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Assessment of Ischemic vs Hemorrhagic Stroke

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Presentation on theme: "Assessment of Ischemic vs Hemorrhagic Stroke"— Presentation transcript:

1 Assessment of Ischemic vs Hemorrhagic Stroke
Cynthia Bautista, PhD, RN, CNRN Nursing Brains, LLC

2 Stroke In the USA 795,000 new or recurrent strokes
Represents 4th leading cause of death in USA Copyright Nursing Brains, LLC

3 Ischemic vs Hemorrhagic
Ischemic stroke is 10x more frequent Hemorrhagic stroke has higher mortality risk Common risk factors Copyright Nursing Brains, LLC

4 Ischemic Stroke 80% of all strokes Blockage in blood vessel
Fatty deposits lining blood vessel wall Thrombosis (50%) Thrombi formed by plaque Greater than 50%stenosis Embolism (30%) Cardiac emboli Atrial Fibrillation Copyright Nursing Brains, LLC

5 Cryptogenic Stroke 30% of ischemic strokes
Infarct of undetermined cause Hemispheral infarction Average age 58 No risk factors Copyright Nursing Brains, LLC

6 Lacunar Stroke 25% of Ischemic strokes
Thrombosis of Lenticulostriate arteries (small penetrating arteries) Predominate in basal ganglia Caused by hypertension and diabetes No treatment Risk factor management Copyright Nursing Brains, LLC

7 Hemorrhagic Stroke 20% of all strokes Rupture of leaking blood vessel
Intracerebral (ICH) High blood pressure Subarachnoid (SAH) Cerebral Aneurysm Arterial Venous Malformation Intraventricular (IVH) ICH and/or SAH Hemorrhagic transformation of ischemic infarct Copyright Nursing Brains, LLC

8 Ischemic Stroke Risk Factors
Copyright Nursing Brains, LLC

9 NonModifiable Risk Factors
Age Risk of stroke doubles every decade after 55 Gender 55,000 more women than men have a stroke each year Men’s stroke incidence rates are greater than women ‘s at younger ages Race African American have almost twice the risk of first ever stroke compared to whites Prior Stroke 5% chance of stroke/year, 10x higher Family History Age....man over women over 55, post menopausal Gender....men are at higher risk (30%) but...more women die Ethnicity……African American, & Hispanics due to severe hypertension….Asian have hemorrhagic Copyright Nursing Brains, LLC

10 Modifiable Risk Factors
High Blood Pressure Incidence of stroke increases with severity Goal ≤ 120/80 with risk factors Diabetes Goal of Hgb A1C < 7% Pre-meal blood glucose mg/dl Hypertension...after advancing age ...hypertension is #1 cause of stroke most important modifiable risk factor...use aggressive approach to BP management 130/85....do diet, exercise, weight reduction, reduce stress..... DM....uncontrolled...unclear whether hyperglycemia is the factor causing stroke or....maybe both..hypermetabolic state and hyperglycemia... Heart disease...atrial fibrillation (5x more likely) use coumadin to reduce incidence of stroke with AF Tias... Carotid artery... Copyright Nursing Brains, LLC

11 Modifiable Risk Factors (con’t)
Tobacco use - #1 preventable cause Ischemic and hemorrhagic stroke Aggravates atherosclerosis Raises blood pressure 50% reduction of risk with cessation Counseling, nicotine products, oral smoking cessation medications Implement 5 A’s ASK about tobacco use ADVISE to quit ASSESS willingness to attempt to quit ASSIST in the quit attempt ARRANGE follow-up Smoking...single greatest preventable cause of stroke...independent risk factor for stroke...# or packs per day and # of years smoking.... 2003 AHA study…Boston Men who smoke > one pack/day had twice the risk for hemorrhage stroke Smoke < 20 cigs/day 1.7 x risk Smoke > 20 cigs/day 2.4x risk Damages arterial walls Former smoker same risk Copyright Nursing Brains, LLC

12 Modifiable Risk Factors (con’t)
Carotid Disease Atrial Fibrillation 50% of all embolic strokes Anticoagulation reduces risk by 68% Cardiac Disease Routine screening Aggressive treatment Sickle Cell Disease Heart disease...cardiomyopathy, valvular disease, endocarditis, patent foramen ovale, atrial septal aneurysm, atrial septal defect…..anticoagulation for EF or </= 25% atrial fibrillation (5x more likely) use coumadin to reduce incidence of stroke with AF Carotid Stenosis….>70% blocked Copyright Nursing Brains, LLC

13 Modifiable Risk Factors (con’t)
High blood Cholesterol Poor diet Physical Inactivity Moderate intensity exercise ≥ 30 minutes most days Obesity Weight reduction Maintain BMI < 25 kg/m2 Waist circumference <40” men, < 35” women Copyright Nursing Brains, LLC

14 Modifiable Risk Factors (con’t)
Alcohol Use Men no more than 2 drinks/day Women no more than 1 drink/day Drink in moderation 1.5 oz hard liquor 4 oz wine 12 oz beer Copyright Nursing Brains, LLC

15 Hemorrhagic Stroke Risk Factors
Copyright Nursing Brains, LLC

16 NonModifiable Risk Factors
Age Risk of stroke doubles every decade after 55 Gender 55,000 more women than men have a stroke each year Men’s stroke incidence rates are greater than women ‘s at younger ages Race African American have almost twice the risk of first ever stroke compared to whites Prior Stroke 5% chance of stroke/year, 10x higher Family History Age....man over women over 55, post menopausal Gender....men are at higher risk (30%) but...more women die Ethnicity……African American, & Hispanics due to severe hypertension….Asian have hemorrhagic Copyright Nursing Brains, LLC

17 Modifiable Risk Factors
High Blood Pressure Incidence of stroke increases with severity Goal ≤ 120/80 with risk factors Hypertension...after advancing age ...hypertension is #1 cause of stroke most important modifiable risk factor...use aggressive approach to BP management 130/85....do diet, exercise, weight reduction, reduce stress..... DM....uncontrolled...unclear whether hyperglycemia is the factor causing stroke or....maybe both..hypermetabolic state and hyperglycemia... Heart disease...atrial fibrillation (5x more likely) use coumadin to reduce incidence of stroke with AF Tias... Carotid artery... Copyright Nursing Brains, LLC

18 Modifiable Risk Factors (con’t)
Tobacco use #1 preventable cause Raises blood pressure 50% reduction of risk with cessation Counseling, nicotine products, oral smoking cessation medications Copyright Nursing Brains, LLC

19 Modifiable Risk Factors (con’t)
Alcohol Use Men no more than 2 drinks/day Women no more than 1 drink/day Drink in moderation 1.5 oz hard liquor 4 oz wine 12 oz beer Copyright Nursing Brains, LLC

20 Modifiable Risk Factors (con’t)
Drug Abuse Occurs first time or long-term user Amphetamines, cocaine, heroin Hypertension Intracerebral Hemorrhage Screen Rehabilitation Copyright Nursing Brains, LLC

21 Ischemic Stroke Presentation
Copyright Nursing Brains, LLC

22 Left (Dominant Hemisphere)
Left gaze preference Right visual field deficit Right hemiparesis Right hemisensory loss Copyright Nursing Brains, LLC

23 Right (Nondominant Hemisphere)
Right gaze preference Left visual field deficit Left hemiparesis Left hemisensory loss Neglect (left hemi-inattention) Copyright Nursing Brains, LLC

24 Brainstem Stroke Syndrome
Decreased consciousness Diplopia, dysconjugate gaze, gaze palsy Hemiparesis or quadriplegia Sensory loss in hemibody or all 4 limbs Dysarthria Dysphagia Vertigo, tinnitus Nausea/vomiting Abnormal respirations Copyright Nursing Brains, LLC

25 Cerebellum Stroke Syndrome
Gait ataxia Limb ataxia Neck stiffness Nystagmus Copyright Nursing Brains, LLC

26 Warning Signs of Stroke Think F-A-S-T
F = FACE numbness or weakness especially one side of body A = ARM numbness or weakness one side of body S = SPEECH slurred or difficulty speaking or understanding T = TIME to immediately call and note time symptoms started or last time person was seen normal Copyright Nursing Brains, LLC

27 Hemorrhagic Stroke Presentation
Copyright Nursing Brains, LLC

28 Hemorrhage Stroke Syndromes
Decreased level of consciousness Focal neurological deficits Headache Neck pain Light intolerance Nausea, vomiting Copyright Nursing Brains, LLC

29 Level of Consciousness Glasgow Coma Scale
Eye Opening 4 - Spontaneous 3 - To Speech 2 - To Pain 1 - None Verbal Response 5 - Oriented 4 - Confused 3 - Inappropriate Words 2 - Inappropriate Sounds Motor Response 6 - Obeys Commands 5 - Localizes 4 - Withdraws 3 - Abnormal Flexion 2 - Abnormal Extension 1 -None NOT AFFECTED UNLESS LARGE STROKE Copyright Nursing Brains, LLC

30 Warning Signs of Stroke “Give Me 5”
Give Me 5 quick stroke check: Walk – Is their balance off? Talk – Is their speech slurred or face droopy? Reach – Is one side weak or numb? See – Is their vision all or partly lost? Feel – Is their headache severe? Copyright Nursing Brains, LLC

31 Ischemic Stroke Imaging
Copyright Nursing Brains, LLC

32 Early CT Finding Hypodensity
Infarction – darker area Obscures gray white matter contrast Effacement of sulci or loss of insular ribbon Copyright Nursing Brains, LLC

33 Early CT Finding Hyperdense Middle Cerebral Artery Sign (HDMCA)
Observed in 50% MCA occlusions Development of large infarct Poor clinical outcomes Copyright Nursing Brains, LLC

34 CT Technologies CT Angiographey CT Perfusion
Details vessels Large vessel occlusions CT Perfusion Tracks arterial blood in brain Perfusion maps Multimodal CT (CT, CTA, CTP) Detects absence of hemorrhage Presence of ischemia Vascular anatomy/perfusion deficits Copyright Nursing Brains, LLC

35 MRI Magnetic energy DWI Gradient Recalled Echo (GRE)
Abnormal within 7 minutes of onset Gradient Recalled Echo (GRE) Detects hemorrhage Fluid attenuated inversion recovery (FLAIR) and T2-weighted Evolving infarction Perfusion-weighted Images (PWI) Abnormal flow Copyright Nursing Brains, LLC

36 DWI and PWI DWI (Diffusion-Weighted Imaging)
Ischemic region within minutes Lesion size, site, age Detects random movements of water protons PWI (Perfusion-Weighted Imaging) Hemodynamic status Provides information regarding cerebral blood flow Extremely sensitive to cerebral ischemia Same lesion size and location are matched Larger PWI lesions are mismatched Copyright Nursing Brains, LLC

37 Carotid Ultrasound Inexpensive, safe Non-invasive screen
Blood velocity Patient that cannot receive contrast or MRA 90% sensitivity and specificity Copyright Nursing Brains, LLC

38 Digital Subtraction Angiography (DSA)
Gold Standard for cerebral vasculature Degree of stenosis Provides interventions Thrombolytics Thrombectomy Angioplasty and stenting Copyright Nursing Brains, LLC

39 Echocardiogram Transthoracic Transesophageal
Noninvasive utilizing sound waves Transesophageal Combines ultrasonography & endoscopy Image posterior of the heart Heart structures Clots, valves, PFO, LV function Copyright Nursing Brains, LLC

40 Hemorrhagic Stroke Imaging
Copyright Nursing Brains, LLC

41 Early CT Finding Hyperdensity
Hemorrhage appears white Petechial is scattered hyperdense points Hematoma is solid, homogenously hyperdense legion Copyright Nursing Brains, LLC

42 Predicting ICH Expansion
Spot sign on CTA Copyright Nursing Brains, LLC

43 MRA Extracranial & intracranial cerebral circulation abnormalities
86% sensitivity 98% specificity Aneurysm detection 95% sensitivity Copyright Nursing Brains, LLC

44 Transcranial Doppler (TCD)
Safe, inexpensive Flow of blood through arteries of the brain High frequency sound waves pass through tissue Detects, monitors stenosis, vasospams, reperfusion Concern with Velocity of >120 Lindegaard ration > 3 Copyright Nursing Brains, LLC

45 Stroke Case Studies Copyright Nursing Brains, LLC

46 Case Presentation #1 T.E. is a 39 year old Caucasian man who works in construction. Ten years ago he had a myocardial infarction, EF 45% with apical akenesis and an intraventricular thrombus (was on warfarin). Has a history of TIAs, hypercholesterolemia and smokes 2-3 packs per day. He left his house about 8:15PM and was found lying on the sidewalk. People passing by called Copyright Nursing Brains, LLC

47 Case Presentation #1 (con’t)
At 8:45 PM T.E. was weak on the RIGHT side, unable to speak, and had a LEFT gaze deviation. Copyright Nursing Brains, LLC

48 Case Presentation #2 Mr. A. is a 41 year old African American, obese, male, with hypertension and a history of CABG 10 years ago. He went to the bathroom at about 3:55PM. His family heard a load noise coming from the bathroom. He was found by his family lying in the shower at 4PM. He was unable to talk and weak on the RIGHT side. They called Copyright Nursing Brains, LLC

49 Case Presentation #3 53 year old male (WR) was in a car accident in which he could not see oncoming traffic. He was having piercing headache in his right occiput. He took ASA 325mg with no relief. He was at work when the symptoms started, went home, and then was driving to the bank with his girlfriend when he crashed his car into the side of the road. His family picked him up and brought him to the ED. Copyright Nursing Brains, LLC

50 Case Presentation #3 (con’t)
Construction worker History of diabetes and hypertension Medications: lisinopril, glipizide, metformin, ASA Quit smoking 4 years ago Drinks 6 pack of beer on the weekends Copyright Nursing Brains, LLC

51 Case Presentation #3 (con’t)
Upon arrival to ED … NIHSS = 2 (LEFT hemianopsia) BP 211/118 Glucose 247 Copyright Nursing Brains, LLC

52 Case Presentation #4 MM is a 60 year old female who was at the gym on an elliptical machine when she experienced the “worst headache of her life”. She went into the restroom with her sister where she began to vomit. Her sister called 9-1-1 She has a history of hypertension and her cousin died of a ruptured cerebral aneurysm Copyright Nursing Brains, LLC

53 Case Presentation #5 D.B. is a 75 year old Caucasian man in good health. He quit smoking over 30 years ago and has no family history of stroke. He has not seen a physician in over 40 years. He was taking his family to McDonalds for lunch. After leaving the drive thru window he began to drive erratically over curbs and islands. D.B. had a sudden onset of right facial droop, right arm weakness, and difficulty speaking. His daughter got him to stop the car and she called

54 Case Presentation #6 A 57-year-old female (CB) last spoke to her relatives on Sunday. She did not answer her phone on Monday. The landlady entered her apartment on Thursday and found her lying face down on floor of living room covered in vomit and feces. Landlady called 9-1-1

55 Case Presentation #6 Pre Hospital Emergency Room
Vital signs 149/94 – 79 – 20, 99.3, pulse oxygenation 98% Not moving right side Emergency Room 162/83 – 87 – 20 Pupils equal react to light Opens eyes, difficult to remain awake

56 Case Presentation #6 History of chronic atrial fibrillation
Coumadin started in 2007 Noncompliant Sub therapeutic INR Patient on ASA only

57 Case Presentation #7 83 year old man (JP) fell at home x2 last night. He was able to getup on his own after the first fall, unable to getup after 2nd fall. According to wife, JP began acting abnormal (asking strange questions, using inappropriate words). Wife dragged JP from living room to bedroom. They slept together on the floor in the bedroom.

58 Case Presentation #7 (con’t)
In the morning the wife was unable to wake JP up and called 9-1-1 JP had right sided weakness, right facial droop History of TIA, CAD, hypertension Pre Hospital 198/80 – 93 – 20 Pulse oxygenation 95%

59 Questions???? Cindy Bautista


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