What Every Stroke Patient Wants

Their Nurse to Know…

Presented by:

Mary Kay Bader

RN, MSN, CCNS, CCRN, CNRN, FAHA

Badermk@aol.com

Disclosures

• Bader– American Association Neuroscience Nurses

• President

– Honorarium

• Bard

– Medical Advisory Board

• Neurooptics and Brain Trauma Foundation

Objectives

• Identify the cerebrovascular anatomy of the brain

and differentiate between strokes in the various

cerebral vessels

• Describe the pathophysiology of occlusion and the

importance of collateral blood flow and BP

• Differentiate between the management of BP in

patients receiving tPA and those who do not

receive tPA

• Describe the major nursing priorities in caring for

the acute stroke patient.

What is a stroke?

• Sudden development of a focal neurologic deficit

caused by blockage in an artery feeding the

brain or a rupture of the artery in the brain

Introduction• Statistics

– 795,000 new strokes each year

• 610,000 1st stroke

• 6.4 million stroke survivors in US

• 130,000 deaths each year (decrease of 18.4% between 1996 and 2006) with 25% reduction by 2008

• 20% survivors institutional care after 3 months

• 25-30% permanently disabled

– 4th leading cause of death in US

CDC Prevalence of Stroke in United States 2006-2010. MMWR. 2012. 61 (20): 379-382.

Circulation of Brain

• Anterior circulation

– Carotid arteries

• Posterior circulation

– Vertebral arteries

What kinds of Stroke?

• Ischemic

• Hemorrhagic

Ischemic Stroke

• 87%

– Thrombotic/atherosclerotic disease

• 20%

– Embolic

• 20%

– Lacunar or subcortical stroke

• 20-25%

• Small vessel disease

– Cryptogenic: cause unknown

• 30%

Hemorrhagic Stroke

• 13%

– Intracerebral

– Subarachnoid Hemorrhage

• Aneurysm

–8 to 10 per 100,000 population

»1-5% of population

–10-12 million

–50-80% don’t rupture over lifetime• Vascular Malformations

The Anatomy of Stroke

Right vs Left Brain

• If clockwise, then you use more

of the right side of the brain

• If counterclockwise, then you

use more of the left side of the

brain

Cerebrum

• Left Hemisphere

– rational/logical reasoning, intellectual

deductive/analytical thinking, science, math,

language, reading, writing, sequential ordering,

and the ability to perform fine motor learned acts

• Right Hemisphere

– imagination, inductive reasoning, spatial, art,

music, nonverbal ideation, spiritual, visual images,

shape, recognizing faces, & facial expressions

Anatomy of Cerebral

Vasculature

• Anterior circulation

• Posterior circulation

Anatomical

Assessment

Arterial Syndromes

• Carotid System– Contralateral hemiparesis with facial asymmetry and

sensory changes

– HH, horner’s syndrome, & amourosis fugax

– Dominant hemisphere- aphasia, dyslexia, agraphia,

acalculia

– Non-dominant hemisphere-loss of spatial

relationships, dressing/constructional apraxia

– Headache over ipsilateral eye

Arterial Syndromes

• ACA:

– Contralateral sensorimotor deficit > foot than arm or

face; urinary incontinence;& rigidity

– Abulia-slowness of all reactions

– Distractibility, perseveration, cognitive impairment,

personality changes

– Expressive aphasia

– Apraxia

– Contralateral grasping reflex & sucking reflex

Arterial Syndromes

• MCA– Contralateral paralysis & sensory loss > arm than leg

& homonymous hemianopia

– Dominant hemisphere- aphasia, dyslexia, agraphia, acalculia

– Non-dominant hemisphere-loss of spatial relationships, dressing/constructional apraxia

– Decrease in LOC with massive infarct

Arterial Syndromes

• Vertebrobasilar Artery Syndrome

– Ataxia, vertigo, nausea, transient global amnesia, dysarthria, dysphagia, dysmetria

– Visual disturbances, HH, diplopia, nystagmus, conjugate gaze paralysis

– Facial weakness, tinnitus, deafness

– Altering hemiparesis

– Drop attacks and syncope

Arterial Syndromes

• Posterior cerebral arteries

– Visual changes: field cuts, possible 3rd

nerve palsy, visual perception, inability to

recognize objects, faces, pictures, colors,

or symbols

– Paralysis of contralateral side if pyramidal

tract is affected

– Some hemi-sensory changes

Arterial Syndromes

• PICA-Wallenburg’s syndrome

– Ipsilateral numbness of face & horner’s syndrome (miosis, ptosis, & anhydrosis)

– Contralateral loss of pain & temperature over half of the body

– Dysphagia, dysphonia, decreased gag reflex, & paralysis of soft palate/larynx

– Nystagmus, diplopia, vertigo, nausea & vomiting, hiccoughs

Stroke Signs/Symptoms

• Key Stroke Syndromes

– Left Vessels (dominant hemisphere)

• Left gaze preference

• Right visual field deficit

• Right hemiparesis

• Right hemisensory loss

– Right Vessels (non-dominant hemisphere)

• Right gaze preference

• Left visual field deficit

• Left hemiparesis

• Left hemisensory loss

Stroke Signs/Symptoms

• Key Stroke Syndromes– Brainstem (basilar-vertebral arteries)

• Nausea and/or vomiting

• Diplopia, dysconjugate gaze, gaze palsy

• Dysarthria, dysphagia

• Vertigo, tinnitus

• Hemiparesis or quadriplegia

• Sensory loss in hemibody or all 4 limbs

• Decreased level of consciousness

• Hiccups, abnormal respirations

– Cerebellum

• Truncal/gait ataxia

• Limb ataxia/neck stiffness

Pathophysiology

of Ischemic Stroke

Pathophysiology of Ischemic

Stroke

• Dense core of dead tissue

• Penumbra

• Interruption of blood flow

Pathology of Occlusion

• Once vessel is occluded

– Systemic arterial BP influences CPP and

collateral blood flow during ischemia

– Permanent ischemic cell death ensues

after 30 minutes

• Continued ischemia (< 50% of baseline

CBF) will kill the rest of the vessel

territory

• What can save this area around core?

Collateral Flow

• Example MCA occlusion

– Leptomeningeal arteries

– Cross perfusion from internal system

• Opposite side

• Posterior circulation

Pathophysiology of

Ischemic Stroke

• Cellular Responses to reduced Flow

• Disturbances in calcium homeostasis

• Buildup of lactic acidosis

• Oxygen free radical production

Pathophysiology of

Ischemic Stroke

• Three Factors Affecting

Outcome

– Time dependent

– Degree of ischemia

– Collateral circulation

Pathophysiological Issues

Related to Stroke

• Edema and Increased ICP

– Occurs as natural evolution of insult

– Minimized if restore perfusion

– Assess for change in neurologic

status

• Do not medicate with sedation

agents unless monitoring for

increased ICP

• Prepare for CT

Pathophysiological Issues

Related to Stroke

• Blood Pressure

• Blood Glucose

• Temperature

Pathophysiology:

BP & Stroke

• Alteration in cerebral blood flow

• Brain perfusion dependent on

MAP

• Increases in BP

– may be normal homeostatic

response

– usually falls spontaneously within

24 hours to several days

• Do Not treat BP unless…...

Pathophysiology:

BP & Stroke

• Treat BP in acute ischemic stroke

– No thrombolytics

• Systolic > 220 mm Hg

• Diastolic > 120 mm Hg

• MAP > 130 mm Hg

– Thrombolytics

• Systolic >185 mm Hg – After tPA 180 mm Hg

• Diastolic >110 mm Hg – After tPA 105 mm Hg

Pathophysiology:

Blood Glucose & Stroke

• Maintain blood glucose <

180

– When blood glucose level

exceeds 180 begin

strategies to lower serum

glucose

Pathophysiology:

Body Temperature & Stroke

• Temperature control

–Avoid hyperthermia

•Stroke – normothermia

Don’t Forget the 5 Fs of Stroke

Care

• Flow – (reestablish flow)

• Flat – (head of bed if no edema)

• Fluids – (euvolemia)

• Fever – (normothermia)

• Finger sticks – (control glucose)

Diagnostic Tests in

Stroke Diagnosis

• All Patients

– Non-contrast CT/MRI

– Blood glucose

– Oxygen saturation

– Serum electrolytes/

renal function tests

– CBC / platelets

– Markers of cardiac

ischemia (if needed)

– PT/INR/aPTT

– ECG

• Selected Patients

– TT or ECT

– Hepatic function

– Tox screen

– Blood alcohol

– Pregnancy

– ABG

– Chest Xray

– LP

– EEG

Diagnostic Tests

• Non Contrast CT

• CT angiogram

• CT Perfusion

• Cerebral Angiogram

• MRI

• MRA

• Diffusion Weighted MRI

Computerized Tomography

• CT – Technique: x-ray beam projected thru narrow section of

brain or spine; detectors at opposite side measure attenuation of radiation as it passes through tissues

– Produce a series of thin slices of adjacent anatomy

– Hyperdense tissue (bone) absorbs more x-rays and appears whiter on image. Hypodense (air,fluid) absorb fewer xrays and appear darker

Computerized Tomography

Angiography

• CT

– Technique: Post contrast CT scan

reconstructed to outline cerebral

vasculature.

– Useful in screening for vascular lesions

such as aneurysms or AVMs.

– Enhance tissue where there is

disruption of blood-brain barrier (i.e.

tumors)

Computerized Tomography: Perfusion

• Perfusion CT

– Technique: Ct scan performed during IV bolus

administration of iodinated contrast material.

– Computer calculations provide measures of

regional CBV, MTT, and RCBF

– Used in acute stroke to determine marginally

perfused areas/vulnerable potentially

salvageable areas, and infarcted tissue

Diagnostic Tests

• MTT Mean Transit Time

– How long does it take blood to get to the capillaries

– Delay in arrival of blood ---- increase MTT

CT Perfusion

• CBV=Cerebral Blood Volume

– Think of the brain as a sponge filled with blood

• If ischemic but not dead—blood still be present

in the tissue (picture normal)

• If completed stroke and tissue irreversible—

lack of flow is visible

• CBF=Cerebral Blood Flow

– Flow map cc/gram/cm3

– See Defect in flow

Magnetic Resonance Imaging

• Technique: magnetic fields and radiofrequency waves create signals that generate an image

• Gadolinium can be added as a contrast agent

• Useful for brain (tissue contrast is better than CT) and spine (better for soft tissues and defining lesions such as cysts, vascular lesions, contusions, tumors, edema, hemorrhage or ischemia)

Cerebral Angiography

• Technique: contrast material is injected into

the vertebral and carotid arteries to enable

radiographic visualization of intracranial and

extracranial vessels

• Requires trained interventional team

Focus on

Ischemic Stroke

Care

Two Effective Therapies for

Stroke

• Thrombolysis

–Reduces death and

disability

• Comprehensive Stroke

Care

–Multidisciplinary teamwork

reduces mortality by more

than 25%

Nursing Priorities

• Approach through Case Studies

– Airway and Breathing

– Circulation: telemetry, BP, DVT prophylaxis

– Deficit: neuro monitoring

• Cerebral edema/ICP

– Temperature control

– System support

• Mobility

• GI/GU

• Skin

• Education

• Emotional support

Case 31 yr old Male

Entry of Stroke Patient

• Hospitals must have an

organized Stroke Intervention

Program

– rapid identification and triage

– organized stroke response team

– protocols for emergent work-up

– nursing protocols for preparing,

administering, and monitoring drug

therapy

Arrival of Stroke Patient in

the Emergency Department

• Rapid identification and work-up

– Key symptoms

• Triage to acute area

– Classify as emergent

• Time of symptom onset is crucial

Initial Management

• Primary & secondary survey

– Neurologic assessment with NIHSS

• Start IV and draw labs

• Check Blood glucose

• Monitor: ECG, SpO2, and serial manual BP assessments

• CT scan of brain without contrast STAT

• 12 Lead EKG and chest x-ray

NIH Stroke Scale

� LOC

� LOC Questions

� LOC Commands

� Gaze Abnormalities

� Visual Loss

� Facial Weakness

� Motor Weakness in

Arms

� Motor Weakness in

Legs

� Limb ataxia

� Sensory Loss

� Language

� Dysarthria

� Extinction and

Inattention

Abbreviated NIHSS

• Level of Consciousness

• Level of Consciousness Questions

• Level of Consciousness Commands

• Motor Weakness in Arms

• Motor Weakness in Legs

• Language

• Cardinal Sign-dependent of patient

Time is Brain �

• 911

• Door to ED Physician exam 10 minutes

• Door to Stroke expertise 15 minutes

• Door to CT scan of brain 25 minutes

• Door to CT interpretation 45 minutes

• Door to drug (tPA) 60 minutes

Anatomy of the Lesion

http://www.google.com/imgres?imgurl

This Case - Signs and Symptoms consistent with

Superior Division:

Brachiofacial paralysis

Sensorimotor deficit involving face and arm, leg to a

lesser extent. Foot is spared.

Ipsilateral deviation of head/eyes.

With Left lesion may have initial global aphasia ->

motor aphasia.

No impairment of alertness.

Medical Management

• Goal: reestablish perfusion

• Rule out stroke mimics

• Interventions:

– Traditional interventions

– Thrombolytics

• IV tPA

• Combination IV/IA

• Intraarterial thrombolytics

Intravenous tPA

• Results of NINDS trial

– patients receiving tPA within 3 hours of symptoms

onset had better outcomes at 3 months than those

treated with placebo

– increase risk of intracerebral hemorrhage in

patients treated with tPA

• NIH stroke score > 201

• Brain edema or mass effect on CT1

1NINDS Study Group. Stroke 1997. 28: 2109-2118.

Treatment Decisions

• Treatment Options Ischemic

– Acute

• Within 180-270 minutes tPA unless

contraindicated

–IV (typical dose 60-90 mg total) given

in ED then admit to ICU

• Within 6 hours of presentation

–IA tPA with typical dose 5-8 mg

–Merci retrieval

device/penumbra/solitaire

Intravenous tPATime Window

was < 3 hours

� �It has now moved to 4 ½

hours

Intravenous tPA

Intravenous tPA: Indications

• Patient symptoms < 4.5 hours from symptom onset– CT scan excludes hemorrhage

– NIH stroke scale > 4

– Isolated aphasia

– Age > 18

• Note exclusions for 3-4.5 hour IV tPA– Age > 80 years

– Taking oral anticoagulants

– NIHSS > 25

– Combination of history of prior stroke and diabetes

IV tPA:

Nursing Management

• Start 2nd IV for thrombolytics

• Reassess neuro status using NIHSS q 15 min

• Weigh patient or assess likely weight

• Avoid invasive tubes: foley/NG

Infusion Guidelines tPA

• Preparation of IV tPA drip

– 0.9 mg/kg

– 10% IV bolus over 1-2 minutes

– 90% IV over 60 minutes

• Administration of tPA

– Monitor VS: Q 15 min x 2 hrs, Q 30 min x 6

hrs, then Q 1 hour x 16 hours

– Treat BP accordingly

Team Priorities

• Goal: preserve life and prevent further

neurologic deterioration

• Airway

• Breathing

• Circulation

Team Priorities

• BP Management

– Do not drop BP rapidly

– Decision to treat is based on treatment options

• Thrombolytics:

–Systolic > 185 or diastolic > 110

After bolus > 180/105

• No thrombolytics

–Systolic > 220 mm Hg

–Diastolic > 130 mm Hg

–Mean > 130 mm Hg

Team Priorities

• BP Medications

– Labetalol

– Nicaridipine

• Never give sublingual nifedipine

Team Priorities

• Fluid Management

• Recheck Blood Glucose

• Start 2nd IV for thrombolytics

• Reassess neuro status using NIHSS q 15 min

• Weigh patient or assess likely weight

• Avoid invasive tubes: foley/NG

Post Infusion Guidelines tPA

• Admit to ICU

• Vigilant monitoring of VS and neuro checks

• Avoid NG/central lines for 24 hours

• If neuro condition worsens, notify MD, and prepare

for stat CT of brain

• Do not administer heparin, warfarin, or ticlopidine for

24 hours after tPA

• Keep patient NPO until swallow assessment

Case 86 year oldAcute onset of stroke signs and symptoms

911 called

Pre-Hospital Care Providers

• EMT and/or Paramedic key role– Stabilization of airway, breathing, circulation

– Recognize signs/symptoms of stroke

• Rapid assessment using pre-hospital stroke scale

– Place IV/ cardiac monitor

– Establishing verification of last seen normal

• Patient history from reliable witness

– Provision of supplemental O2 if hypoxic

– Checking blood glucose level

– Avoiding fluids with dextrose

– Load and GO

• Rapid transport to a facility capable of caring for stroke patients

Hyperacute Ischemic Stroke

Onset 1641

• 86 year old at home when developed acute onset of aphasia, left gaze, and right facial droop/arm hemiparesis (5/5 arm/ 5/5 leg)

– NIHSS 16

• Arrives in ED 1716: Code Stroke

• History– Prior stroke minor

– New onset Atrial fibrillation

– Hypothyroidism and chronic thrombocytopenia (platelets 48,000)

• Medications– Dabigatran x 1 dose

– Levothyroxine

ED Priorities

• Airway and Breathing adequate with

99% pulse oximetry

• Circulation: BP 162/87 Afib

• NIHSS 16 and GCS 11

Anatomy of the Lesion

• Left middle cerebral artery M2 branch

Sylvian (M2) Segment

Middle Cerebral Artery Segment divides

into superior and inferior divisions which

can be a site for an embolus to lodge.

Branches supply:

Temporal Lobe and Insular Cortex (sensory

language area of Wernicke)

Parietal Lobe

(Sensory cortical areas)

Inferolateral frontal lobe.

Anatomy of the

Lesion

This Case - Signs and Symptoms

consistent with Superior Division:

Brachiofacial paralysis

Sensorimotor deficit involving

face and arm, leg to a lesser

extent. Foot is spared.

Ipsilateral deviation of head/eyes.

With Left lesion may have initial

global aphasia -> motor aphasia.

No impairment of alertness.

Treatment Options

• IV tPA 0.9 mg/kg– 10% IV bolus

– 90% over one hour

• To Interventional– IA tPA

– Solitaire retrieval

Diagnostic Pictures

• Occlusion of MCA

• Reopening of vessel with

complete reperfusion

Post Procedural Abbreviated NIHSS

• Taken to SICU at 2300: VS and NC q 15

14 hours Post onset• Improvement in Abbreviated NIHSS

• BP within correct parameters post tPA

Nursing Priorities

in Care

• Neuro assessment

and vital signs

• Parameters to call MD

• O2 saturation> 92%

• Monitor for major

bleeding complications

• ECG monitoring for

72h or more

• I/O

• IV fluids 75-100 ml/h

36 hours Post Intervention

• NIHSS improving to 2

NIHSS Full Score

Pupillometer Assessment

• Minimal cerebral edema

• NPI 4.8/4.9

• Constriction velocity normal

NIHSS Full Score

Patient Education

Hypertension

Diabetes

Patient Education

Cholesterol

Smoking

Alcohol

Patient Education

Obesity

Activity

Other recommendations related to: Interventional

approaches (Extracranial carotid disease/vertebro-

basilar disease), and Cardioembolic (AFib,

cardiomyopathy, valvular disease)

Preparing for DC/Transfer

• Make a connection with Patient and their Care Partner– Involve family in decision making

– Family and team meetings to discuss progress

– Encourage care partner to participate in educational and training sessions

– Conduct a pre-discharge needs assessment of the home before D/C (OT or PT)

– Caregiver training if aphasic, positioning, handling shoulder care, how to promote independence, and mobility

Preparing for DC/Transfer

• Make a connection with Patient and their Care

Partner

– Provide education for patient’s family/Care Partner on

stroke pathology, prevention, stroke s/s, actions to

take, follow-up appointments, treatment plan, and

community resources

– Liaison with community providers

– Review individual patient and care partner

psychosocial needs and support needs

– Provide information on discharge plans and post

discharge management to primary care MD/community

ARU Stay Patient transferred to acute rehab on Day 5 -

Progress by Day 10

Outcome

• Discharged home after 13 day stay in ARU

– Supervised transfer to bed mobilty

– Ambulating 150 feet with contact guard assist only

– Cognition – minimal assist with problem solving

– Speech clear and able to communicate

Outcome

• Discharged home after 13 day stay in ARU

– Supervised transfer to bed mobilty

– Ambulating 150 feet with contact guard assist only

– Cognition – minimal assist with problem solving

– Speech clear and able to communicate

Conclusion