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8 American Nurse Today Volume 6, Number 9 www.AmericanNurseToday.

com
EARLY RECOGNITION and treat-
ment of stroke can improve patient
outcomes significantly. Its essential
that nurses in all settings know
how to recognize signs and symp-
toms of stroke, and alert the stroke
team or activate 911 immediately.
Stroke is a neurovascular condi-
tion affecting blood vessels in the
brain. The two basic types of stroke
are ischemic and hemorrhagic.
In ischemic stroke, occlusion of
a cerebral artery causes damage
to the brain tissue dependent on
blood supply from the affected
vessel.
In hemorrhagic stroke, a cerebral
artery leaks blood, which dam-
ages adjacent brain tissue.
Basics of the brains blood sup-
ply are relatively easy to remember.
The carotid arteries supply the an-
terior portion of the brain, which
includes most of the cerebrum. The
vertebral arteries, housed in the cer-
vical vertebral column, merge to
form the basilar artery feeding the
posterior portion of the brain,
which houses the cerebellum and
brain stem. (See Arteries supplying
the cerebrum.)
This article discusses the major
cerebral blood vessels and the
functional areas each vessel sup-
pliesknowledge that helps you
focus your neurologic assessment.
Then it describes how patient
assessment differs by suspected
stroke location. The American
Stroke Association recommends
clinicians perform neurologic as-
sessments at least every 4 hours
on patients with acute strokes.
More frequent assessment may
be needed for a patient who is
unstable, has fluctuating signs or
symptoms, or has received throm-
bolytics.
Strokes of the middle cerebral
artery
The largest vessel branching off the
internal carotid artery, the middle
cerebral artery (MCA) is the most
common cerebral occlusion site.
For this reason, signs and symp-
toms of MCA strokes are the most
important to remember. (See Major
arteries supplying the brain.)
The MCA feeds an enormous
territory of brain, including the
frontal, temporal, and parietal
lobes and the brains deep struc-
turesbasal ganglia and internal
capsule. The MCA has a main stem
and several branches arising from
it. Occlusion of the main stem af-
fects the entire territory of brain
supplied by the MCA. Distribution
of the MCA is so large that a stroke
of the main stem puts the victim at
risk for severe disability or death.
In contrast, occlusion of an MCA
branch damages a smaller brain
territory and causes less severe dis-
ability. (As an analogy, if a traffic
accident occurs on a large inter-
state, the effect is severe, potential-
ly disrupting an entire region or
city. But an accident that blocks
only a side street has a much
smaller impact.)
Effects of a complete MCA stroke
The hallmarks of an MCA stroke are
the focus of most public-awareness
messages and prehospital stroke as-
sessment toolsfacial asymmetry,
arm weakness, and speech deficits.
Complete MCA strokes typically
cause:
hemiplegia (paralysis) of the con-
tralateral side, affecting the lower
part of the face, arm, and hand
while largely sparing the leg
contralateral (opposite-side) sen-
sory loss in the same areas
contralateral homonymous hemi-
anopiavisual-field deficits af-
fecting the same half of the visu-
al field in both eyes.
MCA strokes affect the face and
arm more severely than the leg, so
make sure to focus your assessment
on the face and arm. Ask the pa-
tient to smile. If your patient cant
follow this or other commands, ap-
ply a noxious stimulus to induce a
grimace, and observe for asymme-
try of the lower part of the face.
Next, assess hand and arm strength.
If your patient is uncooperative, ob-
serve spontaneous movement and
look for differences between the
right and left sides. Also check for
a palmar drift or hand or arm
weakness.
Right side vs. left side
Laterality of an MCA stroke deter-
mines additional signs and symp-
toms. If the stroke affects the left
(or dominant) brain hemisphere,
the patient may experience aphasia
Identify the vessel,
recognize the
stroke
Stroke signs and symptoms vary with the affected
blood vessel. Heres what you need to know when
assessing suspected stroke victims.
By Susan Tocco, MSN, CNS, CNRN, CCNS
x
10 American Nurse Today Volume 6, Number 9 www.AmericanNurseToday.com
(partial or total loss of the ability to
communicate through language).
Aphasia may be expressive (diffi-
culty converting thoughts into lan-
guage), receptive (difficulty under-
standing verbal and written lan-
guage), or both.
To quickly assess for expressive
aphasia, ask the patient to name
common objects, such as a pen, a
watch, or a key. Throughout the
exam, note how the patient con-
verses with you. Does he or she
have difficulty naming objects or
expressing thoughts?
To quickly assess for receptive
aphasia, ask the patient to follow
commands; for example, Show me
two fingers on your left hand or
Open and close your eyes. Note
whether the patient follows these
commands. Does he or she simply
nod or shake the head in response
to a yes or no question? Be
aware that patients with receptive
aphasia can understand nonverbal
communication, including the stress
and intonation patterns of speech;
this may allow them to give the
correct response.
Most people are left-hemisphere
dominant, meaning the speech/
language center is in the brains
left side. Thus, expect a patient
with right-sided weakness to have
aphasia, and focus your exam ac-
cordingly. A small percentage of
left-handed persons have right-
hemisphere dominance. If your pa-
tient has left-sided weakness and
aphasia, ask which is the dominant
hand to better understand his or
her signs and symptoms.
With a stroke affecting the right
(or nondominant) hemisphere, the
patient may show signs of unilater-
al neglect. This complex problem
involves a spectrum of manifesta-
tions, including decreased aware-
ness or failure to attend to the
left side and lack of awareness or
concern about the deficits. Note
whether the patient has the head
turned away from the left side or
seems to ignore stimuli on the left
side. Neglect is most often associ-
ated with right-hemisphere strokes,
so expect a patient with left-sided
weakness to have neglect as
welland stay especially alert for
this sign.
Strokes in other vessels
supplying the cerebrum
Although strokes affecting the
brains other vascular territories are
much rarer than MCA strokes, their
features are important to remember.
Anterior cerebral artery
The anterior cerebral artery (ACA)
branches off the internal carotid
artery and supplies the anterior me-
dial portions of the frontal and pari-
etal lobes. Its the vessel least com-
monly affected by strokes, so a
stroke involving the ACA can easily
be misdiagnosed. Classic signs of an
ACA stroke are contralateral leg
weakness and sensory loss. Be sure
to evaluate lower-extremity strength
and sensation. Keep in mind that
behavioral abnormalities and incon-
tinence also may occur.
Posterior cerebral artery
The posterior cerebral artery (PCA)
arises from the top of the basilar ar-
tery and feeds the medial occipital
lobe and inferior and medial tem-
poral lobes. Vision is the primary
function of the occipital lobe, so a
stroke affecting PCA distribution
commonly causes visual deficits
specifically contralateral homony-
mous hemianopia. (While an MCA
stroke also may cause this symp-
tom, in that case the visual deficit
stems from damage to the visual
pathways rather than direct occipi-
tal-lobe injury.)
A patient who has had a PCA
stroke may report inability to see
out of one eye. To investigate this
complaint, have the patient cover
one eye; assess vision in each of
the eyes four quadrants, and repeat
the exam in the other eye. Know
that although patients with a right
PCA stroke may report poor vision
in the left eye, they actually have a
visual deficit affecting the left side
of the visual field of both eyes.
Larger PCA strokes also may
cause contralateral hemiparesis
and hemisensory loss. Large left
PCA strokes may result in aphasia,
whereas right PCA strokes may
cause neglect.
Vertebral-basilar strokes
A stroke affecting the vertebral-
basilar circulation can affect the
cerebellum, brain stem, or both.
Cerebellar strokes
Cerebellar strokes commonly impair
balance and coordination. Assess for
ataxia (incoordination) by having the
patient extend the index finger and
then alternately touch your finger
and his or her nose. Do this on both
sides. Note difficulty moving the fin-
ger in a straight line. Next, have the
patient slide the heel up and down
the shin of the other leg, and repeat
Arteries supplying the
cerebrum
Understanding which areas of the brain
are supplied by each blood vessel helps
you identify the location of your patients
stroke during your examination. This
color-coded illustration shows the vascu-
lar territories of major cerebral arteries.
Cortical vascular territories
Anterior cerebral artery
Middle cerebral artery
Posterior cerebral artery
www.AmericanNurseToday.com September 2011 American Nurse Today 11
this on the other side. Again, note
whether the patient has difficulty
moving in a straight line.
If possible, have the patient walk
as you assess gait. Can he or she
walk in a straight line, or is the gait
uncoordinated? Know that cerebel-
lar strokes also may cause vertigo,
nausea and vomiting, headache,
nystagmus, and slurred speech.
Brain stem strokes
Although rare, brain stem strokes
can be devastating. Signs and
symptoms differ with the specific
stroke location, but may include
hemiparesis or quadriplegia, senso-
ry loss affecting either the hemi-
body (half of the body) or all four
limbs, double vision, dysconjugate
gaze, slurred speech, impaired
swallowing, decreased level of con-
sciousness, and abnormal respira-
tions. Patients with brain stem
strokes are likely to be critically ill
and may require emergency intuba-
tion and mechanical ventilation.
Hemorrhagic stroke
A hemorrhagic stroke occurs when
a cerebral artery leaks blood into
the brain due to a nontraumatic
cause, such as hypertension or rup-
ture of an aneurysm or an arteriove-
nous malformation. Hemorrhagic
strokes cause the same focal symp-
toms described above, depending
on which artery is affected. Howev-
er, they typically result in more pro-
nounced headaches, neck pain,
light intolerance, nausea and vomit-
ing, and impaired level of con-
sciousness than ischemic strokes.
Generally, patients with hemorrhag-
ic strokes are more critically ill than
those with ischemic strokes.
Differentiating stroke from
other conditions
Keep these key points in mind
when evaluating your patient for
acute stroke signs and symptoms.
Determine if your patients
symptoms had a sudden onset.
Stroke symptoms tend to be
more sudden than those of other
conditions.
Find out if your patient has
stroke risk factors, such as hy-
pertension, atrial fibrillation,
smoking, heart failure, carotid
stenosis, or coronary artery dis-
ease. (But know that patients
without obvious risk factors can
still have strokes.)
Review the medical history. Are
the patients current deficits old
or new?
Assess for nonstroke conditions
that can cause neurologic effects,
such as hypoglycemia, hypona-
tremia, medication, sudden blood
pressure drop, and (if your patient
had a seizure) a postictal state.
Time is brain
Early recognition of a stroke is es-
sential, because a stroke cant be
treated unless its recognized.
Acute stroke interventions are
time-sensitive. In most cases, they
must be initiated within 3 to 6
hours of known onset. The ability
to promptly assess stroke signs and
symptoms can dramatically affect
patient outcomes and reduce the
risk of disability. Be your patients
hero by recognizing a stroke. *
Visit www.AmericanNurseToday.com/
Archives.aspx for a list of selected references,
an illustration of the functional brain areas,
and information about a validated stroke as-
sessment tool.
SusanTocco is a neuroscience clinical nurse specialist at
Orlando Regional Medical Center in Orlando, Florida.
F
ind out if your
patient has
stroke risk
factors, such as
hypertension,
atrial fibrillation,
smoking, or
heart failure.
Major blood vessels supplying the brain
This illustration shows the major blood vessels supplying the brain. They arise from the
circle of Willisthe system of communicating arteries at the base of the brain, where
the carotid and vertebrobasilar arteries form a circle and where other arteries arise.
NIH stroke scale
The National Institutes of Health Stroke Scale (NIHSS) is a validated 15-item neuro-
logic assessment tool that can be used to evaluate the patients current status and
the size of the ischemic stroke. It encompasses level of consciousness, visual-field
deficits, eye movements, motor/sensory changes, ataxia, aphasia, and inatten-
tion/neglect. You can access the tool at http://www.ninds.nih.gov/doctors/
NIH_Stroke_Scale.pdf.
Generally, a complete NIHSS is done in the emergency department or after the
stroke patient is admitted to the unit. Some hospitals instead opt for ongoing neu-
rologic assessments using abbreviated versions of the NIHSS (typically with fewer
than 15 items). However, these versions may miss some neurologic findings, espe-
cially in patients with lower scores. Any decline in a modified NIHSS score should
prompt an immediate assessment using the complete NIHSS to identify changes in
the patients status.
Functional areas of the brain
This illustration shows the brains functional areas. After a stroke, deficits in function
depend on which cerebral artery is affected.
Voluntary eye movement
Motor and speech production
Higher intellect
Self-control
Inhibition
Emotions
Motor and speech production
Motor skills development
Sensation
Language
comprehension
Vision
Memory
Auditory
Equilibrium
and muscle
coordination
ONLINE Sidebars
NIH stroke scale
The National Institutes of Health Stroke Scale (NIHSS) is a validated 15-item neuro-
logic assessment tool that can be used to evaluate the patients current status and
the size of the ischemic stroke. It encompasses level of consciousness, visual-field
deficits, eye movements, motor/sensory changes, ataxia, aphasia, and inatten-
tion/neglect. You can access the tool at http://www.ninds.nih.gov/doctors/
NIH_Stroke_Scale.pdf.
Generally, a complete NIHSS is done in the emergency department or after the
stroke patient is admitted to the unit. Some hospitals instead opt for ongoing neu-
rologic assessments using abbreviated versions of the NIHSS (typically with fewer
than 15 items). However, these versions may miss some neurologic findings, espe-
cially in patients with lower scores. Any decline in a modified NIHSS score should
prompt an immediate assessment using the complete NIHSS to identify changes in
the patients status.
Functional areas of the brain
This illustration shows the brains functional areas. After a stroke, deficits in function
depend on which cerebral artery is affected.
Voluntary eye movement
Motor and speech production
Higher intellect
Self-control
Inhibition
Emotions
Motor and speech production
Motor skills development
Sensation
Language
comprehension
Vision
Memory
Auditory
Equilibrium
and muscle
coordination
ONLINE Sidebars