Stroke

Stroke, formerly known as cerebrovascular accident (CVA), is the interruption of normal blood flow in one or more of the blood vessels that supply the brain. The tissues become ischemic, leading to hypoxia or anoxia with destruction or necrosis of the neurons, glia, and vasculature. According to the American Heart Association (AHA), stroke is the fifth leading cause of death in the United States and affects close to 800,000 Americans annually with approximately 130,000 deaths per year. The incidence of first-time strokes is approximately 610,000 per year, but as the population ages, the incidence will increase to 1 million per year by 2050. The AHA reports that stroke is the leading cause of serious long-term disability in the United States.

Stroke is an acute neurological injury that occurs because of changes in the blood vessels of the brain with a corresponding loss of neurological function. Blood vessel changes can be intrinsic to the vessel (atherosclerosis, inflammation, arterial dissection, dilation of the vessel, weakening of the vessel, obstruction of the vessel) or extrinsic, such as when an embolism travels from the heart. Although reduced blood flow interferes with brain function, the brain can remain viable with decreased blood flow for long periods of time. However, total cessation of blood flow produces irreversible brain infarction within 3 minutes. Once the blood flow stops, toxins released by damaged neurons, cerebral edema, and alterations in local blood flow contribute to neuron dysfunction and death. Complications of stroke include unstable blood pressure, pneumonia, contractures, pulmonary emboli, pain, sensory and motor impairment, speech impairment, memory loss, cognitive loss, labile emotions, infection (encephalitis), cerebral edema, coma, and death.

Causes ⬆ ⬇

Thrombosis, embolism, and hemorrhage are the primary causes of ischemic stroke, characterized by the sudden loss of blood circulation to an area of the brain. Experts estimate that 87% of strokes in the United States are ischemic, 10% are secondary to intracerebral hemorrhage, and 3% are due to subarachnoid hemorrhage. In cerebral thrombosis, the most common cause of stroke, a blood clot obstructs a cerebral vessel. The most common vessels involved are the carotid arteries of the neck and the arteries in the vertebrobasilar system at the base of the brain near the circle of Willis. Cerebral thrombosis also contributes to transient ischemic attacks (TIAs), which are temporary episodes (10–30 min) of poor cerebral perfusion caused by partial occlusion of the arterial lumen. A thrombotic stroke that causes a slow evolution of symptoms over several hours is called a stroke in evolution. When the condition stabilizes, it is called a completed stroke.

In an embolic stroke, a clot is carried into the cerebral circulation, usually by the carotid arteries. Blockage of an intracerebral artery results in a localized cerebral infarction. Hemorrhagic stroke results from hypertension, rupture of an aneurysm, arteriovenous malformations, or bleeding disorder. Risk factors thought to cause blood vessel changes that cause vessel walls to be more susceptible to rupture and hemorrhage include elevated low-density lipoprotein and lowered high-density lipoprotein levels, cigarette smoking, and a sedentary lifestyle. Other risk factors for stroke include hypertension, cigarette smoking, exposure to secondary smoke, diabetes mellitus, obstructive sleep apnea, heart failure, myocarditis, endocarditis, cardiac dysrhythmias, and family history.

Genetic Considerations ⬆ ⬇

Stroke is considered a complex disease with both genetic and environmental risk factors (heritability is estimated to be ~38%). Several susceptibility loci have been reported. Variants in the genes phosphodiesterase 4D (PDE4D), SELP, IL4, F5, prothrombin (F2), MTHFR, ACE, ALOX5AP, EPHX2, and PRKCH have been shown to increase the risk of ischemic stroke. Other risk factors include atrial fibrillation (PITX2), coronary artery disease (ABO, HDAC9, ALDH2), high blood pressure, and smooth muscle cell development (FOXF2). For hemorrhagic stroke, APOE and PMF1.

There are also several single-gene disorders for which stroke is a common feature, although the exact genetic mechanism is unknown. These include cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL; an autosomal dominant stroke syndrome affecting small cerebral vessels), Marfan syndrome, Ehlers-Danlos syndrome, and sickle cell anemia.

Sex and Life Span Considerations ⬆ ⬇

Five percent of the population in North America over age 65 years is affected by stroke. Stroke affects men slightly more often than women and is more common after 50 years, although drug use is causing an increase in strokes in younger people. Approximately 35% of people hospitalized with stroke are less than 65 years of age. Experts note that women are more disabled than men after surviving a stroke, with more problems with mobility, self-care, usual activity, pain/discomfort, and anxiety/depression. They experience more limitation of activity, worse quality of life, and greater levels of poststroke depression than men. Women's symptoms at presentation also differ from men's. They are more likely to experience incontinence, difficulty swallowing, and loss of consciousness, whereas both men and women experience traditional symptoms such as limb weakness, facial weakness, dysarthria, paresthesia, and dysphagia.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Black persons have a 2.5 times higher rate of stroke than White persons because of the former's higher incidence of hypertension. Black persons also suffer greater physical impairment and are nearly twice as likely as White persons to die from stroke. Hispanic persons have a lower overall incidence of stroke than other groups. Health disparities exist for rural dwellers who have stroke. Rural patients, as compared to their urban counterparts, are less likely to receive IV thrombolysis or endovascular therapy and have higher in-hospital mortality.

Sexual and gender minority persons have higher odds for multiple chronic conditions and poor quality of life and are more apt to have disabilities than cisgender males and females. (Cisgender is a term used to describe persons whose gender identity and gender expression are aligned with their assigned sex listed on their birth certificate.) Gender-affirming hormone therapy is the use of hormone therapy for gender transition or gender affirmation and can be masculinizing or feminizing. It may also affect cardiovascular health in transgender females. In a large sample, researchers have found that transgender men and women are more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes, ischemic stroke, angina/coronary disease, and myocardial infarction. Gender-nonconforming men and women reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of any cardiovascular disease than cisgender men (Cacerese, Jackman, et al., 2020; Connelly et al., 2019). While large-scale studies are not available, these factors likely place sexual and gender minority persons at risk for stroke.

Global Health Considerations ⬆ ⬇

The World Health Organization and the AHA report that 25.7 million people experience stroke globally each year, with 10.3 million people having a first stroke. It is the second leading cause of death, after ischemic heart disease, in the world. Stroke is also a leading cause of serious disability in the world.

Assessment ⬆ ⬇

ASSESSMENT

History

Determine if the patient is on any medications or abuses IV drugs. Determine if the patient has any of the following conditions: hypertension, diabetes mellitus, tobacco use, elevated cholesterol, heart disease, heart failure, or atrial fibrillation. Ask about cocaine use, recent trauma, migraine headaches, and oral contraceptive use. Elicit a history of neurological deficits (Table 1). Determine if the patient has experienced a loss of consciousness, an inability to recognize familiar objects or persons through sensory stimuli (agnosia) or any memory loss (amnesia). Elicit a history of speech difficulties such as an inability to understand language or express language (aphasia), poorly articulated speech (dysarthria), or any other form of speech impairment (dysphasia). Note if urinary incontinence occurred. Determine if the patient has lost the ability to comprehend written words (alexia), read written words (dyslexia), or write (agraphia). Establish a history of visual difficulties such as double vision (diplopia), defective vision, or blindness in the right or left halves of the visual fields of both eyes (homonymous hemianopia), lack of depth perception, color blindness, blindness, blurring on the affected side, or drooping eyelids (ptosis).

Table 1 Stroke Sites and Neurological Deficits

STROKE SITE		SIGNS AND SYMPTOMS
Posterior cerebral artery		Visual field deficits, sensory impairments; reading difficulty (dyslexia); coma; cortical blindness resulting from ischemia in the occipital area; paralysis (rarely)
Vertebral or basilar artery		Numbness around the lips and mouth; dizziness; weakness on the affected side; vision deficits (color blindness; lack of depth perception; double vision [diplopia]); poor coordination; difficulty swallowing (dysphagia); slurred speech; amnesia; staggering gait (ataxia)
Internal carotid artery		Headache; weakness; paralysis; numbness; sensory changes; vision disturbances (blurring on the affected side or blindness); altered level of consciousness; bruits over the carotid artery; defective language function (aphasia); speech impairment (dysphasia); eyelid drooping (ptosis)
Middle cerebral artery		Defective language function (aphasia); speech impairment (dysphasia); reading difficulty (dyslexia); visual field deficits; hemiparesis on the affected side (more severe in the face and arm than in the leg)

Elicit a history of motor difficulties such as the inability to move the muscles (akinesia), inability to perform purposeful acts or manipulate objects (apraxia), poor coordination, impairment of voluntary movement (dyskinesia), muscular weakness or partial paralysis affecting one side of the body (hemiparesis), or paralysis of one side of the body (hemiplegia). Ask if the patient has experienced numbness, and ascertain the specific location. Determine if the patient has experienced headaches. Establish a history of personality changes such as flat affect or distractibility.

Physical Examination

Symptoms vary based on the location of the stroke. Common symptoms include altered consciousness, visual defects, speech and language impairment, motor impairment, sensory impairment, paralysis, eyelid or mouth drooping, and numbness. If the patient appears unconscious, quickly determine the patient's airway status and level of consciousness. If the patient is conscious, the patient may be experiencing a TIA or a stroke in evolution. Determine the level of orientation; ability to respond to questions of intellectual functioning; and speech, hearing, and vision ability. Lightly touch the patient's skin on various parts of the body and ask the patient to identify the location. Apply firm pressure to various parts of the body and observe the patient's responses. Be sure to test skin sensations sensed in both hemispheres of the body and compare the responses.

Begin your assessment by determining the patient's understanding of your commands and the appropriateness of the patient's verbal and nonverbal responses. In left-hemisphere stroke, there is likely to be loss of language ability, although memory may be intact. In right-hemisphere stroke, patients are often confused and disoriented, but the ability to speak remains. Determine the presence of hemiplegia or hemiparesis and the patient's muscle strength, gait, and balance. Assess the patient's cranial nerves (V, VII, IX, X, and XII) to determine tongue movement and ability to chew and swallow, as well as the presence of a gag reflex. Assess the patient for the presence of hemianopia by observing whether the patient sees objects on either side of the midvisual field. If the patient is disoriented or has lost the ability to understand language (receptive aphasia), assessing hemianopia is difficult. Try handing the patient a fork on the affected side and ask the patient to tell you what it is you are holding or ask the patient to pick up the fork.

Psychosocial

During the early stages of their condition, many patients with stroke experience great despair and frustration trying to communicate their needs. The inability to communicate causes profound depression. Although patients may laugh or cry or display outbursts of anger and frustration at unusual times, it is impossible to know with any certainty if these responses are inappropriate for the patient.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Computed tomography (CT)	Intact cerebral anatomy	Identification of size and location of site of hemorrhage or infarction	Shows anterior to posterior slices of the brain to highlight abnormalities

Other Tests: Magnetic resonance imaging is more sensitive than CT if the stroke is small and/or in the brainstem. Carotid duplex scanning is used in patients with acute ischemic stroke when carotid artery stenosis or occlusion is suspected. Transcranial Doppler ultrasound is used to evaluate the middle cerebral, intracranial carotid, and vertebrobasilar arteries. Echocardiography is used for patients with acute ischemic stroke when cardiogenic embolism is suspected. Continuous oximetry and electrocardiographic monitoring provide surveillance. Laboratory tests include complete blood count with differential, platelet count, prothrombin time, activated partial thromboplastin time, electrolytes, creatinine, and glucose. Other diagnostic tests that help evaluate cerebral blood flow, identify abnormalities, or locate the stroke include positron emission tomography, cerebral blood flow studies, and transthoracic two-dimensional echocardiography to identify intracardiac sites for thrombi.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisRisk for ineffective cerebral tissue perfusion as evidenced by motor impairment, sensory impairment, speech and/or language impairment, confusion, and/or visual defects

Outcomes

OutcomesCognitive orientation; Tissue perfusion: Cerebral; Neurological status: Cranial sensory/motor function; Knowledge: Stroke management; Self-management: Stroke

Interventions

InterventionsCerebral perfusion promotion; Cerebral edema management; Vital signs monitoring; Oxygen therapy; Neurological monitoring; Self-care assistance; Teaching: Disease process

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Medical.

The primary goal for treatment is to preserve tissue, which might be ischemic but not infarcted. Likely this can be achieved by restoring blood flow to the area of ischemia and supporting collateral circulation. The treatment needs to be initiated rapidly (within 6 hr of the onset of symptoms) to preserve as much brain tissue as possible. Medical management for patients with strokes typically includes support of vital functions and ongoing surveillance to identify early neurological changes as the patient's condition evolves. Although the hallmark of stroke is the abrupt onset of neurological symptoms and deficits due to the interruption of the vascular supply to a specific brain region, therapeutic intervention may save tissue that is at risk for infarction. Recombinant tissue-plasminogen activator (rt-PA) can improve outcome for some patients with acute nonhemorrhagic ischemic stroke if it is given within 3 hours of the onset of symptoms. Medication management centers on these four areas: anticoagulation, reperfusion, antiplatelet function, and neuroprotective function.

Surgical.

When a stroke has occurred, the treatment consists of maintaining life, reducing intracranial pressure (ICP), limiting the extension of the stroke, and preventing complications. For patients who cannot maintain airway, breathing, and circulation independently, assist with endotracheal intubation, ventilation, and oxygenation as prescribed. In hemorrhagic stroke, surgery may be required to evacuate a hematoma or to stop bleeding. A ventricular shunt may be placed to drain cerebrospinal fluid.

Physical therapy is begun as soon as the patient's condition stabilizes. Flaccid muscles soon become spastic and subject to contractures. Use passive range-of-motion exercises on the affected side. Strengthening the unaffected side assists the patient in compensating for the losses of the opposite hemisphere. The physical therapist teaches the patient to transfer with the use of assistive devices, and the physical or occupational therapist teaches the patient how to perform self-care activity.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Recombinant tissue-plasminogen activator (rt-PA) (alteplase, recombinant)	0.9 mg/kg up to a maximum of 90 mg with the first 10% given IV over 1 min and the remainder given by infusion pump over 1 hr	Thrombolytic; activates the fibrinolytic system by directly cleaving the bond in plasminogen-producing plasmin; increases perfusion to ischemic areas	Increases perfusion to at-risk tissue; note that aspirin, heparin, and warfarin are not given during the first 24 hr; can be given up to 4.5 hr after symptom onset
Antiplatelet agents	Varies by drug	Block prostaglandin synthetase action, which then inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2; aspirin, dipyridamole, clopidogrel	Decrease blood clotting and prevent embolic stroke

Pharmacologic Comments: Contraindications to rt-PA: Duration of stroke for more than 4.5 hours, recent surgery, head injury or gastrointestinal/urinary hemorrhage, seizure at stroke onset, bleeding disorder, hypertension. Some patients receive anticonvulsant agents to reduce the risk of seizures (diazepam, lorazepam), stool softeners to decrease straining, corticosteroids to decrease cerebral edema, and analgesics to reduce headache. Cerebral edema may be reduced through dehydrating measures and the use of steroids and osmotics. For thromboembolic strokes, pharmacologic agents such as warfarin, apixaban, and dabigatran are used to limit the extension of the stroke.

Independent

Position the patient to maintain a patent airway by elevating the head of the bed 30 degrees to promote pulmonary drainage and limit upper airway obstruction. Suction the patient's mouth and, if needed, the nasopharynx and trachea. Before suctioning, oxygenate the patient well; to minimize ICP increases, limit suctioning to 20 to 30 seconds at a time.

The patient with a stroke is at extremely high risk for complications caused by immobility. If appropriate, use compression boots to promote venous return and help prevent phlebitis. To reduce the risk of pulmonary infection, promote skin integrity, and prevent contractures, turn and reposition the patient every 2 hours. Keep the patient's joints in a functional position and keep the affected hand elevated slightly on a pillow. Use a trochanter roll to prevent external rotation of the hip. Keep the patient safe by putting the bed in a low position and keeping the side rails up.

Prevent aspiration pneumonia by first determining the patient's ability to handle solids and liquids. Keep a suction machine nearby while feeding the patient. Some patients have difficulty with liquids, so thicken fluids with soft foods like cooked cereal, applesauce, soup, or mashed potatoes.

Make sure the patient has a bowel movement each morning after breakfast to stimulate normal peristalsis and prevent constipation. A catheter may be in place immediately after the stroke, but the goal is to have the patient gain control through a bladder training program. If the patient has expressive aphasia (inability to transform sounds into speech), give the patient ample time to respond to questions and be supportive if the patient becomes frustrated during speech. Be sure to accept any method of self-expression the patient uses, such as pointing, gesturing, or writing. Some patients find it easier to point to a picture that describes a word rather than trying to say the word.

Remember that the patient's family undergoes a struggle to deal with the patient's illness and needs support. If the patient or family seems to be coping poorly, arrange for a referral to a clinical nurse specialist, chaplain, or social worker. A magazine, Stroke Connection, can be subscribed to by writing AHA Stroke Connection, 7272 Greenville Avenue, Dallas, TX 75231 or http://strokeconnection.strokeassociation.org.

Evidence-Based Practice and Health Policy

Kim, Y., Twardzik, E., Judd, S., & Colabianchi, N. (2021). Neighborhood socioeconomic status and stroke incidence: A systematic review. Neurology. Advance online publication. https://doi.org/10.1212/WNL.0000000000011892

The authors aimed to summarize the impact of neighborhood socioeconomic status on stroke incidence using a systematic review of existing literature. The authors reviewed four electronic databases and contacted corresponding authors to locate additional studies.
They found that higher neighborhood disadvantage was associated with higher stroke risk in some studies but not all. The relationship between neighborhood socioeconomic status and stroke risk within different racial and ethnic groups in the United States was inconclusive, possibly because of individual-level characteristics and neighborhood-level racial composition.

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DRG Information ⬇

Introduction ⬆ ⬇