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INTRODUCTION

Stroke (cerebral vascular accident or brain attack) is an emergency condition in
which neurologic deficits result from a sudden decrease in blood flow to a localized area
of the brain. Strokes may be ischemic (when blood supply to a part of the brain is
suddenly interrupted by a thrombus, embolus, or blood vessel stenosis), or hemorrhagic
(when blood vessel ruptures, spilling blood into spaces surrounding neurons).
A stroke is caused by the interruption of the blood supply to the brain, usually
because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen
and nutrients, causing damage to the brain tissue
There are types of stroke: the ischemic stroke; [transient ischemic attack, large vessel
(thrombotic) stroke, small vessel stroke (lacunar infarct), cardiogenic embolic stroke]
and hemorrhagic stroke, [intracerebral hemorrhage and subarachnoid hemorrhage].
Infarct is when there is death of tissue with surrounding inflammation due to a sudden
and complete loss of arterial blood supply. It is often preceded by ischemic injury but if it
is gradual and there is only partial ischemia, the body can quickly develop collateral
blood supply to the target area.
Ischemia and an infarct can occur in any tissue or organ in the body but is the
most life threatening when it affects the heart (heart attack) or brain (cerebrovascular
accident or stroke). Although ischemia and infarct are often discussed in the context of a
blockage in the artery, like plaques in atherosclerosis or a blood clot (thrombus or
embolus), it can also arise from a rupture in the artery thereby preventing oxygenated
blood from reaching the target tissue.
Causes of Cerebrovascular accident:
 Intracerebral hemorrhage (rupture of a blood vessel in the pia mater or brain
 Emboli (blood clots)
 Atherosclerosis (formation of plaque) of the cerebral arteries.
Types of Stroke by Etiology:

Usually a cardiac origin . evolve over 1 –2 hours. Ischemic Strokes (remaining 85%) • Large (40%) or small (20%) vessel thrombosis . Subarachnoid (5%) – result from aneurismal rupture of a cerebral artery with blood loss into space surrounding the brain. Hemorrhage stroke (intracranial hemorrhage) • 5% of all strokes • Two division: a.Most commonly occur in presence of atherosclerotic cerebrovascular disease .Frequently result of chronic ischemic cardiovascular disease with secondary ventricular wall hypokinessis or atrial arrhythmia – both conditions increase risk of intracardiac thrombus formation .1.Vascular changes or lipohyalinosis found in small deep penetrating arteries as associated with chronic hypertension can lead to small vessel thrombosis. arteriovenous malformation or tumor b. -rapid or prolonged interval of onset and may lead last many hours • Cerebral embolism (20%) . Transient ischemic attack (TIA) –neurologic symptoms develop and disappear over several minutes and completely resolve in 24 hours –most frequently associated with atherosclerotic carotid artery disease .Quick onset and fully develop in a matter of minutes Temporal Classification of Stroke 1. 2. Intracerebral (10%) – due to rupture of weakened vessels within brain parenchyma as result of Hypertension.

Death rates from cerebrovascular diseases increased enormously both in men and women. The male to female ratios in the agestandardized death rates increased during this 9-year period. This increase in mortality was seen in all age groups.0 in 2005. This excess mortality in males is mostly due to the increased cardiovascular disease death rate. This is a clear example of how chronic non-communicable diseases are becoming major health problems in countries where they previously have not been prevalent. Age-standardized mortality increased clearly in the male population but decreased in the female population of the Philippines. Stroke in Evolution –describe an unstable ischemic event characterized by the progressive development of more severe neurologic impairment –often associated with active occlusive thrombosis of a major cerebral artery.3 in 2000 to 78. Cardiovascular disease mortality in the Philippines was studied from the existing vital statistics for 2000-2008.2.Etiology unknown . The age-standardized mortality rate in men rose from 33. Immediate preventive measures are needed in .4 to 34.5. Reversible Ischemic Neurologic Deficit . –Once stable called Complete Stroke –Most important sign – Intellectual Regression STATISTICS CVD is the most disabling of all neurologic diseases. Approximately 50% of survivors have a residual neurologic deficit and greater than 25% require chronic care. and that of women from 15.Likely the result from small infarctions (Lacunes) of the deep subcortical gray and white matter resulting in only temporary impairment 3.

Infarctions will result in weakness and loss of sensation on the opposite side of the body. COMPLICATIONS             Altered LOC Aspiration Cerebral Edema Cognitive impairment Contractures Fluid Imbalances Infections (pneumonia) Paralysis Pulmonary Embolism Sensory Impairment Unstable blood pressure( from loss of vasomotor control) Death RISK FACTORS     Alcohol or cocaine use Cardiac disease including atrial fibrillation and vulvar disease Cigarette smoking Diabetes Familial hyperlipidemia . SIGNS AND SYMPTOMS Symptoms of cerebral infarction are determined by the part/s of the brain affected. If the infarction occurs on the left side brain. If the infarct is located in primary motor cortex. Reflexes may be aggravated as well. Millard-Gubler syndrome. Benedikt syndrome or others. Physical examination of the head area will reveal abnormal pupil dilation. speech will be slurred. where disease rates are rapidly increasing. such as ours. light reaction and lack of eye movement on opposite side. Weber's syndrome. With brainstem localization.contralateral hemiparesis is said to occur.order to control cardiovascular diseases in countries. brainstem syndromes are typical: Wallenberg's syndrome.

sedentary lifestyle Sickle cell disease Use of hormonal contraceptives TOP 5 RISK FACTORS      Advanced age Hypertension Smoking Cardiac disease Hypercholesterolemia .        Family history of stroke History of transient ischemic attacks Hypercholesterolemia Hypertension Increased alcohol intake Obesity.

and swallowing. and medulla. A Brainstem . Many simple or primitive functions that are essential for survival are located here. passing messages back and forth between various parts of the body and the cerebral cortex. Ten of the twelve cranial nerves originate in the brainstem. temporal.ANATOMY AND PHYSIOLOGY Brain The brain is composed of the cerebrum. cerebellum. body temperature. wake and sleep cycles. 1 Midbrain . and cerebrum. sneezing. It performs many automatic functions such as breathing. and occipital. pons.includes the midbrain. vomiting. It consists of three structures: the midbrain. It acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. The brainstem is the lower extension of the brain. parietal. coughing. It serves as a relay station. and brainstem The brain is composed of three parts: the brainstem. heart rate.is an important center for ocular motion . cerebellum. The cerebrum is divided into four lobes: frontal. located in front of the cerebellum and connected to the spinal cord. pons and medulla oblongata. digestion.

humans cannot survive. 3 Medulla oblongata . It controls levels of wakefulness. Four pairs of cranial nerves originate from the pons: nerves 5 through 8. The two sides of the brain are joined at the bottom by the corpus callosum.2 Pons . The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex C Cerebellum . which forms the major portion of the brain. neck. and balance.located under the cerebrum. B Cerebrum . enables people to pay attention to their environments. The corpus callosum connects the two halves of the brain and delivers messages from one half of the brain to the other. It is separated from the cerebrum by the tentorium (fold of dura). pons. heart rhythms and swallowing. the fine movements of fingers as they perform surgery . The cranial nerves for smell and vision originate in the cerebrum. is divided into two major parts: the right and left cerebral hemispheres. A fissure or groove that separates the two hemispheres is called the great longitudinal fissure. medulla and part of the thalamus. shoulder and tongue muscles. Destruction of these regions of the brain will cause "brain death. The cerebrum. The reticular activating system is found in the midbrain. The cerebellum fine tunes motor activity or movement. e. taste. eye movement. Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent through the pons and the brainstem.g. hearing and balance. facial sensation. swallowing and movements of the face." Without these key functions. Its function is to coordinate muscle movements.the largest part of the brain and is composed of right and left hemispheres. blood pressure. Originating in the brainstem are 10 of the 12 cranial nerves that control hearing.is involved with coordinating eye and facial movements. and is involved in sleep patterns. facial sensations. The cerebrum is a term often used to describe the entire brain. maintain posture.controls breathing.

Beneath the cerebral cortex or surface of the brain. and fine control of movement. It performs higher functions like interpreting touch. Each lobe may be divided. parietal and occipital lobe." The surface of the brain appears wrinkled. vision and hearing. learning. once again. It helps one maintain posture. The cerebral cortex appears grayish brown in color and is called the "gray matter. temporal. The cerebrum or brain can be divided into pairs of frontal. into areas that serve very specific functions. emotions. it can effectively be divided into pairs of "lobes.or paint a picture. by controlling the tone of muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid and repetitive actions such as playing a video game. sense of balance or equilibrium." Lobes are simply broad regions of the brain. parietal and occipital lobes." The cerebral hemispheres have several distinct fissures. The lobes of the brain do not function alone – they function through very complex relationships with one another. . reasoning. connecting fibers between neurons form a white-colored area called the "white matter. The cerebral cortex has sulci (small grooves). fissures (larger grooves) and bulges between the grooves called gyri. Each hemisphere has a frontal. as well as speech. By locating these landmarks on the surface of the brain. temporal.

words  Sense of touch. self-awareness Parietal lobe  Interprets language. pain. hearing. temperature (sensory strip)  Interprets signals from vision. sensory and memory  Spatial and visual perception Occipital lobe  Interprets vision (color. planning. motor. problem solving  Speech: speaking and writing (Broca’s area)  Body movement (motor strip)  Intelligence.Lobes of the brain Frontal lobe  Personality. movement) Temporal lobe  Understanding language (Wernicke’s area)  Memory  Hearing  Sequencing and organization . emotions  Judgment. concentration. behavior. light.

or from the deep structures of the brain to another region in the central nervous system. Deep structures Hypothalamus . sleep. blood pressure.The hypothalamus is located in the floor of the third ventricle and is the master control of the autonomic system.Messages within the brain are delivered in many ways. The result will be a loss of function such as speech. or the ability to follow simple spoken commands. . and secretion of hormones. the ability to read. from one side of the brain to the other. It plays a role in controlling behaviors such as hunger. from one lobe of the brain to structures that are found deep in the brain. e. emotions. The signals are transported along routes called pathways. It also regulates body temperature. from one lobe to another. thalamus. Messages can travel from one bulge on the brain to another (gyri to gyri). Any destruction of brain tissue by a tumor can disrupt the communication between different parts of the brain.g. thirst. and sexual response.

and memory. hypothalamus. It plays a role in pain sensation. salivate VIII Vestibulocochlear hearing.The thalamus serves as a relay station for almost all information that comes and goes to the cortex. shoulder and tongue muscles originate in the brainstem. swallowing and movement of the face. swallow X Vagus heart rate.The basal ganglia include the caudate. learning.Thalamus . putamen and globus pallidus. The cranial nerves for smell and vision originate in the cerebrum. pupil IV Trochlear moves eye V Trigeminal face sensation VI Abducens moves eye VII Facial moves face. facial sensations. digestion XI Accessory moves head XII Hypoglossal moves tongue . eye movement. attention. Limbic system . Included in this system are the cingulate gyri. Cranial nerves The brain communicates with the body through the spinal cord and twelve pairs of cranial nerves ten of the twelve pairs of cranial nerves that control hearing. amygdala (emotional reactions) and hippocampus (memory). balance IX Glossopharyngeal taste. neck. Number Name Function I Olfactory Smell II Optic sight III Oculomotor moves eye.The limbic system is the center of our emotions. alertness and memory. taste. Basal ganglia . These nuclei work with the cerebellum to coordinate fine motions. such as fingertip movements.

The communication .Blood supply Blood is carried to the brain by two paired arteries. the two vertebral arteries join together to form a single basilar artery. The basilar artery and the internal carotid arteries “communicate” with each other at the base of the brain called the Circle of Willis. brainstem. and the underside of the cerebrum. The vertebral arteries supply the cerebellum. After passing through the skull. The internal carotid arteries supply most of the cerebrum. the internal carotid arteries and the vertebral arteries.

the anterior spinal artery. The Circle of Willis The Circle of Willis or the Circulus Arteriosus is an arterial polygon where the blood carried by the two internal carotid arteries and the basilar system comes together and then is redistributed by the anterior. and posterior cerebral arteries. it gives rise to numerous paramedian. it is possible for collateral blood flow to come across the Circle of Willis and prevent brain damage. Vertebral Artery The two vertebral arteries run along the medulla and fuse at the pontomedullary junction to form the midline basilar artery. The posterior cerebral artery is connected to the internal carotid artery by the posterior communicating artery. Internal Carotid System The internal carotid artery divides into two main branches called the middle cerebral artery and the anterior cerebral artery. The anterior cerebral artery supplies blood to the frontal lobes and medial aspects of the parietal and occipital lobes. Before this divide. Before this divide. also called the vertebro-basilar artery. middle. the posterior inferior cerebellar artery (PICA) and branches to the medulla. Before forming the basilar artery. If one of the major vessels becomes blocked. The middle cerebral artery supplies blood to the frontoparietal somatosensory cortex. the internal carotid artery gives rise to the anterior communicating artery and the posterior communicating artery.between the internal carotid and vertebral-basilar systems is an important safety feature of the brain. the basilar artery divides into the two posterior cerebral arteries. Basilar Artery At the ponto-midbrain junction. each vertebral artery gives rise to the posterior spinal artery. short and long .

tricyclic antidepressants. halofenate. in the "cascade" proper. and antipsychotic drugs). or in the thrombolytic phase? "Full anticoagulation" is desirable and is initiated with heparin and followed by maintenance coumarin drugs. similar actions have been reported for numerous other compounds (antihistamines. Drugs affect different steps in this sequence. barbiturates.circumferential penetrators and two other branches known as the anterior inferior cerebellar artery and the superior cerebellar artery. phenoprofen. clofibrate. sulfinpyrazone) and for the pyrimidopyrimidine compounds (dipyridamole. aggregation. Antiaggregant effects have been demonstrated for non-steroidal anti-inflammatory agents (aspirin. MEDICAL-SURGICAL INTERVENTIONS  Anticoagulants Whether anticoagulation therapy should be given to a patient with completed infarction has not been resolved after 25 years of discussion. sudoxicam. should treatment affect the platelet phase of the coagulative process. papaverine.7  Thrombolytic therapy  Vasodilators Patient’s Medications:     Aspilet 80mg Atorvastatin 40mg . platelets undergo adhesion. cyproheptadine. If it is used.↓ 10 mg Perindopril 5mg ½ tab if BP ≥180mmHg Lactulose (Lilac) 20cc . prostaglandin PGE. and consolidation. release reaction. but most of the "antiplatelet" agents employed interfere with adhesion or aggregation. pyridinolcarbamate).  Platelet Antiaggregants During hemostasis. propranolol. phenylbutazone.

- Carotid angioplasty – for cerebral stenosis Extracranial-intracranial bypass – reestablishes blood flow to the affected area of - the brain Endarterectomy – to remove atherosclerotic plaque . to restore blood flow when a stroke has already occurred or to repair vascular damage or malformations.  Citicholine 1gm IV Ampicillin 750mg IV Possible surgery: Surgery may be performed to prevent the occurrence of a stroke.

Be informed about the expected outcome of stroke.DISCHARGE PLAN MEDICATIONS Name ASA Atorvastatin Citicoline Dosage 80mg 10mg 1gm Frequency/Time Once a day @ 1pm Once a day/HS @ 8pm 2x a day @ 8am 6pm for 6 Perindopril Ampicillin Sulbactam 5mg ½ tab 750mg weeks Once a day for BP >160/90 2x a day 8am 6pm for 7 30cc days Once a day/HS PRN for Lactulose constipation (hold for BM  ≥2x day) Strictly adhere to medication regimen especially to prescribed medications EXERCISE   Have frequent short periods of exercise Safely engage in active and passive range of motion exercises on the affected  extremity Speech therapy to help the patient improve swallowing as well as how to relearn  language and communication skills Occupational therapy provides assistive devices and a plan for regaining lost motor skills that greatly improve quality of life after a stroke TREATMENT  Encourage to have enough rest and comply to the physician whenever health   problems occur Consult with speech therapist to improve ability to communicate. . HEALTH TEACHINGS   Given positive reinforcement and emotional support from his family. and his family should be counseled to avoid doing things for him that he can do. Make sure that follow-up care is adhered to religiously.

low-fat diet such as avoidance of canned and processed    foods Advise to eat nutritional foods like fruits and vegetables Eat well balanced diet Instruct to limit eating foods high in fats and with cholesterol SPIRITUAL  Advise patient not to be discouraged and to have strong faith in Allah . Have at least one family member who will be taught how to take blood pressure to enable the family to monitor the patient’s blood pressure at home. exacerbation of present signs and symptoms and seek prompt medical attention when deterioration of neurological status is apparent such as loss of consciousness DIET  Adhere to a low-sodium. with the help of his family. OUT PATIENT/REFERRALS   Instruct patient to come back for follow up check up on the date ordered report.

pdf scribd.healthhype.html http://stroke.com .REFERENCES BOOKS Medical-Surgical Nursing LeMone 5th edition Straight A’s in Pathophysiology Lippincott Williams & Wilkins INTERNET http://www.com/medical-terminology-ischemia-and-infarct.full.ahajournals.org/content/12/1/7.