CEREBROVASCULAR INSUFFICIENCY

Cerebrovascular insufficiency is an interruption or inadequate blood flow to a focal area of the

brain resulting in transient or permanent neurologic dysfunction. Transient ischemic attack (TIA)
lasts less than 24 hours.

Transient ischemic attack (TIA), sometimes called ministroke, is a brief period of localized
cerebral ischemia that causes neurologic deficits lasting for less than 24 hours (usually less than
1 to 2 hours).

The deficit may be present for only minutes or may last for hours. TIA are often warning signals
of an ischemic thrombotic stroke. One or many TIAs may precede a stroke, with the time
between TIA and a stroke ranging from hours to months

Etiology

 Inflammatory artery disorders

 Sickle cell anemia
 Atherosclerotic changes in cerebral blood vessels
 Thrombosis and emboli ( Thromboembolism from ulcerated plaque in carotid arteries is
the most common cause of TIA accounting for 80% of cases)

Pthophysiology

Similar to that of stroke. The major differences are the short duration of ischemia the lack of
permanent deficits associated with TIAs.

Neurologic manifestations

Manifestation of TIAs vary, depending on which area of brain is affected.

 Sudden onset and often disappears within minutes to hour ( usually 10 to 20 minutes)

 Sudden numbness, tingling, weakness, or paralysis in your face, arm, or leg, especially on only
one side of your body.
 Sudden vision changes.( diplopia)
 Dysphagia
 dysarthria
 Sudden trouble speaking.
 Sudden confusion or trouble understanding simple statements.
 Sudden problems with walking or balance.( ataxia)
 A sudden, severe headache that is different from past headaches

Diagnostic Evaluation
  Auscultation for carotid bruit

 Cerebral angiography, digital subtraction angiography, CT angiography, MRA, Doppler

ultrasound all provide information about carotid and intracranial circulation.
 Partial prothrombin time (PTT) or International Normalized Ratio (INR) if
anticoagulation is considered. Blood levels are monitored to document therapeutic ranges
and determine dosing. PTT is utilized for heparin therapy and INR is utilized for oral
warfarin (Coumadin) therapy.
 Diffusion-weighted MRI may be done to rule out stroke.
 Transesophageal echocardiography to rule out emboli from heart.
 ECG to assess for arterial fibrillation

Management

 Platelet aggregation inhibitors, such as aspirin, ticlopidine (Ticlid), dipyridamole/aspirin

200/25 (Aggrenox), and clopidogrel (Plavix), to reduce risk of stroke.
 Surgical or endovascular intervention to increase blood flow to brain carotid
endarterectomy, extracranial/intracranial anastomosis, transarterial stenting, or
angioplasty.
 Reduction of other risk factors to prevent stroke, such as control of hypertension,
diabetes, and hyperlipidemia, and smoking cessation.
 Treatment of arrhythmias.
 Treatment of isolated systolic hypertension.
 Anticoagulation agents for patients who continue to have symptoms despite antiplatelet
therapy and those with major source of cardiac emboli.
 Carotid Endarterectomy is useful to prevent stroke
 Cerebral angioplasty ( is similar to coronary angioplasty. A balloon catheter is threaded
through the arterial system via the femoral artery to the area of carotid stenosis. A small
balloon is inflated to dilate the lesion. A stent catheter can also be used to further open
the area of stenosis.

Complications

 Complete ischemic stroke

 Hemorrhagic conversion of ischemic stroke
 Cerebral edema

Nursing Assessment

 Obtain history of possible TIA; hypertensive and diabetic control; hyperlipidemia;

cardiovascular disease, such as atrial fibrillation; smoking.
 Perform physical examination, including neurologic, cardiac, and circulatory systems; be
sure to listen for carotid bruit.
  Assess patient for history of headache and, if positive, for duration of headache.

Nursing Diagnoses

 IneffectiveTissue Perfusion (cerebral) related to underlying arteriosclerosis

 Risk for Injury related to surgical procedure
 Readiness for Enhanced Knowledge of risk factors and therapeutic lifestyle changes

Nursing Interventions
Improving Cerebral Perfusion

 Teach patient signs and symptoms of TIA and need to notify health care provider
immediately.
 Administer or teach self-administration of anticoagulants, antiplatelet agents,
antihypertensives, and other medication, monitoring for adverse effects and therapeutic
effect.
 Prepare patient for surgical or endovascular intervention as indicated (see page 484).

Providing Care and Preventing Complications After Surgical Procedure

 After surgery, closely monitor vital signs and administer medication as prescribed to
avoid hypotension (which can cause cerebral ischemia) or hypertension (which may
precipitate cerebral hemorrhage).
 Perform frequent neurologic checks, including pupil size, equality, and reaction; handgrip
and plantar flexion strength; sensation; mental status; and speech. Notify the health care
provider of any deficits immediately.
 Observe operative area closely for swelling. Mild swelling is expected, but if hematoma
formation is suspected, prepare patient for immediate surgery.
 Medicate for pain and avoid agitation or sudden changes in position, which could affect
BP.
 Elevate head of bed when vital signs are stable.
 Following carotid endarterectomy:
o Monitor for hoarseness, impaired gag reflex, or difficulty swallowing and facial
weakness, which indicate cranial nerve injury.
o Keep head in neutral position to relieve stress on surgical site; monitor drainage.
o Keep tracheostomy tube at bedside and assess for stridor; hematoma formation
can cause airway obstruction.
 Following extracranial-intracranial anastomosis, avoid pressure over the anastomosis of
the superior temporal artery (extracranial) and the middle cerebral artery (intracranial) to
prevent rupture or ischemia of the site. If the patient wears glasses, remove the eyeglass
arm on the operative side to avoid this possible pressure point.
 Following transcranial stenting, administer medications as directed.
o Heparin bolus given intraprocedure then continuous I.V. drip postprocedure to
maintain PTT within ordered range; monitor PTT every 6 hours.
 o Clopidogrel (Plavix) before procedure, as ordered. Can be given as a loading dose
of 150 mg the evening before procedure, 300 mg loading dose before procedure,
75 mg 48 hours before procedure or 75 mg daily 1 week before procedure. Dosing
is physician-dependent.
o Daily dosing of 75 mg clopidogrel for 30 to 90 days, as directed.
o Aspirin 81 mg daily as directed.

Encouraging Lifestyle Changes to Reduce Risk

 Help patient begin to formulate a plan for smoking cessation

 Teach patient and family members the basics of the food pyramid, how to read labels,
and how to follow a low-fat, and particularly a low saturated fat diet
 Obtain a referral to a nutritionist for help with weight management and low-fat, low-
sodium diet as indicated.
 Encourage daily activity for 30 minutes if possible. Obtain physical therapy referral for
endurance training and monitoring as indicated.

Patient Education and Health Maintenance

 Encourage patient receiving long-term oral anticoagulants to comply with follow-up

monitoring of INR and to report any signs of bleeding.
 Encourage patients receiving antiplatelets agents to report any signs of bleeding.
 Encourage the use of electric razors and toothbrushes to prevent bleeding.
 Reinforce with patient and family importance of accessing the medical system, by calling
911, when symptoms first occur.
 Refer to National Institute of Neurologic Disorders and Stroke, for additional information
and support