Acute Brain Injury LHS Stroke Center

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.

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

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

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

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

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

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

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

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

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

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

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

Meninges

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

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

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 10-15 mm Hg

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

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.

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

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

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

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.

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.

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

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"

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

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.

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

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

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.

Embolism

Ischemic Stroke

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

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

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

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).

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

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

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

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

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.

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.

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

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

Facial Asymmetry (Droop) 48

Arm Drift

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

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

Decorticate & Decerebrate Posturing

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

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

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

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.

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

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

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

Questions

Bibliography www.stroke.org www.strokeassociation.org www.kuakini.org www.americanheart.org http://rn.modernmedicine.com