Cerebrovascular Accident a.k.a. CVA is the medical term used when referring to a stroke. A Cerebrovascular Accident happens when there is an infarction (obstruction) of a part of the brain resulting from ischaemia (insufficient blood supply) or haemorrhage (blood vessel rupture). The blood vessel in which the infarct happens determines the area and the extent of the brain damage caused.
Prognosis
- Between 25-35% of patients who experience a cerebrovascular accident end up with long-lasting and quite often permanent neurologic dysfunction.
- Most patients recover within the first few weeks following a stroke.
- Up to 1 year following a stroke, minor improvements may occur.
- Mortality following a stroke is mostly caused due to respiratory compromise, depression of the vital centres of the medulla, brain stem failure, and haemorrhage.
Ischaemic Cerebrovascular accident
Haemorrhagic Cerebrovascular Accident
Thrombotic Cerebrovascular accident
Arteriovenous Malformation (AVM)
NOTE: Blood clots can ONLY originate from the LEFT side of the heart. From there they travel down to the left ventricle and are pumped out from the Aorta, carrying oxygenated blood to the other parts within the body, including to the brain, which is where a cerebrovascular accident may happen.
Thus, blood clots can NEVER originate from Deep Vein Thrombosis since the venous system carries de-oxygenated blood back to the heart and not to other parts of the body.
Blood Circulation – Arteries vs Veins
Cerebrovascular Accident Risk Factors
- HYPERTENSION– causes blood vessel damage through narrowing, rupturing or leaking; may also cause blood clots to form within the arteries which supply blood to the brain, leading to a blockage that can easily result in a cerebrovascular accident.
- SMOKING – increases blood pressure, reduces oxygen in the blood, increases blood stickiness resulting in an increased risk of blood clot formation.
- HYPERCHOLESTEROLEMIA– increases the risk of cardiovascular disease – a risk factor for stroke. Fat deposits within the arteries due to cholesterol may block the blood flow to the brain, leading to a reduction in oxygenated blood reaching the brain.
- CARDIOVASCULAR DISEASE – causes hypertension – risk factor for cerebrovascular accident.
- DIABETES MELLITUS – excessive sugar in the blood causes damage to the blood vessels, causing blood vessel stiffness and build-up of fat deposits in the arteries.
- RACE – there seem to be a higher risk of a cerebrovascular accident to happen in blacks than in whites
Cerebrovascular Accident Clinical Manifestations
- Feeling weak
- Numbness
- Visual impairment
- Impaired speech
- Lack of coordination
- Cranial nerve abnormalities
- Transient Ischaemic Attack (TIA) – “mini stroke” or “riħ ta’ puplesija” in Maltese, caused by a temporary disruption in the blood supply to part of the brain.
Cerebrovascular Accident Diagnosis
- Patient history
- Physical assessment
- CT Scan – through a series of x-rays and a computer device, a CT Scan produces 3D imagery of soft tissues and bones. It is painless and non-invasive.
- MRI – used to investigate or diagnose conditions affecting soft tissue.
- Cerebral angiography – through the use of a catheter, x-ray imaging guidance along with injected contrast material allows the examination of blood vessels in the brain which can help detect vascular abnormalities.
- Echocardiogram – transthoracic echocardiography can help identify causes of CVA that may require an intervention (eg. atrial abnormalities and infective endocarditis).
Cerebrovascular Accident Clinical Management
- proper patient positioning for the prevention of contractures and aspiration
- physical therapy
- occupational therapy
- speech therapy – SLP review
- swallowing therapy
- drugs such as Aspirin, Ticlopidine, Warfarin, Heparin, Steroids
CVA Intervention using Stent Retriever
Physical Therapy
Occupational Therapy
Speech Therapy
Swallowing therapy
Cerebrovascular Accident Complications
Complications following a cerebrovascular accident include fatigue, shoulder pain, incontinence, formation of pressure sores, urinary tract infections, depression, as well as a direct impact on the person’s job, transportation, independence and relationships.
Other serious complications include:
- Brain stem damage – causes dizziness or lack of motor function; very rarely results also in paralysis, coma or death.
- Hemiplegia – a.k.a. Hemiparesis (Hemi = Half); causes weakness, stiffness and lack of control in one side of the body.
- Respiratory complications – atelectasis (when one or more areas within in the lung collapses) and pneumonia – infection in the lung parenchyma.
- Acute respiratory distress syndrome ARDS – rapid onset of widespread inflammation within the lungs that results in respiratory failure.
- Neurogenic pulmonary oedema -increased pulmonary interstitial and alveolar fluid caused by an acute central nervous system injury.
- Pulmonary embolism – blood clot formation in a blood vessel (most commonly in the leg) that travels to an artery within the lungs, blocking blood flow.
- Seizures – sudden uncontrolled electrical disturbance in the brain that may cause behavioural changes, movements or feelings.
- Deep vein thrombosis – blood clot formation in a deep (non-superficial) vein.
- Hypothalamic syndrome – a problem within the hypothalamus – the control centre for the pituitary glands and is responsible for multiple body functions; may lead to diabetes insipidus (causes frequent urination and excessive thirst), and hypothermia (loss of bodily heat resulting in lower body temperature).
Nursing Care
- Avoid aspiration
- Ensure adequate nutrition
- Address constipation
- Address self-care deficit
- Address aphasia (impaired verbal communication)
- Address impaired physical mobility – refer for physiotherapy review, encourage mobility exercises, make use of compression socks to avoid possible DVT, and check regarding administration of a blood thinner eg. Clexane or Heparin (depending on the type of CVA – in case of a haemorrhagic CVA do not administer anticoagulants)
- Promote independence in relation to activities of daily living
- Place patient belongings at reach from the affected side to avoid its neglect
- If patient is incontinent, use nappies but change frequently to avoid formation of sacral pressure ulcers. Make sure skin is cleaned well (use a wet incopad to clean patient if needed) and dry thoroughly. If barrier creams are applied, use only a thin layer and make sure it is absorbed well by the skin, as moisture promotes ulcer formation
- If a patient is awaiting SLP review, do not give thin fluids as this may cause aspiration. Unless NBM, try feeding with the use of thickeners whilst patient is propped up well. Keep a pulse oxymeter on the patient and monitor SPO2…if the oxygen saturation level decreases whilst patient is being fed, aspiration is to be suspected, in which case feeding should be avoided
Patient Discharge Plan
- Ensure home environment is safe and altered to reflect any changes in the patient’s body condition eg. phone with large numbers and mobility requirements.
- Teach safety measures such as leaving clear pathways at home, provision of adequate lighting, and Telecare service if recommended.
- Teach home care methods, targeting personal hygiene, frequent turning and repositioning, transfer techniques, bowel and bladder training, adequate clothing (to promote positive self-worth feelings), catheter care, tube feeding, as well as social stimulation and emotional support.
- Suggest appropriate community services such as support groups, daycare, outpatient services, rehabilitation services, caregiver support, support services, and state-funded programs.
Review
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Claire Galea is a mum of three currently in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta, as a mature student.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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