I.

Definition
CVD (Cerebrovascular disease) - refers to a group of conditions, diseases, and disorders that affect the
blood vessels and blood supply to the brain. If a blockage, malformation, or hemorrhage prevents the brain cells
from getting enough oxygen, brain damage can result. Cerebrovascular disease can develop from a variety of
causes, including atherosclerosis, where the arteries become narrow; thrombosis, or embolic arterial blood clot,
which is a blood clot in an artery of the brain; or cerebral venous thrombosis, which is a blood clot in a vein of
the brain.
Cerebrovascular diseases include stroke, transient ischemic attack (TIA), aneurysm, and vascular malformation.

II. Overview of the system Involved

The heart pumps blood up to the brain through two sets of arteries, the carotid arteries and the vertebral arteries. The
carotid arteries are located in the front of the neck and are what you feel when you take your pulse just under your jaw.
The carotid arteries split into the external and internal arteries near the top of the neck with the external carotid arteries
supplying blood to the face and the internal carotid arteries going into the skull. Inside the skull, the internal carotid
arteries branch into two large arteries – the anterior cerebral and middle cerebral arteries and several smaller arteries – the
ophthalmic, posterior communicating and anterior choroidal arteries. These arteries supply blood to the front two-thirds of
the brain.

The vertebral arteries extend along side the spinal column and cannot be felt from the outside. The vertebral arteries join
to form a single basilar artery near the brain stem, which is located near the base of the skull. The vertebra-basilar system
sends many small branches into the brain stem and branches off to form the posterior cerebellar and posterior meningeal
arteries, which supply the back third of the brain. The jugular and other veins carry blood out of the brain.

Because the brain relies on only two sets of major arteries for its blood supply, it is very important that these arteries are
healthy. Often, the underlying cause of an ischemic stroke is carotid arteries blocked with a fatty buildup, called plaque.
During a hemorrhagic stroke, an artery in or on the surface of the brain has ruptured or leaks, causing bleeding and
damage in or around the brain.

Whatever the underlying condition and cause are, it is crucial that proper blood flow and oxygen be restored to the brain
as soon as possible. Without oxygen and important nutrients, the affected brain cells are either damaged or die within a
few minutes. Once brain cells die, they cannot regenerate, and devastating damage may occur, sometimes resulting in
physical, cognitive and mental disabilities.

III. Causes and Risks

Causes
Cerebrovascular disease develops for a variety of reasons. If damage occurs to a blood vessel in the brain, it will
not be able to deliver enough or any blood to the area of the brain that it serves. The lack of blood interferes
with the delivery of adequate oxygen, and, without oxygen, brain cells will start to die.

Brain damage is irreversible. Emergency help is vital to reduce a person’s risk of long term brain damage and
increase their chances of survival.

Atherosclerosis is a primary cause of cerebrovascular disease. This occurs when high cholesterol levels,

together with inflammation in the arteries of the brain, cause cholesterol to build up as a thick, waxy plaque that
can narrow or block blood flow in the arteries.

This plaque can limit or completely obstruct blood flow to the brain, causing a cerebrovascular attack, such as a
stroke or TIA.

Risks factors

The risk of stroke increases with age, especially if an individual or their close relative have previously had a
cerebrovascular attack. This risk doubles every 10 years, between 55 and 85 years of age. However, a stroke can
occur at any age, even during infancy.

Factors that increase the risk of stroke and other types of cerebrovascular disease include:

 hypertension, which the American College of Cardiology define as blood pressure of 130/80 mm Hg or
higher
  Smoking
 obesity
 poor diet, and lack of exercise
 diabetes
 blood cholesterol levels of 240 milligrams per deciliter (mg/dl) or higher

The same factors increase a person’s chances of a cerebral aneurysm. However, people with a congenital
anomaly or have experienced head trauma may also be at higher risk of a cerebral aneurysm.

Pregnancy can also increase the chance of cerebral venous thrombosis, which is a blood clot affecting a vein in
the brain.

Other risk factors of cerebrovascular disease include:

 Moyamoya disease, a progressive condition that can lead to a blockage of the cerebral arteries and their
major branches
 venous angiomas, which affect around 2% of the U.S. population and rarely bleed or cause symptoms
 a vein of Galen malformation, an arterial disorder that develops in a fetus during pregnancy

Certain drugs and medical conditions can make the blood more likely to clot and increase the risk of ischemic
stroke.

Hormone replacement therapy (HRT) may increase the risk of an attack in a person who already has
atherosclerosis or carotid artery disease.

IV. Complications

Other symptoms of a TIA or stroke include:

 severe headache
 vertigo or dizziness
 vomiting and nausea
 memory loss or confusion
 numbness and tingling in the arm, leg, or face, usually on only one side of the body
 slurred speech
 vision problems
 difficulty or inability to walk

V. Pathophysiology of Disease

Cerebrovascular disease is a heterogeneous group of disorders which are set apart from one another by their
unique pathophysiologic mechanisms and clinical manifestations. When classified in this manner, stroke is
divided into two major categories: hemorrhagic stroke--which results from rupture of a cerebral blood vessel
into the subarachnoid space (subarachnoid hemorrhage) or brain parenchyma (intraparenchymal hemorrhage);
and ischemic stroke--which results from occlusion of a cerebral artery due to degenerative vessel wall disease
(atherosclerosis or lipohyalinosis) or emboli. Early recognition of the specific stroke types promises to lead to
more effective diagnosis and treatment of cerebrovascular disease.
VI. Management
A. Medical Management

Patients who have experienced TIA or stroke should have medical management for secondary prevention.

 Recombinant tissue plasminogen activator would be prescribed unless contraindicated, and there

should be monitoring for bleeding.
 Increased ICP. Management of increased ICP includes osmotic diuretics, maintenance of PaCO2 at
30-35 mmHg, and positioning to avoid hypoxia through elevation of the head of the bed.
 Endotracheal Tube. There is a possibility of intubation to establish patent airway if necessary.
 Hemodynamic monitoring. Continuous hemodynamic monitoring should be implemented to avoid
an increase in blood pressure.
 Neurologic assessment to determine if the stroke is evolving and if other acute complications are
developing
Surgical management may include prevention and relief from increased ICP.

 Carotid endarterectomy. This is the removal of atherosclerotic plaque or thrombus from the carotid

artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.
 Hemicraniectomy. Hemicraniectomy may be performed for increased ICP from brain edema
in severe cases of stroke.

B. Nursing Management
After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.

Nursing Assessment

During the acute phase, a neurologic flow sheet is maintained to provide data about the following important
measures of the patient’s clinical status:

 Change in level of consciousness or responsiveness.

 Presence or absence of voluntary or involuntary movements of extremities.
 Stiffness or flaccidity of the neck.
 Eye opening, comparative size of pupils, and pupillary reaction to light.
 Color of the face and extremities; temperature and moisture of the skin.
 Ability to speak.
 Presence of bleeding.
 Maintenance of blood pressure.

During the postacute phase, assess the following functions:

 Mental status (memory, attention span, perception, orientation, affect, speech/language).

 Sensation and perception (usually the patient has decreased awareness of pain and temperature).
 Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration
status, skin integrity, activity tolerance, and bowel and bladder function.
 Continue focusing nursing assessment on impairment of function in patient’s daily activities.