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VASCULAR DISTURBANCES (MODULE C)

CEREBROVASCULAR ACCIDENT (CVA)

-stroke; brain attack; counterpart of MI- interruption of blood supply to the brain, causingtemporary or loss of movements, thoughts, speechor sensation.

Predisposing factors:

Hereditary ( familial predisposition)Age ( increase age increase risk) 55 y.o.Gender

Types:>Large Artery Thrombotic stroke>Small Penetrating Artery thrombosis

- lacunar stroke; most common>Cardiogenic Embolic stroke

- assoc. with atrial fibrillation>Cryptogenic stroke

- no known cause>Other causes: migraine, drug use, coagulopathies

Precipitating factors:

HPN, DM, Smoking, Atrial fibrillation, obesity,hyperlipidemia, increase alcohol consumption,stressful lifestyle

Atherosclerotic plaque

*Thrombotic slow, progressive ( LAT and SMA)Embolic sudden

HEMORRHAGIC STROKE

Precipitating factor :Uncontrolled HPNArteriovenous malformation rupture of vessel

Intracranial aneurysm bleeding(rupture)Intracranial neoplasm

Onset: sudden, rapid

Manifestations:>motor deficits dysarthria; hemiparesis/plegia;ataxia(staggering, unsteady gait)>frozen shoulder>Subluxation of shoulder>Painful shoulder hand dystrophy>Addduction of arm with internal rotation. Flexion ofelbow, wrist and fingers>External rotation of leg at hip joint, flexion at kneeand plantar flexion and supination of ankle.

>shortened heel cord>speech difficulties and visual disturbances

Interventions:>pillow below the axilla (side-lying position)>free palm relieve pressureFor flaccid paralysis:>dorsal wrist splint spastic upper extreme.> passive ROM affected

Active ROM unaffected4-5x daily

>turn to sides q 2h>15-30mins in prone

>less amount of time in affected area decreasedsensation

Pillow on headBlanket on hip promote normal gaitKnees and thigh should not be flexed venous returnUnilateral neglect move affected part withunaffected part

1 MOTOR DEFICITSAtaxia ambulation devices; provide safetyDysarthria gestures; ample time to respondPsychological emotional supportDysphagia chew properly and on unaffected side

Sit upright when eating or out of bed NGT Tuck chin to chest swallowing; prev.

aspiration

2 VERBAL DEFICITSAphasia loss/ineffective speech3 types:>Sensory/Receptive/Wernickes/Fluent

>Motor/Expressive/Brocas/Non-Fluent>Global

Interventions:Use simple sentencesEncourage gestures and picturesAlternative meansTalk slowly and clearlyAmple time to respondEnc. to repeat alphabet sound esp on brocasBe consistent and repeat if necessary

3 VISUAL DEFICITS**Homonymous Hemianopsia

Left Homonymous Hemianopsia

Right Homonymous Hemianopsia

>Approach on unaffected side>Provide safety>Allow to scan room

**Aplopia consistent placing of things in same place>Explain location

**Horners Syndrome paralysis of sympatheticnerve

Ptosis / sinking of eyeballs Constriction of pupils Tearing

>Explain location of things>Proper lighting

4 SENSORY DEFICITS**Paresthesia numbness/tingling sensation ofaffected extremities.>Dont use affected areas as dominant limb.>ROM affected area.

5 EMOTIONAL DEFICITS~depression ~mood swings~hostility ~loss of self-control

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~anger ~decrease tolerance to stimuli~fear>Encourage verbalization of feelings>Participate in group activities

DX TESTS: Carotid Ultrasound

CT Scan

Cerebral Angiography PET Scan

MRI

ECG

MANAGEMENT

MED:Goal : To allow brain to recover from initial insult

To restore cerebral blood flowTo provide complications and tissue damage.

1. Maintain patent airway

2. Reperfusion and hemodilution with volume

expanders.3. Thrombolytic therapy4. Antihypertensive therapy5. Diuretic therapy6. Calcium channel blockers7. Anticoagulant therapy8. Stool softeners

SURG: Craniotomy

>>Nuchal Rigidity sign of altered cerebral tissueperfusion

TRANSIENT ISCHEMIC ATTACK

Silent Stroke can go unnoticed

>lasts 5-20 mins>temporary disruption of blood supply>mini-stroke copies s/s of stroke>warning stroke

DX TESTS: Auscultation of Carotid Artery CT Scan Rule out stroke

Transesophageal Echocardiography (TEEC)

MGT: Prevent occurrence of stroke

>TIA caused by Atrial Fibrillation-> Anticoagulant Therapy

>Exercise 10 mins everyday.>Determine risk factors

SURG : Carotid EndarterectomyCerebral Angioplasty

INTRACRANIAL ANEURYSM>a thin-walled outpouching or dilation of an artery ofthe brain>develop usually at Circle of Willis and InternalCarotid Artery

>> BerrySaccular saccular outpouching

Fusiform - outpouching of vesselDissecting intimal layer

>Usually aymptomatic until-- compress surrounding tissue or cranial nerve-- rupture and cause the classical symptoms of

subarachnoid hemorrhageETIOLOGY: Atherosclerosis Genetics Congenital conditions Trauma Infection Inflammation Increase turbulence in a section of a vessel HPN Smoking

Pathophysio:Vasospasm - > ischemiaSubarachnoid hemorrhage - > blood in CSF

S/S: N/V increased ICPVisual disturbances

COMPLI : HydrocephalusCerebral VasospasmSeizuresRebleeding in 1st 7-14days

DX TESTS: Lumbar Tap presence of blood in

subarachnoid space; except for increase ICP Angiography definitive exam

Skull X-rays

CT-Scan

Hunt-Hess Scale -bleeding

TX:MED:>Antifibrinolytic agent Epsilon Aminocaproic acid>Increase ICP Dexamethasone>Prophylactic anticonvulsant

SURG:Balloon TherapyGamma knife

NG:Glasgow Coma ScaleMonitoring changes in ICP

Monitor for focal neurologic deficits

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MYELOMALACIA

>softening or infarction of spinal cord from spinalartery occlusion>poor prognosis>little or no return of normal fxn>transverse myelitis

MANIF:INITIAL : Areflexia

Flaccid limbsMotor paralysisSensory loss below level of lesionParalysis of bladder and bowel sphincters

TX:>Symptomatic care of probs rxlting from cord lesion>Tx of ds that caused vascular lesion

NG:>Provide pain relief>Maintain body fxns>Preventing complications of immobility>Intensive rehab for 12-48 hrs after onset ofmanifestations

HEMATOMYELIA

>hemorrhage into substance of spinal cord

Cause : TraumaVascular malformationBleeding d/o

MANIF:>immediately happens after spinal injury; dependson size of hemorrhage>motor deficits

DX TESTS:X-RaySpinal AngiographSpinal CT-ScansMRI

TX:>Immediate surgery to relieve cord compression>Ligating the feeding vessels>Excising the entire malformation

NG:>Provide pain relief

>Maintain body fxn>Prevent compli of immobility>Intensive rehab 12-14hrs pc onset of manif