CEREBROVASCULAR

ACCIDENT
(CVA)
vs.
TRANSIENT ISCHEMIC ATTACK
(TIA) Stroke ;Apoplexy
CHARMAINE JOELYN A. LACHICA
The human brain
Cerebral circulation
• Cerebrovascular accident or stroke (also
called brain attack) results from sudden
interruption of blood supply to the brain,
which precipitates neurologic dysfunction
lasting longer than 24 hours. Stroke are
either ischemic, caused by partial or
complete occlusions of a cerebral blood
vessel by cerebral thrombosis or embolism or
hemorrhage (leakage of blood from a vessel
causes compression of brain tissue)
• A TIA is a "warning stroke" or "mini-stroke"
that produces stroke-like symptoms but no
lasting damage. Recognizing and treating TIAs
can reduce your risk of a major stroke.
• TIAs occur when a blood clot temporarily
clogs an artery, and part of the brain doesn't
get the blood it needs. The symptoms occur
rapidly and last a relatively short time. Most
TIAs last less than five minutes. The average
is about a minute. Unlike stroke, when a TIA
is over, there's no injury to the brain.
CLINICAL EPIDEMIOLOGY
• Six out of 10 Filipinos 60 years and older has
had a stroke. Next to heart disease, stroke is
the leading cause of death in the Philippines.
• In the Philippines, stroke affects 486 out of
100,000 Filipinos
• Worldwide and in the country, stroke is the
No. 1 one cause of serious long-term
disability. 
PATHOPHYSIOLOGY
 Predisposing Factors: Precipitating Factors:
1) Age ۞ 1) Hypertension ۞
2) Heredity ۞ 2) Cigarette Smoking
3) Race 3) Diabetes Meliitus ۞
4) Sex ۞ 5) Atrial Fibrillation
5) Prior Stroke, TIA or heart 8) Undesirable levels of
attack ۞ cholesterol
6) Socioeconomic Factors ۞ 9) Poor diet ۞
10) Physical inactivity
11) Obesity

Atheroma
Formation/
Clot
atherosclerosis formation

thrombosis embolism

Occlusion of major blood

vessel

Vascular wall becomes

weakened and fragile
CEREBRAL
HYPOPERFUSION
Leaking of blood from the
fragile vessel wall
Impaired distribution of
Cerebral Hemorrhage oxygen and glucose

Tissue hypoxia and

Blood seeps into the Vasospasm of
cellular starvation
ventricles tissue and arteries

Obstruction of CSF Cerebral Ischemia

passageway
 Transient Ischemic Attack
Accumulation of CSF in
the ventricles
Brain sustains an irreversible
cerebral damage
Increased ICP
Structural integrity loss of brain
tissue and blood vessels

Breakdown of the protective

Blood Brain Barrier

Cerebral edema

Vascular Congestion

Impaired perfusion and

function

Middle Cerebral Anterior cerebral Posterior CerebraI Internal Carotid

Artery artery Artery Artery

Continued insufficiency of blood

flow

Coma

Cerebral Death

Cessation of physiologic
functions

Systemic Failure

DEATH
The symptoms of a stroke are dependent on what
portion of the brain is damage.
• LEFT HEMISPHERE CVA
– Right side weakness
– Aphasia

• RIGHT HEMISPHERE CVA

– Left side weakness
– Perceptual deficit (vulnerable to
accident)
Clinical Manifestation
• Numbness or weakness of the face, arm or
leg, especially on one side of the body
• Confusion
• Trouble in speaking or understanding speech
• Visual disturbances
• Loss of balance
• Sudden severe headache
Signs and Symptoms
• TIA
– Temporary vision loss
– Transient hemiparesis
– Vertigo
– confusion
• CVA
– Perceptual defects
– Apraxia
– Loss of voluntary movement in 1 side
– Communication problem
– Emotional liability
– Impaired judgment and memory
Direct Causes of Stroke
 Cerebral thrombosis – a blood clot or plaque
blocks an artery that supplies a vital brain
center
 Cerebral hemorrhage or aneurysm – an
artery in the brain bursts, weakens the
aneurysm wall; severe rise in BP causing
hemorrhage and ischemia
 Cerebral embolism – a blood clot breaks off
from a thrombus elsewhere in the body,
lodges in a blood vessel in the brain and shuts
off blood supply to that part of the brain
Types of Stroke
• Ischemic stroke - when arteries are
blocked by blood clots or by gradual build
up of plaque and other fatty deposits.
– Almost 85% of strokes are ischemic.
• Hemorrhagic stroke – when a blood vessel
in the brain breaks leaking blood into the
brain.
– About 15% of all strokes but responsible
for 30% of stroke deaths
Ischemic Stroke:

• A blood vessel becomes blocked and the

blood supply to that part of your brain is
blocked.
• Types of Ischemic strokes:
– Thrombotic Stroke
– Embolic Stroke
Hemorrhagic Stroke

• A small blood vessel in the brain

becomes weak and ruptures.
Transient Ischemic Attack (TIA)

• Blood supply to the brain is only

briefly interrupted
• Symptoms do not last long
• Warning Stroke- steps should be
taken to prevent future stroke.
Diagnostic Procedures
 Magnetic resonance imaging (MRI) and/or computed
tomography (CT) imaging, computed axial tomography
(CAT) scan
 Used to identify edema, ischemia and necrosis
 Hemorrhage and infarction
 Magnetic resonance angiography (MRA) or cerebral
angiography
 To identify presence of cerebral hemorrhage,
abnormal vessel structures, vessel ruptures, and
regional perfusion of blood flow in the brain
• Carotid Ultrasonography
• The procedure of carotid ultrasonography is used to detect
the exact place where the carotid artery has narrowed and is
causing a patient the risk of a stroke. The carotid artery is the
main artery in the neck and supplies blood to the brain.
 INTERVENTION: MEDICAL
• DRUG THERAPY
• Anticoagulants:
– WARFARIN SODIUM (Coumadin)
– Antagonist of Vit. K which is necessary for the
synthesis of clotting factors VII, IX, X and PT, it
disrupts coagulation cascade
– Contra: bleeding disorder, Vit. K deficiency , severe
hpn.
– SE: Spontaneous bleeding, red orange discoloration
of urine, weakening of bones
– NI: Monitor bleeding tendency
– Vit. K must be used as antidote
– Monitor PT as ordered.
• Antiplatelet Agents
• ASPIRIN
Inhibit platelet aggregation, analgesic, antipyretic
Prophylaxis against or reduction of the recurrence of
TIA and MI
Contra: Bleeding disorder
SE: decrease pt. aggregation; increase bleeding
potential
NI: Give with milk or full glass of H20 to decrease
gastric irritation
• CLOPIDOGREL (Plavix)
• C: antiplatelet
• Action: Suppress platelet aggregation in arterial
circulation
• Uses: Secondary prevention of MI, CVA and vascular
events
• Contra: Active bleeding
• SE: Abdominal bleeding, dyspepsia, diarrhea, rash
• NI: Administer with food to diminish GI upset
Report unusual bleeding
Platelet count monitored
Thrombolytic Therapy
tPA- Tissue Plasminogen Activator
• Work to directly or indirectly convert plasminogen to
plasmin, an enzyme that acts to digest fibrin matrix or clots
• Uses: treatment of acute MI, pulmonary embolism,
thrombotic stroke and dvt
• Contra: Active bleeding
History of intracranial hemorrhage
Current use of oral anticoagulant
Another stroke or serious head injury in previous 3
months
Prior intracranial hemorrhage
Dose: 0.9mg/kg administered IV 1h;
10% of total dose is given as bolus over 1
minute before initiation of IV dose
 SURGICAL
• CAROTID ENDARTERECTOMY
• Carotid endarterectomy (CEA) is a surgical procedure used to
prevent stroke, by correcting stenosis (narrowing) in
the common carotid artery. Endarterectomy is the removal of
material on the inside (end-) of an artery.
• Atherosclerosis causes plaque to form in the carotid arteries,
usually at the fork where the common carotid artery divides
into the internal and external carotid artery. The plaque can
build up in the inner surface of the artery (lumen), and
narrow or constrict the artery. Pieces of the plaque,
called emboli, can break off (i.e. embolize) and travel up the
internal carotid artery to the brain, where it blocks
circulation, and can cause death of the brain tissue.
Nursing Management for CEA
• Initiate preoperative instruction for patient and family
– Explain purpose , benefit, risk
– Teach deep breathing exercise
– Discuss critical care environment
– Encourage to express fears and concern
• Check operative permission
• Withhold food and water the night before surgery
• Administer preop meds.
Nursing Diagnosis
• Ineffective tissue perfusion (cerebral)
• Disturbed sensory perception
• Impaired physical mobility
• Risk for injury
• Self-care deficit
• Impaired verbal communication
• Impaired swallowing
• Independent Nursing action:

• Act F.A.S.T.
• F = Face Ask the person to smile. Does
one side of the face droop?
• A = Arms Ask the person to raise both
arms. Does one arm drift
downward?
• S = Speech Ask the person to repeat a simple
sentence. Does the speech sound
slurred or strange?
• T = Time Call 911 immediately!
 Maintain patent airway.
 Monitor for changes in the client’s level of
consciousness (increased intracranial
pressure sign).
 Elevate the client’s head to reduce ICP and to
promote venous drainage. Avoid extreme
flexion or extension, maintain the head in a
midline neutral position and elevate the head
of bed to 30 degrees.
• Maintain a non-stimulating environment.
• Assist with communication skills if the client’s speech
is impaired.
• Assist with safe feeding.
– Assess swallowing reflexes.
– Thicken liquid to avoid aspiration.
– Eat in an upright position and swallow with the
head and neck flexed slightly forward.
– Place food in the back of the mouth on the
unaffected side.
– Suction on standby.
 Maintain skin integrity.
 Encourage PROM every 2 hr to the affected
extremities and AROM every 2 hr to the unaffected
extremities.
 Elevate the affected extremities to promote venous
return and to reduce swelling.
 Maintain a safe environment to reduce the risks of
falls.
 Scanning technique (turning head from side to side)
when eating and ambulating to compensate for
hemianopia.
• Dependent Nursing Action
 Administer medications as prescribed.
 Systemic or catheter directed thrombolytic
therapy restores cerebral blood flow. It must be
administered within hours of the onset of
symptoms. It is contraindicated for treatment of
hemorrhagic stroke and for clients with an
increased risk of bleeding. Rule out hemorrhagic
stroke with an MRI prior to initiation of
thrombolytic therapy.