1. Acute Brain Injury
LHS Stroke Center

2. Objectives Understand need for stroke protocol.
Review Brain Anatomy and function.
Understand cerebral perfusion.
Differentiate the different types of strokes.
Identify signs & symptoms of potential stroke patients.
Will be able to understand neuro deficits through an accurate neuro exam.
Treatment of Acute Brain injury.

3. Brain
Body’s controlling organ
Responsible for organizing functions of other body organ systems

4. Brain Anatomy Review Occupies 80% of intracranial space Divisions
Cerebrum
Cerebellum
Brain Stem

6. Brain Anatomy Review
Cerebrum: largest and most advanced portion of brain.
Cortex
Frontal lobe
Parietal lobe
Temporal lobe
Occipital lobe

7. Cerebrum Frontal lobe:
controls planning, organizing, problem solving and selective attention.
The prefrontal cortex controls personality and higher cognitive functions such as behavior and emotions.
The back of the frontal lobe consists of pre-motor and motor areas which control movements
Damage – hemiparesis, facial droop, expressive aphasia, impulsive behavior

8. Cerebrum (cont): Parietal Lobes:
contain the primary sensory cortex,
controls sensation (touch and pressure)
fine sensation ( judgment of texture, weight, size, shape)
Damage to the right parietal lobe can cause
visual-spacial deficits, making it hard for a patient to find their way around new or familiar places.
Neglect of affected side
Damage to the left parietal lobe may disrupt the ability to understand spoken and/or written communication

9. Cerebrum (cont): Temporal Lobes: Located around ear level
Allows differentiation of smells and sounds
Helps sort new information
Responsible for short-term memory
Right lobe is primarily involved in visual memory (faces and pictures)
Left lobe is primarily involved in verbal memory (names and words)
Damage - aphasia, memory loss, may be temporary

10. Cerebrum (cont): Occipital Lobe: Processes visual information
Visual reception
Visual recognition of shapes and colors
Damage to this lobe can cause visual deficits

11. The Cerebellum Second largest area of the brain
Controls reflexes, balance and certain aspects of movement and coordination, equilibrium, fine motor skills
Damage from a Stroke:
lack of coordination (ataxia), clumsiness, balance problem
Inability to walk, talk, eat and perform other self-care tasks

12. The Brain Stem Responsible for the Critical Functions of Life
Breathing, digestion, heart beat, temperature
Includes alertness and arousal or the state of being awake
Damage from a stroke:
Most devastating and life threatening as they can disrupt involuntary functions essential to life
People who survive a brain stem stroke will remain in a vegetative state or left with severe impairments

13. Brain Anatomy Review Brain Stem
connects hemispheres, cerebellum and SC
responsible for vegetative functions & VS
Midbrain
relay point for visual and auditory impulses
Pons
conduction pathway between brain and other regions of body
Medulla oblongata
cardiac, respiratory, and vasomotor control centers
control of vomiting and coughing

14. Brain Anatomy Review Brain Stem Cranial Nerves
Reticular Activating System
level of arousal (level of consciousness)
Primary control along with cerebral cortex
Meninges
Dura mater: tough outer layer, separates cerebellum from cerebral structures, landmark for lesions
Arachnoid: web-like, venous vessels that reabsorb CSF
Pia mater: directly attached to brain tissue

15. Meninges

16. Brain Metabolism High metabolic rate consumes 20% of body’s oxygen
largest user of glucose
requires thiamine
can not store nutrients

17. Brain Perfusion Blood Supply vertebral arteries
Cerebral Blood Flow (CBF)
dependent upon CPP
flow requires pressure gradient
Cerebral Perfusion Pressure (CPP)
pressure moving the blood through the cranium
autoregulation allows BP change to maintain CPP
CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)
Blood Supply
vertebral arteries
supply posterior brain (cerebellum and brain stem)
carotid arteries
most of cerebrum

18. Brain Metabolism & Perfusion
Mean Arterial Pressure (MAP)
largely dependent on cerebral vascular resistance (CVR) since diastolic is main component
blood volume and myocardial contractility
MAP = Diastolic + 1/3 Pulse Pressure
usually require MAP of at least 60 mm Hg to perfuse brain
Intracranial Pressure (ICP)
edema, hemorrhage
ICP usually mm Hg

19. Blood Flow of the Brain Cerebral circulation
The movement of blood through the network of blood vessels supplying the brain.
The arteries deliver oxygenated blood, glucose and other nutrients to the brain
the veins carry deoxygenated blood back to the heart, removing carbon dioxide, lactic acid, and other metabolic products.
The cerebral circulatory system has many safeguards.
Failure of these safeguards results in cerebral vascular accidents, commonly known as strokes

20. Blood Flow of Brain
There are two main pairs of arteries that supply the cerebral arteries and the cerebellum.
Internal Carotid Arteries: These large arteries are the left and right branches of the common carotid arteries in the neck which enter the skull.
The external carotid branches supply the facial tissues.
The internal carotid artery branches into the anterior cerebral artery and continues to form the middle cerebral artery.
Both internal carotid arteries, within and along the floor of the cerebral vault, are interconnected via the anterior communicating artery.
Both internal carotid arteries are interconnected with the basilar artery via bilateral posterior communicating arteries.

21. Blood flow of the Brain
The Circle of Willis, long considered to be an important anatomic vascular formation, provides backup circulation to the brain.
If one of the supply arteries is occluded, the Circle of Willis provides interconnections between the internal carotid arteries and basilar artery along the floor of the cerebral vault, providing blood to tissues that would otherwise become ischemic

22. Cushing’s Triad Increasing Intracranial Pressure
Increasing systolic blood pressure
Widening pulse pressure
Bradycardia
Bradypnea
These are late signs and probable irreversible. Brain Stem herniation is in progress

23. Cerebrospinal Fluid (CSF
Surrounds brain, spinal cord in space between arachnoids and pia mater (subarachnoid space)
Acts as a shock absorber
Protects brain from jolts, shocks

24. Brain Attack Facts
Stroke is also known as a cerebrovascular accident or "brain attack.“
A stroke is a life-threatening event in which part of the brain is deprived of adequate oxygen.
Strokes are extremely dangerous, accounting for more than 160,000 deaths each year, according to the Centers for Disease Control and Prevention.

25. Brain Attack Facts
Stroke is the third leading cause of death in the United States, behind heart disease and cancer.
It is also a leading cause of adult disability and institutionalization.
Each year, about 700,000 people suffer strokes. Of those, 500,000 are first-time strokes, and 200,000 are recurrent.

26. Symptoms Symptoms may be sudden and include:
weakness or numbness of the face, arm, or leg, especially on one side of the body
confusion or difficulty speaking or understanding
problems with vision such as dimness or loss of vision in one or both eyes
dizziness or problems with balance or coordination
problems with movement or walking
severe headaches with no other known cause

27. Symptoms
Other, less common, symptoms of stroke may include the following:
sudden nausea, vomiting, or fever not caused by a viral illness
brief loss or change of consciousness such as fainting, confusion, seizures, or coma
transient ischemic attack (TIA), or "mini-stroke"

28. Risk factors for stroke that can be changed, treated, or medically managed
high blood pressure
diabetes mellitus
heart disease
cigarette smoking
history of transient ischemic attacks (TIAs)
high red blood cell count
high blood cholesterol and lipids
lack of exercise, physical inactivity
Obesity
excessive alcohol use
drug abuse
abnormal heart rhythm
cardiac structural abnormalities
The most important controllable risk factor for brain attack is controlling high blood pressure
Diabetes is treatable, but having it increases the risk for stroke. However, persons with diabetes are at higher risk of having a stroke as a result of the long-term effects of diabetes
Heart disease is the second most important risk factor for stroke, and the major cause of death among survivors of stroke.
The use of oral contraceptives, especially when combined with cigarette smoking, greatly increases stroke risk
A person who has had one (or more) TIA is almost 10 times more likely to have a stroke than someone of the same age and sex who has not had a TIA
A moderate increase in the number of red blood cells thickens the blood and makes clots more likely, thus increasing the risk for stroke
Intravenous drug abuse carries a high risk of stroke from cerebral embolisms (blood clots). Cocaine use has been closely related to strokes, heart attacks, and a variety of other cardiovascular complications. Some of them, even among first-time cocaine users, have been fatal
New evidence shows that cardiac structure abnormalities including patent foramen ovale and atrial septal defect increase risk for embolic stroke

29. Risk factors for stroke that cannot be changed:
age
gender
race
history of prior stroke
heredity/genetics
For each decade of life after age 55, the chance of having a stroke more than doubles
Men have about a 19 percent greater chance of stroke than women.
African-Americans have a much higher risk of death and disability from a stroke than Caucasians, in part because the African-American population has a greater incidence of high blood pressure.
The risk of stroke for someone who has already had one is many times that of a person who has not had a stroke.

30. Types of Brain Attacks Ischemic—”deprived of blood”
Sometimes called “occlusive”
Accounts for 83% stroke cases
Hemorrhagic—”caused by bleeding”
Hypertension primary cause
Loss of blood flow for 3-5 minutes causes necrosis of the CNS
Accounts for 17% of stroke cases

31. Ischemic Stroke Thrombotic Embolic
Artery is gradually occluded by a plug of material the collects in a given site
Uncommon in smaller arteries
Usually in areas of disturbance like twists and bends in an artery
Atherosclerosis: Greek “hard paste”
Artery is suddenly occluded by material that moves through the vascular system to occlude an artery
Often a fragment from a thrombosis
Atrial fibrillation is a common cause

32. Ischemic Strokes Source
The most common source of an embolic stroke is the left atrium of the heart:
Atrial Fibrillation
Another source is from the carotid artery,
atherosclerotic plaque and clots detach and are carried through the blood stream into cerebral vasculature.

33. Embolism

34. Ischemic Stroke

35. Hemorrhagic stroke (cerebral hemorrhage)
Caused by disruption of a cerebral blood vessel, bleeds into surrounding tissue
Due to weakness of the vessel wall.
Aneurysm
AV Malformation
Traumatic injury to the vessel
pressure on arterial walls or chronic hypertension—causing “microaneurysms”
DO NOT TREAT WITH THROMBOLYTICS

36. Hemorrhages Extracerebral hemorrhages—bleeding outside of the brain
Subarachnoid
subdural
extradural
Intracerebral hemorrhages
Within brain substance bleed

37. Aneurysm “Pouches” formed in arterial walls Most are due to injury to:
berry or saccular, term depends upon the shape
Nearly 50% of extracerebral aneurysms occur in the arteries at the base of the brain (vertebrals, basilar, internal carotid and Circle of Willis)
Most are due to injury to:
MCA Middle Cerebral Artery
ACA Anterior Communicating Artery
2-3% occur in the posterior cerebral artery

38. Lacunar Stroke Small blood vessels in brain
The word lacunar comes from the Latin word meaning "hole" or "cavity." these are small vessels.
Lacunar infarctions are often found in people who have diabetes or hypertension (high blood pressure).

40. Right & Left Hemisphere CVA
Feature
Left
Right
Language
Aphasia
Impaired sense of humor
Memory
Deficit
Disoriented
Vision
Right visual field deficit
Problem Reading
Spatial deficits
Loss of depth perception
Behavioral
Slow
cautious
Impulsive
Euphoric

41. Stroke Assessment
Single most important assessment is Level of consciousness
Sternal Rub
cautious, can be easily bruised
Trapezius Squeeze
Muscle at top of shoulder
Supraorbital Pressure
Avoid if facial fractures
Central stimulation preferred, Peripheral stimulation such as nail bed pressure may only elicit reflexive movement
*Consider patients past medical history and baseline

42. In stuporous or comatose patients
Assess gag, corneal, and swallow reflex
Assess Babinski
Positive - Toes flare
Negative - Toes curl downward
Assess Doll’s eyes (If no neck injury)
Open eyes and turn head left then right
Positive or normal – the eyes automatically move in the direction opposite the rotation
Negative - the eyes move in the same direction as the head rotation. This could indicate brain death

43. Cranial Nerve Assessment
Olfactory
Sense of smell II
Optic
Can the patient read? Have patient focus forward and test peripheral vision by counting your fingers
III
Oculomotor
Pupils equal, reactive, and accommodation IV
Trochlear
Have patient look down and in V
Trigeminal
Lateral jaw movement and face sensation. In a comatose patient, check corneal reflex VI
Abducens
Move eyes side to side
VII
Facial
Have patient smile and raise eyebrows
Acoustic
Any change in hearing ? IX
Glossopharyngeal
Can the patient swallow ? X
Vagus
Does the patient have a gag ? Is speech affected ? XI
Spinal Accessory
Have patient shrug shoulders and turn head side to side.
XII
Hypoglossal
Have patient extend tongue. Can patient articulate a certain phrase

44. Level of Consciousness
Alert & Oriented
Alert, attentive, following commands. If asleep, awakens and remains attentive.
Lethargic
Drowsy but will awaken to stimulation. Slow to answer questions or inattentive.
Obtunded
Difficult to arouse, needs constant stimulation to follow commands. Will fall back to sleep without stimulation
Stupor
Patient needs vigorous and continuous stimulation. Often requires painful stimuli. Will NOT follow commands. May moan and withdrawal from pain
Coma
No response to painful stimuli, no verbal sound, reflexive movement only.

45. Glasgow Coma Scale The Glasgow Coma Scale
Most widely used scoring system for use in quantifying level of consciousness following traumatic brain injury.
Simple
Relatively high degree of interobserver reliability
Correlates well with outcome following severe brain injury.

46. Glasgow Coma Scale Eye Opening (E) Verbal Response (V)
4. Spontaneous 5. Normal Conversation
3. to Voice 4. Disoriented Conversation
2. To Pain 3. Incoherent words
1. None 2. No words, only sounds
1. None
Motor response (M)
6. Normal
5. Localized to Pain Total = E+V+M
4. Withdraws to Pain Score 3-15
3. Decorticate Posturing
2. Decerebrate Posturing

47. ACT F.A.S.T. USE THE FACE, ARM AND SPEECH TEST
Facial Weakness – Ask the person to smile. Look for drooping at the mouth or eye
Arm Weakness – Ask the person to raise both arms. Look for unilateral drift or weakness
Speech – Ask the person to talk noting if the speech is clear and they understand what you are saying
Test all 3 symptoms and if one fails, initiate the ITeam. 47

48. Facial Asymmetry (Droop)48

49. Arm Drift

50. Speech Normal: Patient uses correct words with no slurring
Abnormal: Slurred or inappropriate words or mute
Aphasia – Inability to articulate speech
Dysphasia - impairment of speech
Receptive Dysphasia - Inability to comprehend
Expressive Aphasia – Inability to communicate

51. Fast Stroke Screening Tool
1. Patient Name: ____________________________________
2. Information/History from : Caregiver ________
Patient
Family
Other__________
3. Time last seen normal/baseline and awake ___:___ __/___/____
4. Patient is having new:
Facial Droop YES NO UNABLE TO ASSESS
Arm drift YES NO UNABLE TO ASSESS
Speech Difficulty YES NO UNABLE TO ASSESS
5. History of seizures
or epilepsy absent YES NO UNKNOWN
6. Symptom duration < 24 hours YES NO UNKNOWN
7. Patient not wheelchair bound
or bedridden at baseline YES NO UNKNOWN
8. Glucose between 60 and 400 YES NO UNKNOWN
9. GCS ___________
ALL YES ? INITIATE CODE BRAIN ATTACK PROTOCOL
*Not a permanent part of patient record

52. Decorticate & Decerebrate Posturing

53. Cincinnati Stroke Scale
Facial Droop (ask patient to smile or show their teeth)
Arm Drift (Ask patient to close eyes and hold both arms out with palms up)
Speech (Ask patient to say “The sky is blue in Cincinnati”)
Time is crucial!
Both sides should move equal
Both arms move the same
Patient uses correct words no slurring
About 3 hours before treatment won’t help

54. Ischemic Brain Attack Management
Maintain airway--oxygenate
Neuro assessment Glasgow Coma Scale
Treat with tPA (tissue plasminogen activator) within 3 hours
Correct hypoglycemia, watch for hyperglycemia
No free water IV fluids
Raise serum osmolality to 310 mOs/L
Blood pressure management

55. Blood Pressure Management
Optimal blood pressure targets remain to be determined. Many patients are hypertensive on arrival. Recent American Stroke Association guidelines have reinforced the need for caution in lowering blood pressures acutely.
In the small proportion of patients with stroke who are relatively hypotensive, pharmacologically increasing blood pressure may improve flow through critical stenoses

56. LHS Stroke Protocol Orders Blood Pressure guidelines
During Alteplase
For SBP 200 mmHg or greater or DBP 110 mmHg or greater give Labetalol 20 mg IVP over 1-2 minutes. May repeat Labetalol 20mg IVP q10min to total dose of 150 mg.
Post Alteplase
Labetalol HCL 20mg IVP q10min x 3 doses for SBP greater than 180 mmHg or DBP greater than 105 mmHg.

57. Blood Pressure Guidelines for those not receiving tPA
Notify physician if
SBP greater than or equal to 180 mmHg
DBP greater than or equal to 105 mmHg,
if there are changes in neuro status

58. Treatment with tPA for Ischemic Brain Attack
Administer tissue plasminogen activator (tPA) within 3 hours.
Must do diagnostic CT first
Determine eligibility

59. tPA dosaging
Total recommended dose is 0.9mg/kg; maximum total dose is 90mg
Patients < 100kg infuse as follows:
Load with 0.09mg/kg bolus (10% of 0.9mg/kg dose) over 1 minute
Then administer 0.81mg/kg infusion (90% of 0.9mg/kg dose) over 1 hour
Patients ≥ 100kg infuse as follows:
Load with 9mg bolus (10% of 90mg)over 1 minute
Then administer 81mg infusion (90% of 90mg dose) over 1 hour
**Doses should be given within 3 hours of symptom onset
**Administering anticoagulants or aspirin within 24 hours of alteplase is not recommended

60. Questions

61. Bibliography www.stroke.org www.strokeassociation.org www.kuakini.org