
Converting Enzyme (ACE) Angiotensin II
Angiotensin II
(vascular resistance) Angiotensin Converting
Enzyme (ACE) bradykinin
Angiotensin Converting Enzyme (ACE)
2 Angiotensin II
bradykinin

15
Management of hemorrhagic stroke

..
Cause of Hemorrhegic
Ruptured Aneurysm
Ruptured AVM
Tumor Bleeding
Small VV. Disease
Hemorrhegic Infarct
Surgery for Stroke
To Relief Intracranial Pressure
To Prevent Rebleeding
To Monitor Intracranail Pressure
To Get Definite Pathological Dx
To Increase Blood Supply to Brain
To Relief ICP
Emergency or urgently
Wide craniectomy clot removal
Craniotomy clot removal
Ventriculostomy UNI / Bilateral


ICP Monitor feeding tube
scale 0 30 ICP
To Prevent Rebleeding
Clipping of Aneurysm
Removal of Cavernous Angioma
Removal of AVM
Aneurysm
()
Aneurysm Circle of Willis pressure

Sudden, Severe Headache (

15% )

16

( Minigitis ),
pressure subarachnoid

CT Scan
: warning leak CT Scan
:
: Anemia CT Scan
3 Lumbar plungture 3

Investigation 24 80
Surgical
48 100

1. Clipping ( Aneurysm)
2. Coiling ( Aneurysm )
AVM (Arteriovenous malformation)

()

Glue embolization AVM ( AVM

)
Radiosurgery ( AVM)

Rebleeding

Urgent Work Up & Surgery / Target Within 24 hr

Perfect Clipping of Aneurysm
Preserved All Parent & Distal vv.
Avoid Injury to Brain & Cranial Nerve
Complete Occlusion of Neck
Removal of Subarachnoid Blood

17
Vasospasm
flow

Triple H Regimen After Clipping

Hypervolumia / CVP 10 12 cmH20
Hemodilution / HCT 35%
Hypertension
Removal of Subarachnoid Blood
Balloon Angioplasty Stent Intra-Arterial Papaverine
Hydrocephalus
Correlated With Amount of Subarachnoid Blood
Intra OP Removal of SAH
Spinal Drainage
Intermittent LP.
Shunt If Needed
Epilepsy
High Risk in Middle Cerebral Area
High Risk in Poor Grade PT.
Prophylaxis (short course)
2
Intercerebral Hemorrhage

pressure ( )
Cerebral Edema
Hemorrhage
*** record Glasgow Coma Score
, record
drop 2 point

18
Cerebellar Hematoma
Posterior Fossa Hemorrhage
Medulla oblongata
Smaller Space
Less Warning Sign Before Apnea
10 ml is Consider Big
Careful For Post OP Hydrocephalus
Cerebellar Edema is Dangerous
Brainstem Hematoma
cranial neuropathy

Hypoglycemia
remove blood clot hemorrhage

140/90 mmHg

130/80 mmHg
residual deficit

weakness
,
speech difficulty

pain syndrome
infarction lesion thalamus
thalamic pain syndrome (,
)
sling
sensory loss

19
memory deficit

,
psychosocial
30% psychosocial,
bowel / bladder / sex
,
1 2
(
)
loss of awareness
Awareness
, loss
of body image

20
Medical Nutrition Therapy for Stroke

.
/

() X 25 30 ()
stroke
1.
2.
3.
90% stroke HT, DM, Hyperlipidemia

1.
2.
3.
4.



5.
6.

()
( )

-
-

21

:

- 24 (24 hour dietary recall)

- 3 7 (Food record : 3 7 days)

-
acute stroke
/



stroke
/

22

2
1) (Simple carbohydrate) (sugar)
2) (Complex carbohydrate) (starch)
(dietary fiber)



glycemic response

CHO

(
)

23

2,400 3,000 /

2,400 / ( 6 / )

complex ( ,
)
10 20%
300 /
( LDL 100 / 200 / )


10 20 %
45 60 % < 300 /

< 3,000 /

24

-
-
-

-
-

-
-
:

-
-

-
-

25

- /
-
- /
-
-

Cholesterol
200 mg/dl
Triglyceride
150 mg/dl
HDL-cholesterol
40 mg/dl ()
50 mg/dl ()
LDL-cholesterol
130 mg/dl

1. (Milk based Formula)

Lactose intolerance

26
2. (Blenderized Formula)
5


3. (Commercial Formula)


Lactose Free

27
Rehabilitation of stroke

.
(Paralysis)
(Paresis)
(Hemiplegia)
(Paraplegia)
(Tetraplegia)

1.
2.
3.
4.
5.

1)
2)
3)
4)
5)
6)
7) /
8)
9)

28

10 30 2

1.

2 (
)
2

2.

(
)
2 (
)

29

2 (
)

(
2
)

()

()

2 3 5

2
2

30

2
8 12
45

( )

45 2

31

-
- (
)

2 (
)

32
Activity daily living care and preparing home and environment of stroke

.

,
function ,
***
***
,

,
/

, / , /

3 4
2

33

,
3

1. Activities of Daily Living Training
&
2. Hand Function Training
&
3. Neuromuscular Function

4. Sensory Integration
/
5. Perception and Cognitive Function
&
6. Swallowing Training
&
7. Adaptive / Assistive Device

8. Splint
&
(Activities of Daily Living)

(Physical Daily Living)
(Grooming & Hygiene)
(Feeding / Eating)
(Dressing)
(Functional Mobility)
(Functional Communication)

/ (Psychosocial / Emotional Daily Living)
/ (Self Concept / Self Identity)
(Situational Coping)
(Community Involement)

34

1.
2. &
3.
4.
5.
&




/
&

ADL
Feeding /
Eating

Dressing

(,
)

Grooming

&
Hygiene

&

,
(
,
)
(
/
)

(
)

35
()

Oral structure
,
Oral mechanism
, ,
/
, /
Hyposensitivity
/
Hypersensitivity

36
Oromuscular Exercise

, , ,
,

3 / , 10
2 reflex
gag reflex ()
cough reflex ()

( )

37
Complications of stroke : prevention and treatment

..

: ,
:

: ,


3 , ,
clear O2
( 2
)
,

stage 1

stage 2
, tissue
stage 3

stage 4

38

stage 1

stage 3, 4

(passive exercise)
/

2





passive exercise
, botex

Aspirin oral O.D.
Antipepsin
(B.P.) 135/85 mmHg, 120 mmHg
HbA1C 7 % 100 mg/dl
150 mg/dl

39

( syringe )

,
*** ,

2 3 ,

clear

40
(Hygeine)
(care giver)
(disposable)

(retained foleycath) pampers

(
pampers)

100%
stroke

,

Aspirin Antiplatelet

:
:
Warfarin
Melina ( )
(NPO)

sensory
control

, burn

41
Psychology care of stroke

:
: 40 60%
: stroke

1)




2)

3)

4)


5)

42

1)



2)
40



3)

(1 3 ) 2

stroke
1
Acute
3
Subacute
3
Chronic

43
:
2
1.


2.

,
06.00 07.00 .
,
16.00 17.00 .

stroke
POSTSTROKE DEPRESSION (PSD)
Information , (Active education)
Empowering
Life review therapy 3 /

Motivational interviewing (MI)

5

stroke, stroke

44
Physical exercise

Supportive program stroke
, ,

Music therapy

45
Nursing care of ischemic stroke

.

1. FAST
F
=
Face
A
=
Arms
S
=
Speech
T
=
Time
2.
3. Lab
(FBS, BUN, Cr, Electrolyte, Coagulogram PT, INR)
4. CT Scan, Chest X-ray, EKG
5. NPO
6. rTPA 90
7. record I/O
8. 24 CT Scan
9.
10. emergency BP drop, bleeding

rTPA acute 4.5 Ischemic Stroke

1) 3
2) (Myocardial Infarction) 3
3) 21
4) 14
5)
6)
7) 185 mmHg 110 mmHg
8)
9) INR 1.7
10) heparin warfarin 48 PTT (Partialthromboplastin time)
11) 100,000 / 3
12) 50 . / . 400 . / .
13)

46
14) hypodensity > 1/3 cerebral hemisphere

1) stroke unit ICU

2) best rest : 15 30
3) keep BP
4) ()
37.5

rTPA 24
heparin / warfarin / antiplatelet
NG Tube / Foleys cath
(central line)
Arterial Blood gas
30

rTPA
CT brain emergency

: CBC, Plt, INR, PTT, PT
FFP (Fresh Frozen Plasma) 10 c.c./kg.
COMPOSURE
C
=
Consciousness
O
=
Oxygenation
M
=
Motor function
P
=
Pupils
0
=
Ocular movement
S
=
Signs
U
=
Urinary output
R
=
Reflexes
E
=
Emergency

47
(D/C)


48

: /
:
: / /
: /
:
: (Quality of Care)

, , ,

DMETHOD Model
DMETHOD Model
D
=
Diagnosis
M
=
Medication
E
=
Environments & Economics
T
=
Treatment
H
=
Health
O
=
Out patient referal
D
=
Dietary

/

48

/ / /



(Ischemic Stroke)
1. 72


2.

3.

4.

5. / /

6.

49
Nursing care of hemorrhagic stroke

.
(Hemorrhagic Stroke)
ICH (Intracerebral Hemorrage)
IVH (Intraventricular Hemorrhage)
SAH (Subarachnoid Hemorrhage)
BGH (Basal ganglion Hemorrhage)

CT Scan
MRI
Angiogram

1.
2.
3.
4.
5.
Conscious Level

Alert
Drawsy
Stupor
Semi Coma
Coma

15 30

V/S, N/S 15 60

50

1.

V/S, N/S

2.



Active Passive Exercise

51
3.






HHC
PCU
4.

weak

52

6 8

5
1.
small talk
,


2.


3.


6

53
4.


5.
/

54
Counseling of stroke

1 3

(care giver) 1 2 care giver
1

55
(care giver)

()

shopping,

***
Discharge planning and Home care of stroke

1 1 2
2 - 4 1 2
5
1 ( care giver )

/
/

56
Preparing care giver and Family care of stroke
.

stroke

Neuromed

Neurosurg.

stroke
life after stroke stroke

life after
stroke

Discharge Planning
Preparing Caregiver

Sudden
symptom

Sudden
interrupt

Sudden
role

57
(care giver)