2Objectives 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.
3BrainBody’s controlling organResponsible for organizing functions of other body organ systems
4Brain Anatomy Review Occupies 80% of intracranial space Divisions CerebrumCerebellumBrain Stem
6Brain Anatomy ReviewCerebrum: largest and most advanced portion of brain.CortexFrontal lobeParietal lobeTemporal lobeOccipital lobe
7Cerebrum 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 movementsDamage – hemiparesis, facial droop, expressive aphasia, impulsive behavior
8Cerebrum (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 causevisual-spacial deficits, making it hard for a patient to find their way around new or familiar places.Neglect of affected sideDamage to the left parietal lobe may disrupt the ability to understand spoken and/or written communication
9Cerebrum (cont): Temporal Lobes: Located around ear level Allows differentiation of smells and soundsHelps sort new informationResponsible for short-term memoryRight 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
10Cerebrum (cont): Occipital Lobe: Processes visual information Visual receptionVisual recognition of shapes and colorsDamage to this lobe can cause visual deficits
11The Cerebellum Second largest area of the brain Controls reflexes, balance and certain aspects of movement and coordination, equilibrium, fine motor skillsDamage from a Stroke:lack of coordination (ataxia), clumsiness, balance problemInability to walk, talk, eat and perform other self-care tasks
12The Brain Stem Responsible for the Critical Functions of Life Breathing, digestion, heart beat, temperatureIncludes alertness and arousal or the state of being awakeDamage from a stroke:Most devastating and life threatening as they can disrupt involuntary functions essential to lifePeople who survive a brain stem stroke will remain in a vegetative state or left with severe impairments
13Brain Anatomy Review Brain Stem connects hemispheres, cerebellum and SCresponsible for vegetative functions & VSMidbrainrelay point for visual and auditory impulsesPonsconduction pathway between brain and other regions of bodyMedulla oblongatacardiac, respiratory, and vasomotor control centerscontrol of vomiting and coughing
14Brain Anatomy Review Brain Stem Cranial Nerves Reticular Activating Systemlevel of arousal (level of consciousness)Primary control along with cerebral cortexMeningesDura mater: tough outer layer, separates cerebellum from cerebral structures, landmark for lesionsArachnoid: web-like, venous vessels that reabsorb CSFPia mater: directly attached to brain tissue
16Brain Metabolism High metabolic rate consumes 20% of body’s oxygen largest user of glucoserequires thiaminecan not store nutrients
17Brain Perfusion Blood Supply vertebral arteries Cerebral Blood Flow (CBF)dependent upon CPPflow requires pressure gradientCerebral Perfusion Pressure (CPP)pressure moving the blood through the craniumautoregulation allows BP change to maintain CPPCPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)Blood Supplyvertebral arteriessupply posterior brain (cerebellum and brain stem)carotid arteriesmost of cerebrum
18Brain Metabolism & Perfusion Mean Arterial Pressure (MAP)largely dependent on cerebral vascular resistance (CVR) since diastolic is main componentblood volume and myocardial contractilityMAP = Diastolic + 1/3 Pulse Pressureusually require MAP of at least 60 mm Hg to perfuse brainIntracranial Pressure (ICP)edema, hemorrhageICP usually mm Hg
19Blood 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 brainthe 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
20Blood Flow of BrainThere 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.
21Blood flow of the BrainThe 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
22Cushing’s Triad Increasing Intracranial Pressure Increasing systolic blood pressureWidening pulse pressureBradycardiaBradypneaThese are late signs and probable irreversible. Brain Stem herniation is in progress
23Cerebrospinal Fluid (CSF Surrounds brain, spinal cord in space between arachnoids and pia mater (subarachnoid space)Acts as a shock absorberProtects brain from jolts, shocks
24Brain Attack FactsStroke 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.
25Brain Attack FactsStroke 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.
26Symptoms Symptoms may be sudden and include: weakness or numbness of the face, arm, or leg, especially on one side of the bodyconfusion or difficulty speaking or understandingproblems with vision such as dimness or loss of vision in one or both eyesdizziness or problems with balance or coordinationproblems with movement or walkingsevere headaches with no other known cause
27SymptomsOther, less common, symptoms of stroke may include the following:sudden nausea, vomiting, or fever not caused by a viral illnessbrief loss or change of consciousness such as fainting, confusion, seizures, or comatransient ischemic attack (TIA), or "mini-stroke"
28Risk factors for stroke that can be changed, treated, or medically managed high blood pressurediabetes mellitusheart diseasecigarette smokinghistory of transient ischemic attacks (TIAs)high red blood cell counthigh blood cholesterol and lipidslack of exercise, physical inactivityObesityexcessive alcohol usedrug abuseabnormal heart rhythmcardiac structural abnormalitiesThe most important controllable risk factor for brain attack is controlling high blood pressureDiabetes 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 diabetesHeart 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 riskA 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 TIAA moderate increase in the number of red blood cells thickens the blood and makes clots more likely, thus increasing the risk for strokeIntravenous 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 fatalNew evidence shows that cardiac structure abnormalities including patent foramen ovale and atrial septal defect increase risk for embolic stroke
29Risk factors for stroke that cannot be changed: agegenderracehistory of prior strokeheredity/geneticsFor each decade of life after age 55, the chance of having a stroke more than doublesMen 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.
30Types of Brain Attacks Ischemic—”deprived of blood” Sometimes called “occlusive”Accounts for 83% stroke casesHemorrhagic—”caused by bleeding”Hypertension primary causeLoss of blood flow for 3-5 minutes causes necrosis of the CNSAccounts for 17% of stroke cases
31Ischemic Stroke Thrombotic Embolic Artery is gradually occluded by a plug of material the collects in a given siteUncommon in smaller arteriesUsually in areas of disturbance like twists and bends in an arteryAtherosclerosis: Greek “hard paste”Artery is suddenly occluded by material that moves through the vascular system to occlude an arteryOften a fragment from a thrombosisAtrial fibrillation is a common cause
32Ischemic Strokes Source The most common source of an embolic stroke is the left atrium of the heart:Atrial FibrillationAnother source is from the carotid artery,atherosclerotic plaque and clots detach and are carried through the blood stream into cerebral vasculature.
35Hemorrhagic stroke (cerebral hemorrhage) Caused by disruption of a cerebral blood vessel, bleeds into surrounding tissueDue to weakness of the vessel wall.AneurysmAV MalformationTraumatic injury to the vesselpressure on arterial walls or chronic hypertension—causing “microaneurysms”DO NOT TREAT WITH THROMBOLYTICS
36Hemorrhages Extracerebral hemorrhages—bleeding outside of the brain SubarachnoidsubduralextraduralIntracerebral hemorrhagesWithin brain substance bleed
37Aneurysm “Pouches” formed in arterial walls Most are due to injury to: berry or saccular, term depends upon the shapeNearly 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 ArteryACA Anterior Communicating Artery2-3% occur in the posterior cerebral artery
38Lacunar 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).
40Right & Left Hemisphere CVA FeatureLeftRightLanguageAphasiaImpaired sense of humorMemoryDeficitDisorientedVisionRight visual field deficitProblem ReadingSpatial deficitsLoss of depth perceptionBehavioralSlowcautiousImpulsiveEuphoric
41Stroke AssessmentSingle most important assessment is Level of consciousnessSternal Rubcautious, can be easily bruisedTrapezius SqueezeMuscle at top of shoulderSupraorbital PressureAvoid if facial fracturesCentral stimulation preferred, Peripheral stimulation such as nail bed pressure may only elicit reflexive movement*Consider patients past medical history and baseline
42In stuporous or comatose patients Assess gag, corneal, and swallow reflexAssess BabinskiPositive - Toes flareNegative - Toes curl downwardAssess Doll’s eyes (If no neck injury)Open eyes and turn head left then rightPositive or normal – the eyes automatically move in the direction opposite the rotationNegative - the eyes move in the same direction as the head rotation. This could indicate brain death
43Cranial Nerve Assessment OlfactorySense of smellIIOpticCan the patient read? Have patient focus forward and test peripheral vision by counting your fingersIIIOculomotorPupils equal, reactive, and accommodationIVTrochlearHave patient look down and inVTrigeminalLateral jaw movement and face sensation. In a comatose patient, check corneal reflexVIAbducensMove eyes side to sideVIIFacialHave patient smile and raise eyebrowsAcousticAny change in hearing ?IXGlossopharyngealCan the patient swallow ?XVagusDoes the patient have a gag ? Is speech affected ?XISpinal AccessoryHave patient shrug shoulders and turn head side to side.XIIHypoglossalHave patient extend tongue. Can patient articulate a certain phrase
44Level of Consciousness Alert & OrientedAlert, attentive, following commands. If asleep, awakens and remains attentive.LethargicDrowsy but will awaken to stimulation. Slow to answer questions or inattentive.ObtundedDifficult to arouse, needs constant stimulation to follow commands. Will fall back to sleep without stimulationStuporPatient needs vigorous and continuous stimulation. Often requires painful stimuli. Will NOT follow commands. May moan and withdrawal from painComaNo response to painful stimuli, no verbal sound, reflexive movement only.
45Glasgow Coma Scale The Glasgow Coma Scale Most widely used scoring system for use in quantifying level of consciousness following traumatic brain injury.SimpleRelatively high degree of interobserver reliabilityCorrelates well with outcome following severe brain injury.
46Glasgow Coma Scale Eye Opening (E) Verbal Response (V) 4. Spontaneous 5. Normal Conversation3. to Voice 4. Disoriented Conversation2. To Pain 3. Incoherent words1. None 2. No words, only sounds1. NoneMotor response (M)6. Normal5. Localized to Pain Total = E+V+M4. Withdraws to Pain Score 3-153. Decorticate Posturing2. Decerebrate Posturing
47ACT 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 eyeArm Weakness – Ask the person to raise both arms. Look for unilateral drift or weaknessSpeech – Ask the person to talk noting if the speech is clear and they understand what you are sayingTest all 3 symptoms and if one fails, initiate the ITeam.47
50Speech Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or muteAphasia – Inability to articulate speechDysphasia - impairment of speechReceptive Dysphasia - Inability to comprehendExpressive Aphasia – Inability to communicate
51Fast Stroke Screening Tool 1. Patient Name: ____________________________________2. Information/History from : Caregiver ________PatientFamilyOther__________3. Time last seen normal/baseline and awake ___:___ __/___/____4. Patient is having new:Facial Droop YES NO UNABLE TO ASSESSArm drift YES NO UNABLE TO ASSESSSpeech Difficulty YES NO UNABLE TO ASSESS5. History of seizuresor epilepsy absent YES NO UNKNOWN6. Symptom duration < 24 hours YES NO UNKNOWN7. Patient not wheelchair boundor bedridden at baseline YES NO UNKNOWN8. Glucose between 60 and 400 YES NO UNKNOWN9. GCS ___________ALL YES ? INITIATE CODE BRAIN ATTACK PROTOCOL*Not a permanent part of patient record
53Cincinnati 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 equalBoth arms move the samePatient uses correct words no slurringAbout 3 hours before treatment won’t help
54Ischemic Brain Attack Management Maintain airway--oxygenateNeuro assessment Glasgow Coma ScaleTreat with tPA (tissue plasminogen activator) within 3 hoursCorrect hypoglycemia, watch for hyperglycemiaNo free water IV fluidsRaise serum osmolality to 310 mOs/LBlood pressure management
55Blood 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
56LHS Stroke Protocol Orders Blood Pressure guidelines During AlteplaseFor 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 AlteplaseLabetalol HCL 20mg IVP q10min x 3 doses for SBP greater than 180 mmHg or DBP greater than 105 mmHg.
57Blood Pressure Guidelines for those not receiving tPA Notify physician ifSBP greater than or equal to 180 mmHgDBP greater than or equal to 105 mmHg,if there are changes in neuro status
58Treatment with tPA for Ischemic Brain Attack Administer tissue plasminogen activator (tPA) within 3 hours.Must do diagnostic CT firstDetermine eligibility
59tPA dosagingTotal recommended dose is 0.9mg/kg; maximum total dose is 90mgPatients < 100kg infuse as follows:Load with 0.09mg/kg bolus (10% of 0.9mg/kg dose) over 1 minuteThen administer 0.81mg/kg infusion (90% of 0.9mg/kg dose) over 1 hourPatients ≥ 100kg infuse as follows:Load with 9mg bolus (10% of 90mg)over 1 minuteThen 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