Otterbein UniversityDigital Commons @ OtterbeinMaster of Science in Nursing (MSN) StudentScholarship Student Research & Creative Work

2017

The Pathophysiology Of Acute Ischemic StrokeRahel Mitikurahel.mitiku@otterbein.edu

Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn

Part of the Nursing Commons

This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has beenaccepted for inclusion in Master of Science in Nursing (MSN) Student Scholarship by an authorized administrator of Digital Commons @ Otterbein.For more information, please contact shickey@otterbein.edu.

Recommended CitationMitiku, Rahel, "The Pathophysiology Of Acute Ischemic Stroke" (2017). Master of Science in Nursing (MSN) Student Scholarship. 240.https://digitalcommons.otterbein.edu/stu_msn/240

ThePathophysiologyOfAcuteIschemicStroke

RahelMitiku,RN,BSN

IntroductionTherearetwotypesofstroke:hemorrhagicandischemicstroke(Davis,&Lockhart,2016).Forthisposter,thestudentwillfocusonthePathophysiologyofAcuteIschemicStroke(AIS).AISischaracterizedbytheimpactofanobstructionwithinabloodvesselsupplyingbloodtothebrain.Strokeisoneoftheleadingcausesofdeathanddisabilityworldwide(Saccoetal.,p.2065,2013).

Thisstudentworkedasanurseatinterventionalradiology;observingpatientswithAISundergoingclotretrievalprocedureorreceivingtissueplasminogenactivator(tPA)andthrombolysistreatment.

Consequently,thestudentpickedupthistopictofurtherunderstandAIS,indepth,anditsrelationswithpathophysiology.

Suwanwelastatedthat(ascitedbyPaspaljetal.,2015),epidemiologicaldatahaveshownthatstrokeistheleadingcauseofadultdisabilityandthesecondorthirdleadingcauseofdeathinthemostofdevelopedcountries(Paspaljetal.,2015).

Theurgencytotreatacuteischemicstrokeisapparentlycomparablewithacutemyocardialinfraction(MI)inhospitals.Bothrequirerapidandtimelymanagementwhicharenecessarytorestorenormalbloodflowtothebrainorheartandtoreducepermanenttissuedamage.Pathophysiologyissignificantinrelationtocellularlevelbraintissue.

UnderstandingtheearlysignsandsymptomsofAISandthetimelytreatmentwillreducethedevastatingeffects.Mozaffarianexplainedthat(ascitedbyAlfierietal.,2016),AIShasaheterogeneousetiologycausedbymodifiableriskfactorsincludinghypertension,diabetesmellitus(DM),highlevelbloodcholesterol,sedentarylifestyle,smoking,aswellas,unmodifiableriskfactors,suchasgenetic,age,andsex(Alfierietal.,2016).

ThisposterdiscussesthepathophysiologyofAISandtheimportanceoftimelyinterventiontominimizeirreversibletissuedamage.

.

OtterbeinUniversity,Westerville,Ohio

Figure6.Algorithmforthemanagementofpatientswithacuteischemicstroke.IV-

tPAindicatesintravenoustissueplasminogenactivator;RX,treatment.Theabove

informationisretrievedfromwww.circ.ahajournals.org/content/116/13/1504

Conclusion

Ischemicstrokeischaracterizedbytheimpactofanobstructionwithina

bloodvesselsupplyingbloodtothebrain.Theunderlyingpathophysiologyprocess

ofacuteischemicstrokeiscausedbytheblockageofbloodflowtothebraindue

tobloodclot(thrombus)oraplaque(fattydeposits)whichdeprivethebrain

tissue,fromthenecessarynutrientsandoxygen.Advancepracticenurses,likethis

student,shouldequipthemselveswiththecurrentprotocolsandtimely

interventionstosavepatientsfromdevastatingAISdisabilityandfinancialburden.

Atthisjuncture,manyadvancepracticenursesareworkinginfrontlineon

identifyingstrokesymptomsandprovidingthecrucialcarethatpatientsneed.

SignificanceOfPathophysiology

Ø IntheUnitedStates,thesignificanceofAISisitsdevastatingeffectsonhundredsofthousandsof

patientsontheirdaytodayactivities.Forinstance,795000peopleexperiencestrokeseveryyear

hereintheUnitedStates(Babkair,2017).

Ø Theblockageofbloodflowtothebraininevitablycausesacuteischemicstroke(Xingetal,2012).

Oncethetissueoxygenationstarts,dependingonthetimeelapsed,thesituationofthepatient

changes.Thelesserthetimethebettertheprognosis.

Ø ForAIStreatment,tPAisthegoldstandardandalsoassociatedwithimprovedclinicalpatient

outcome(Xingetal.,2012).ThesoonertheIVtPAisadministeredaftertheonsetofstroke

symptoms,thebettertheoutcome(Anderson,2014).

Ø AccordingtotheNationalInstituteofNeurologicalDisordersandStroke(NINDS),patientswhoare

candidatesfortPAshouldreceive0.9mg/kgtPAandforsevereischemicdeficitswithNIHSSscore≤

10orocclusionoflargerarteriesshowninCTangiogram;endovasculartreatmentrecommended

(Payabvashetal.,2015).

Ø ForpatientswhoarenotcandidatesforIVt-PAandpresentedtothehospitalwithin8hoursofthe

symptom,currently,avarietyofothertreatmentssuchaslowdoseIAthrombolytic,mechanical

thrombectomy,angioplasty,andstentplacements(Payabvash etal.,2015).

Figure4.Thetechniquesanddevicesareconstantlyevolvingandimproving,sothatmoreandmorearteriescanbeopenedsafelyandeffectively,asseeninthefollowingcase,whereanoccluded(closed)arterywasreopened.Retrievedfromhttps://med.nyu.edu/radiology/about-us/subspecialties/neuro-interventional/our-services/acute-ischemic-strokeØ OncethetreatmentprotocolinitiatedwithtPAorendovasculartreatment,interventionalnurse,

theneuroICUnurses,andEDnursesandAPNsneedacloseassessmentandrequiredtodoneuro

checksfrequentlyforanyneurologicaldeteriorationorchanges.

Ø Althoughthemaingoalofthetreatmentistorestoreorimprovecerebralbloodflow,the

reperfusionitselfcanalsocausecascadesofsecondaryinjury(Xingetal.,2014).

Stroke

Complementcascadeactivation(C3a/C3aR)C3aRAntagonist

BrainedemaandHemorrhages

NeurodegenerationFigure5.Theaboveinformationretrievedfrom(Zhaoetal.,2017)

PathophysiologicalProcess

SignsandSymptoms

RecognizingthesignsandsymptomsofacuteischemicstrokeintimelyfashionisveryimportantbecausethetreatmentwindowtoreceivetPAis3–4.5fromtheonsetofthesymptom(Anderson,J.,2014).

SomeofthesignandsymptomsofAISinclude,butnotlimitedto:• Slurredspeech&facialdroop• Blurredvisionordoublevision• Suddenonsetofheadacheandvertigo• Unsteadygaitandisolatedweaknessofthearmorleg(Anderson,p.24,2014).

Ø Currently,AmericanHeartAssociation(AHA)andNationalInstituteofNeurologicalDisordersandStroke(NINDS)recommendhealthcarefacilitiesdisplayingpostersandeducationalmaterialforthepublic(Davis&Lockhart,2016).

Astheadagegoes:“timeisbrain”. Bewareofthewarningsignsofstroketoyourownlifeorthelifeoflovedones.

Figure2.Retrievedfromhttps//nurseslab.com

UnderlyingPathophysiology

Asagraveneurologicalproblem,stroke,isconsideredoneofthemostprevalentdiseasesthathumanbeingshavefaced.Thepathophysiologyofstrokeissocomplicated.Thepathophysiologicalprocesscomprisesofdifferentinflammatorypathways,mechanisms,oxidativedamagesandimbalances.Theend-resultofischemicstrokeistheseveredamageofneuronalfunctionsleadingtoneuronaldeathanddisability(Xingetal.,2012).

Intheareaofthebrainwithreducedbloodsupplyorblockage,adenosinetriphosphate(ATP)usecontinuesinspiteofreducedsynthesis,affectingthetotalATPleveltoreduceandinitiatelactateacidosis,leadinglossofionichomeostasis,andneuronalinjury(Xingetal,2012).

Atthecellularlevel,thesuddeninterruptionorblockageofbloodflowtothebrainduetobloodclot(thrombus)oraplaque(fattydeposits)deprivesthebraintissue,fromthenecessarynutrientsandoxygenwhichleadstoirreversiblebraintissuedamage.Ischemicstrokecausesmitochondrialcelldeath.

Hypoxiaiscausedbyischemicchanges.Hypoxiainducesinflammationandinflamedlesions.InflammationandInflammatorymarkersareverybigpartofAISpathophysiologyespeciallyinreferencetoreperfusion.Clottingcascade:inflammationcausescoagulationorclotting.Cascadeofcerebralischemiabeginswitharterialocclusionandendswithcelldeath.

Alfieri,D.F.,Lehmann,M.F.,Oliveira,S.R.,Flauzino,T.,Delongui,F.,Araujo,M.M.,&...Reiche,E.V.(2017).VitaminDdeficiencyisassociatedwithacuteischemicstroke,C-reactiveprotein,andshort-termoutcome.MetabolicBrainDisease,(2),493.doi:10.1007/s11011-016-9939-2.Retrivefromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=congale&AN=edsgcl.485042795&site=eds-live&scope=site

Anderson,J.A.(2014).ThegoldenhourPerforminganacuteischemicstrokeworkup.TheNursePractitioner,39(9),22-29.doi:10.1097/01.NPR.0000452974.46311.0f.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=25083767&site=eds-live&scope=site

Babkair,L.A.(2017).CardioembolicStroke:ACaseStudy.CriticalCareNurse,37(1),27-39.doi:10.4037/ccn2017127.Retrivedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=120801684&site=eds-live&scope=site

Davis,C.,&Lockhart,L.(2016).Update:strokeguidelines.NursingManagement,(2).24.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsghw&AN=edsgcl.444289461&site=eds-live&scope=site

Falluji,N.,Abou-Chebl,A.,Castro,C.,&Mukherjee,D.(2012).ReperfusionStrategiesforAcuteIschemicStroke.Angiology,63(4),289-296.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edswsc&AN=000302711700009&site=eds-live&scope=site

Little,P.,Kvist,O.,Grankvist,R.,Jonsson,S.,Damberg,P.,Söderman,M.,&...Holmin,S.(2017).PreservedCollateralBloodFlowintheEndovascularM2CAOModelAllowsforClinicallyRelevantProfilingofInjuryProgressioninAcuteIschemicStroke.PlosONE,12(1),1-15.doi:10.1371/journal.pone.0169541.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=fsr&AN=120641054&site=eds-live&scope=site

Lyden,P.D.,Hemmen,T.M.,Grotta,J.,Rapp,K.,&Raman,R.(2014).Endovasculartherapeutichypothermiaforacuteischemicstroke:ICTuS2/3protocol.InternationalJournalOfStroke,9(1),117-125.doi:10.1111/ijs.12151.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=93256353&site=eds-live&scope=site

Paspalj,D.,Nikic,P.,Savic,M.,Djuric,D.,Simanic,I.,Zivkovic,V.,&...Jeremic,N.(2015).Redoxstatusinacuteischemicstroke:correlationwithclinicaloutcome.Molecular&CellularBiochemistry,406(1/2),75-81.doi:10.1007/s11010-015-2425-z.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=fsr&AN=108354835&site=eds-live&scope=site

Payabvash,S.,Qureshi,M.H.,Taleb,S.,Pawar,S.,&Qureshi,A.I.(2015).MiddleCerebralArteryResidualContrastStagnationonNoncontrastCTScanFollowingEndovascularTreatmentinAcuteIschemicStrokePatients.JournalOfNeuroimaging:OfficialJournalOfTheAmericanSocietyOfNeuroimaging,25(6),946-951.doi:10.1111/jon.12211.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=25684437&site=eds-live&scope=site

Qureshi,A.I.,Qureshi,M.H.,Siddiq,F.,Kainth,D.,Hassan,A.E.,&Maud,A.(2015).Preprocedurechangeinarterialocclusioninacuteischemicstrokepatientsundergoingendovasculartreatmentbycomputedtomographicangiography.AmericanJournalOfEmergencyMedicine,33(5),631-634.doi:10.1016/j.ajem.2015.01.054.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=fsr&AN=102805244&site=eds-live&scope=site

Sacco,R.L.,Kasner,S.E.,Broderick,J.P.,Caplan,L.R.,Connors,J.B.,Culebras,A.,&...Vinters,H.V.(2013).Anupdateddefinitionofstrokeforthe21stcentury:astatementforhealthcareprofessionalsfromtheAmericanHeartAssociation/AmericanStrokeAssociation.Stroke,44(7),2064-2089.doi:10.1161/STR.0b013e318296aeca.Retrievedfromhttp://search.ebscohost.com.webproxy3.columbuslibrary.org/login.aspx?direct=true&db=cmedm&AN=23652265&site=ehost-live&scope=site

Sozener,C.B.,&Barsan,W.G.(2012).Impactofregionalpre-hospitalemergencymedicalservicesintreatmentofpatientswithacuteischemicstroke.AnnalsOfTheNewYorkAcademyOfSciences,1268(1),51-56.doi:10.1111/j.1749-6632.2012.06746.x.Retrievedfromhttp://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=80204824&site=eds-live&scope=site

Xing,C.,Arai,K.,Lo,E.H.,&Hommel,M.(2012).Pathophysiologiccascadesinischemicstroke.InternationalJournalofStroke :OfficialJournaloftheInternationalStrokeSociety,7(5),378–385.Retrievedfromhttp://doi.org/10.1111/j.1747-4949.2012.00839.x

Zhao,X.,Larkin,T.M.,Lauver,M.A.,Ahmad,S.,&Ducruet,A.F.(2017).Tissueplasminogenactivatormediatesdeleteriouscomplementcascadeactivationinstroke.PlosONE,12(7),1-15.doi:10.1371/journal.pone.0180822http://ezproxy.otterbein.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=fsr&AN=124006785&site=eds-live&scope=site

Reference

Figure1.Theaboveinformationisretrievedfromhttp://www.educatehealth.ca/physician/quick-reviews-(qr)/cerebrovascular/risk-factors-for-ischemic-stroke.aspx.

Ischemicstroke:abruptonsetofneurologicaldeficitsresultingfromreducedcerebralbloodflowmostoftenathrombo-embolicvaso-oclusion event.

ImplicationforNursingCare

Ø Itisimportantforthisnurseinhercurrentjobandinthefuture,advancedpracticenursecareer,tounderstandthepathophysiologyofacuteischemicstrokeandtheimplicationsofimplementingtimelyintervention.Mostimportantly,theadvancepracticenurseneedstounderstandthenewguidelinesforacuteischemicstrokemanagement.

Ø Currently,theAPNsareusedalongsidewithphysicians,moreandmore,inemergencydepartmentsandoutsidethehospital,aswellas,inhospitalmanagement.Earlyidentificationofstrokepatientsiscrucialforsavingthelivesofmanypatients,preventingdisability,inadditionto,reducingfinancialburdens.

Ø Theimplicationsofnursinginterventionandthenurse’sroleinAISincludes,propertriage,earlyidentifications,orderingnon-contrastCT,callingstrokealert,callingpharmacywithpatientweightfortPA,fingerstickforbloodglucoseandstartingtwolargeboreIV’sandbloodworks.

Ø TheAmericanHeartAssociationguidelinesrecommendanoninvasivenon-contraststudysuchascomputedtomography(CT)fortheinitialimagingfollowedbyCTangiogramorperfusionstudies(Qureshietal.,2015).

Ø Thenurseshouldworkwiththephysiciantogatherathoroughpastmedicalhistoryandcurrentmedicationlistsforthephysiciantocompleteinclusion/exclusionchecklistbeforeadministeringtPA.

Ø Thestrokealertwillinitiatetheteamtobeginthediagnostictestprocess;butitisveryimportanttoprovidethenecessaryinformationtothemultidisciplinaryteamthroughareportordebriefingsothateveryoneisinthesamepage.

Ø NationalInstituteofhealthStrokeScale(NIHSS)isusedtobestassessandconfirmthepresenceofstrokeandtoquantifythedegreeofneurologicaldeficits(Anderson,2014).

TheinstituteofNeurologicalDisordersandStroke(NINDS)goldenhourworkupforAIStimetargets:

ü 10mininitialassessmentofpatientü 15minpatientseenbystroketeamü 25minnon-contrastCTscanperformedü 45minCTscanresultsavailableü 60mininitiationoffibrinolytictherapy(Anderson,2014).

Figure3.Theaboveinformationisretrievedfromwww.accessmedicine.mhmediccal.comEventually,thesemultimodalcascadeswillresultinneuronaldeath.Tofullygraspthepathophysiologyprocess,understandingthesignificanceofpathophysiologyiscrucial.