Cerebrovascular Accident (CVA)

• 87% of all strokes

• Occurs when a blood clot blocks or narrows an artery leading to the brain. Clot’s can be categorized as:

  • Thrombotic: where the clot grows in size sufficiently to block an artery. Usually results from atherosclerosis

  • Embolic: where the clot originates in a different site and lodges in a vessel that’s too small, blocking arterial blood flow. Usually results from atrial fibrillation.

• Sudden mortality: 8-12%

• Treatments Include:

  • BP Regulation: check orders as parameters can change and be very high

  • Tissue Plasmingen Activator (tPA): Administered (via IV or IA) within 4.5 hours of symptom onset to break down clots. Transferred to ICU where blood pressure is monitored for 24 hours, anticoagulants are held, invasive procedures are avoided, and therapy is deferred for the first 8 hours

  • Intra-Arterial Thrombectomy (IAT): Clot retrieval via a catheter. Can be performed up to 24 hours post-stroke. Bed rest parameters based on location & procedure (i.e., femoral artery approach)

• 13% of all strokes

• Brain bleed occurring as a result of a head injury/trauma or spontaneously from a ruptured cerebral aneurysm—categorized as subarachnoid hemorrhage (SAH; bleeding in the subarachnoid space) and intracranial hemorrhage (ICH; bleeding between the brain tissue and skull or within the brain tissue itself)

• Sudden mortality within 30 days: SAH: 33-50%; ICH: 50-67%

Subarachnoid Hemorrhage (SAH)

• Aneurysmal

  • Treatment: craniotomy for aneurysm clipping, endovascular embolization (coils, stent, or blood diversion), manage blood pressure (beta-blockers: do not increase ICP; hydralazine & Ca channel blockers: lower increase in ICP than nitro), hydrocephalus/ICP management (EVD/lumbar drain)

  • Vasospasm is a potential complication leading to longer LOS (up to 21+ days)

    • Window 5-10 days after SAH; can cause a secondary stroke (ischemic)

    • Treatment: manage BP, medications to dilate vessels via endo, daily TCDs, follow-up angiogram

  • Minute ventilation for pCO2 30-35; hyperventilation can potentiate vasospasm and ischemia

  • Therapy implications: variable anti-coagulation & activity restrictions per MD

• Non-Aneurysmal: traumatic, occult aneurysm/cavernous malformation, AVM (intracranial/spinal), intracranial arterial dissection

  • Same medical management & monitoring

Intracranial Hemorrhage (ICH)

• This can lead to increased pressure on the brain and spasm of blood vessels

• Treatment: reverse anticoagulation, BP management, & ICP management

• Intraventricular Hemorrhage (IVH): extension of ICH, poor prognostic sign

  • IVH Treatment: EVD, BP management, fibrinolysis as appropriate.

• Bulge in a blood vessel caused by a weakness in the blood vessel wall. This weakness in the artery can cause the aneurysm to rupture leading to bleeding in the brain. Risk of rupture is dependent on size, shape, and location upon other variables.

• Symptoms: Many people are unaware they have an aneurysm and many small brain aneurysms go unnoticed. Often, even with larger aneurysms, there are no symptoms until it ruptures. Symptoms can include:

  • Large unruptured aneurysm: pupil dilation, double or blurred vision, numbness on one side of the face, or drooping eyelid

  • Leaking aneurysm: sudden and severe headache

  • Aneurysm rupture: sudden and severe headache, nausea, vomiting, neck stiffness, seizure, confusion, blurred vision, eye pain, dilated pupils, sensitivity to light, drooping eyelid, loss of balance, muscle weakness, speech impairment, or loss of consciousness

• Treatment: depends on size of the aneurysm and if it has already ruptured. Small aneurysms typically have a low risk for rupture can be monitored regularly. But risk of rupture increases as the size increases. Goal of treatment is to reduce the risk of rupture or future rupture.

  • Endovascular Treatment: catheter is threaded through a blood vessel to “coiling” or “stenting”

  • Surgical clipping: requiring bony window in the skull, craniotomy, to express the aneurysm. Following this, the neurosurgeon places a metal clip at the neck of the aneurysm to prevent blood flow to the aneurysm.

For further reading/viewing: Brain Aneurysm Treatments

• Abnormal, tangled connection between the arteries and veins. Can occur in the spinal cord or brain.

• Normal circulation: blood flows from arteries > capillaries > veins. Blood goes from high pressure to low pressure gradually

  • In AVM’s: blood flows directly from arteries to veins through an abnormal passageway (fistula) rather than capillaries. Leads to effects such as increased flow and pressure. Over time these vessels fatigue and can rupture.

• Symptoms: Most people are unaware they have an AVM and experience no symptoms. However, symptoms can include:

  • New onset seizure, muscle weakness/paralysis, impaired coordination, dizziness, headache, visual changes, language difficulties, cognitive changes (memory, attention, confusion), abnormal sensations (pain, numbness), and hallucinations.

• Treatment: depends on the location and size of the AVM. Can be treated with:

  • Serial imaging & observation: observed in yearly imaging and clinical follow-up. These AVMs are typically best left “untreated” and monitored.

  • Endovascular embolization: inject material to block blood flow to the AVM

  • Surgical resection: remove AVM from spinal cord or brain

  • Stereotactic radiosurgery (SRS): direct highly focused beams at the AVM.

• Damage occurs: 1) rupture of the AVM (considered a type of ICH, SAH, or SDH depending on location), 2-4% of all AVMs hemorrhage, 2) compressing or displacing parts of the brain or spinal cord, or 3) gradual deficits over time as blood flow and oxygen to the brain decreases.

• Occurs when a blood clot forms in the brain’s venous sinuses. Clot keeps blood from draining out of the brain, resulting in pressure build-up in the blood vessels. The buildup of pressure can lead to swelling and hemorrhage in the brain.

• Symptoms: headache, blurred vision, fainting/loss of consciousness, loss of control over movement in a part of the body, seizures, and coma.

• Rare in the general population but one of the more common causes of stroke in patients <45 years old. Flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. After the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow. May occur after physical trauma to the neck (i.e., blunt injury), strangulation, or after sudden neck movements. However, can occur spontaneously.

• Symptoms: head/neck pain, intermittent or permanent stroke symptoms (i.e., difficulty speaking, impaired coordination, and visual loss.)

• Treatment: antiplatelets or anticoagulation for 3-6 months, angioplasty (balloon), or stenting

• Separation of the layers of the artery wall supplying oxygen-bearing blood to the head and brain. Most common cause of stroke in young adults. May occur after physical trauma to the neck (i.e., blunt injury), strangulation, or after sudden neck movements. However, can occur spontaneously.

• Non-Ischemic symptoms: localized headache, neck pain, swollen tongue, decreased pupil size, or tinnitus

• Ischemic symptoms: temporary vision loss, ischemic stroke

• Treatment: antiplatelets or anticoagulation for 3-6 months, angioplasty (balloon), or stenting