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Stroke - Cerebrovascular Accident (CVA)

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on 9 February 2011

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Transcript of Stroke - Cerebrovascular Accident (CVA)

Cerebrovascular Accident (CVA)
- Stroke - 700,000 cases / Year
1 stroke / 45 seconds World's 3rd most common cause of death Some Statistical Facts A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. Blockage of an Artery

Narrowing of the small arteries within the brain
Hardening of the arteries (atherosclerosis) leading to the brain.
Embolism to the brain from the heart. cerebrovascular accident (CVA)
Overview
Pathophysiology
Risk factors and preventive measures
Sings and symptoms
Treatments Usually vary depending on the location of the bleed and the amount of brain tissue affected.
Usually develop suddenly, without warning, and often during activity.
They may come and go (be episodic) or slowly get worse over time Two main pairs of arteries that supply the cerebral arteries and the cerebellum:
Internal carotid arteries
Vertebral arteries Brain is highly vascular:
15% of the cardiac output is devoted to CNS Overview Rapture of an Artery (hemorrhage)

Bleeding within the brain substance Pathophysiology of
Hemorrhagic Stroke Blood flow is interrupted by a ruptured blood vessel
Less common (<15%)
Associate with a significantly higher mortality rate
Tend to look more ill than ischemic strokes 50 % die within the
first 48 hours
Sings & Symptoms Signs

Facial Drooping
Aphasia/Dysphasia
Hemiparesis
Hemiplegia
Paresthesia
Gait Disturbances
Incontinence
Symptoms

Headache
Confusion
Agitation
Dizziness
Vision Problems Cerebral Resuscitation

- Medical Management Priorities
Preserve the airway
Maintain adequate ventilation and oxygenation
Maintain euvolemia
Manage changes in intracranial pressure

- Surgical Intervention AIRWAY

As cerebral function decreases, vital functions such as airway preservation may be lost
It may be necessary to artficially manage the airway of a compromised patient
Intubation may be necessary with a GCS of 8 or less or in the scenario where ventilation is comprised. VENTILATION
- No signs of herniation:
Maintain adequate ventilation
Ventilations should be maintained at 10 bpm
- Signs of herniation:
Hyperventilate the patient to a PCO2 of 25 to 35 mm Hg
Normocapnia is a PCO2 of 35 to 45 mm Hg FLUID RESUSCITATION

- Support oxygen delivery and avoid hypotension
- Maintain euvolemia
Mainstay of therapy is isotonic crystalloid solution
- Hypertonic saline . . . ?
Beneficial in animal studies
Ongoing clinical trials with mixed results
May have a benefit in hypotensive patients
- versus mannitol OTHER THERAPIES
- Mannitol (20%)
0.5-1.0 g/kg every 4 hours
- Lidocaine with RSI
prevents increase in intracranial pressure (ICP) with intubation
no study; thus far, has shown an impact on transient increases in ICP on patient outcome OTHER THERAPIES

- Sedation and analgesia
treat hypotension, hypoxemia, hypoglycemia,and patient discomfort first
- head elevation
no more that 30 degrees DECOMPRESSIVE SURGERY

CRANIOPLASTY Recovery

Stroke rehabilitation is essential to improve function

When delayed, patients develop secondary complications (start within 2 to 7 days)

Demographics

Recovery usually takes place within the first 3 months

Only minor improvements occur after 6 months

Rare cases after 6 months



Treatment & Prognosis May be beneficial in the case of significant cerebral edema
Forsythe, et al. “Role of Hypertonic Saline for the Management of Intracranial Hypertension After Stroke and Traumatic Brain Injury”. Pharmacotherapy, April 2008.
HYPERTONIC SALINE  Durwald, et al. “Cerebral and cardiovascular responses to changes in head elevation in patients with intracranial hypertension”. Journal of Neurosurgery, December 1983
DEFINITIVE MANAGEMENT ICP MANAGEMENT
Maintain:
HOB 30º upright or reverse Trendelenberg
appropriate analgesia and sedation ± neuromuscular paralysis CRANIOPLASTY


Normal ICP 0 – 10mmHg
Intracranial hypertension (ICH) usually defined as ICP > 20 – 25mmHg Emergency Department

- ABC’s
- Neurologic assessment
- Immediate CT Head after initial stabilization
characterizes anatomic injury
identifies surgical lesion
May rule out hemorrhage - further testing for infarct OTHER THERAPIES

Seizure prophylaxis
Avoidance of hyperthermia
Tight glucose control
Barbiturate coma
Surgery CT (Computed Tomography) Intracranial Pressure Monitoring DECOMPRESSIVE SURGERY RECOVERY Stroke rehabilitation is essential to improve function

When delayed, patients develop secondary complications (start within 2 to 7 days)
Recovery usually takes place within the first 3 months
Only minor improvements occur after 6 months
Rare cases after 6 months
By: Amir, Anna, Will, Jami
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