Cerebrovascular Disorders

is an umbrella term that refers to any functional abnormality of the central nervous system (CNS) that occurs when the
normal blood supply to the brain is disrupted. Stroke is the primary cerebrovascular disorder in the United States and in
the world.

Strokes can be divided into two major categories: ISCHEMIC (85%), in which vascular occlusion and significant
hypoperfusion occur, and HEMORRHAGIC (15%), in which there is extravasation of blood into the brain

ISCHEMIC STROKE
 An ischemic stroke, cerebrovascular accident (CVA), or what is now being termed “brain attack” is a sudden
loss of function resulting from disruption of the blood supply to a part of the brain.
 This event is usually the result of long-standing cerebrovascular disease.
 The term “brain attack” is being used to suggest to health care practitioners and the public that a stroke is an
urgent health care issue similar to a heart attack.
 Ischemic strokes are subdivided into five different types according to their cause:
 large artery thrombosis (20%) - due to atherosclerotic plaques in the large blood vessels of the brain.
Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction.
 small penetrating artery thrombosis (25%)- it affect one or more vessels and are the most common type
of ischemic stroke. Small artery thrombotic strokes are also called lacunar strokes be cause of the cavity that
is created once the infarcted brain tissue disintegrates.
 cardiogenic embolic stroke (20%)- are associated with cardiac dysrhythmias, usually atrial fibrillation.
Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle
cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation
therapy in patients with atrial fibrillation.
 cryptogenic (30%) and other (5%) - The last two classifications of ischemic strokes are cryptogenic
strokes, which have no known cause,
other strokes, from causes such as cocaine use, coagulopathies, migraine, and spontaneous dissection of
the carotid or vertebral arteries

Pathophysiology
In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This
disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade

Clinical Manifestations
 Numbness or weakness of the face, arm, or leg, especially on one side of the body
 Confusion or change in mental status
 Trouble speaking or understanding speech
 Visual disturbances
 Difficulty walking, dizziness, or loss of balance or coordination
 Sudden severe headache
 Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted.
Assessment and Diagnostic Findings
 Any patient with neurologic deficits needs a careful history and a complete physical and neurologic
examination.
 Initial assessment will focus on airway patency, which may be compromised by loss of gag or cough reflexes and
altered respiratory pattern; cardiovascular status (including blood pressure, cardiac rhythm and rate, carotid bruit),
and gross neurologic losses.
 Strokes using the time course are commonly classified in the following manner: (1) transient ischemic attack
(TIA); (2) reversible ischemic neurologic deficit; (3) stroke in evolution; and (4) completed
 Transient Ischemic Attack - Temporary episode of neurologic dysfunction manifested by a sudden loss
of motor, sensory, or visual function. It may last a few seconds or minutes but not longer than 24 hours.
Complete recovery usually occurs between attacks. The symptoms result from temporary impairment of blood
flow to a specific region of the brain due to atherosclerosis, obstruction of cerebral microcirculation by a
small embolus, a decrease in cerebral perfusion pressure (CPP), or cardiac dysrhythmias. A TIA may serve as
a warning of impending stroke, which has its greatest incidence in the first month after the first attack. Lack
of evaluation and treatment of a patient who has experienced previous TIAs may result in a stroke and
irreversible deficits.
 Reversible Ischemic Neurologic Deficits - Signs and symptoms are consistent with but more
pronounced than a TIA and last more than 24 hours. Symptoms resolve in days with no permanent
neurologic deficit.
 Stroke in Evolution- Worsening of neurologic signs and symptoms over several minutes or hours. This
is a progressing stroke.
 Completed Stroke- Stabilization of the neurologic signs and symptoms. This indicates no further
progression of the hypoxic insult to the brain from this particular ischemic event.

 initial diagnostic test for a stroke is a Noncontrast Computed Tomography (CT) Scan performed emergently to
determine if the event is ischemic or hemorrhagic (which determines treatment).
 A 12-lead electrocardiogram and a carotid ultrasound are standard tests.
 Other studies may include cerebral angiography, transcranial Doppler flow studies, transthoracic or
transesophageal echocardiography, magnetic resonance imaging of the brain and/or neck, xenon CT, and
single photon emission CT

 In a patient with a Transient Ischemic Attack (TIA)

 a bruit (abnormal sound heard on auscultation resulting from interference with normal blood flow) may be
heard over the carotid artery.
 There are diminished or absent carotid pulsations in the neck.
 Diagnostic tests for TIA may include carotid phonoangiography; this involves auscultation, direct
visualization, and photographic recording of carotid bruits. Oculoplethysmography measures the
pulsation of blood flow through the ophthalmic artery. Carotid angiography allows visualization of
intracranial and cervical vessels. Digital subtraction angiography is used to define carotid artery
obstruction and provides information on patterns of cerebral blood flow.

Prevention
 Stroke risk screenings are an ideal opportunity to lower stroke risk by identifying high-risk individuals or
groups and educating the patients and the community about recognition and prevention of stroke
 Specifically, high-risk groups include people over the age of 55, because the incidence of stroke more than
doubles in each successive decade, and men, who have a higher rate of stroke than women (due to the higher
prevalence of women in the elderly population, however, the absolute numbers of men and women with stroke are
similar)
 Modifiable risk factors for ischemic stroke include hypertension, cardiovascular disease, high cholesterol,
obesity, smoking, and diabetes
 For people at high risk, interventions that alter modifiable factors, such as treating hypertension and
hyperglycemia and stopping smoking, will reduce stroke risk.
 Many health promotion efforts involve encouraging a healthy lifestyle, including eating a low-fat, low-
cholesterol diet and increasing exercise.
 Patients with moderate to severe carotid stenosis are treated with carotid endarterectomy
 In patients with atrial fibrillation, which increases the risk of emboli, administration of warfarin (Coumadin),
an anticoagulant that inhibits clot formation, may prevent both thrombotic and embolic strokes.

NURSING ALERT
 Many people take herbal remedies and nutritional supplements but do not think of them as “medications” and do
not always report their use to health care providers. Patients receiving anticoagulation following a stroke, TIA,
or diagnosis of atrial fibrillation need to be cautioned that two herbs, ginkgo and garlic, have demonstrated
effects on warfarin (Coumadin). Ginkgo has been associated with increased bleeding times and increased rates of
spontaneous hemorrhage and subdural hematomas. Garlic and warfarin taken together can greatly increase the
International Normalized Ratio (INR), increasing the risk for bleeding
Medical Management
THROMBOLYTIC THERAPY

 Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow
to the brain.
 Recombinant t-PA is a genetically engineered form of t-PA, a thrombolytic substance made naturally by the body.
It works by binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the
atherosclerotic lesion.
 Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in patients with ischemic stroke
leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months