1. CEREBROVASCULAR
DISEASE
CASE PRESENTATION
By: ICU Department

2. INTRODUCTION
Patient with a wide variety of medical problems are cared for in
the intensive care units (ICU). In some cases, care is focused
primarily on one or two target systems, and the purpose of the
ICU stay is relatively straightforward. As an example, the ICU
care of the patient suffering from CerebroVascular disease
often follows a fairly conventional course. More often
however, the critically ill patient has problems affecting
multiple systems, frequently further compromised by general
debilitation and decreased resistance, which presdisposes the
patient to significant complications.

3. The patient who suffers stroke typifies this latter situation and
challenges the critical care nurse to devise and execute a plan of
care that addresses numerous threats to various systems. A
comprehensive approach is required to relate the deficiency in
one system to real or potential deficiencies in other systems.

4. BACKGROUND OF THE STUDY
A stroke or "brain attack" occurs when a blood clot blocks an
artery (a blood vessel that carries blood from the heart to the
body) or a blood vessel (a tube through which the blood moves
through the body) breaks, interrupting blood flow to an area of
the brain. When either of these things happen, brain cells begin
to die and brain damage occurs.

5. When brain cells die during a stroke, abilities controlled by that
area of the brain are lost. These abilities include speech,
movement and memory. How a stroke patient is affected
depends on where the stroke occurs in the brain and how much
the brain is damaged.
For example, someone who has a small stroke may experience
only minor problems such as weakness of an arm or leg. People
who have larger strokes may be paralyzed on one side or lose
their ability to speak. Some people recover completely from
strokes, but more than 2/3 of survivors will have some type of
disability.

6. ANATOMY AND
PHYSIOLOGY (Overview)
The Nervous System
The functional unit of the nervous system is the nerve cell,
or neuron. The nervous system consist of the central nervous
system (CNS), which includes the brain and spinal cord, and
the peripheral nervous system (PNS), which includes the
cranial nerves and the spinal nerves. The autonomic nerve
system (ANS) is a subdivision of the PNS that automatically
controls body functions such as breathing and heartbeat. It is
further divided into the sympathetic and parasympathetic
nervous system.

7. NEURON
A. Primary component of the nervous system; composed of the cell body
(gray matter), axon, and dendrites.
B. Axon: Elongated process or fiber extending from the cell body;
transmits impulses (messages) away from the cell body to dendrites or
directly to the cell bodies of other neurons; neuron usually has only
one axon.
C. Dendrites: short, branching fibers that receive impulses and conduct
them toward the nerve cell body. Neurons may have many dendrites.
D. Synapse: Junction between neurons where an impulse is transmitted.
E. Neurotransmitters: Chemical agents (e.g. acetylcholine,
norepinephrine) involved in the transmission of impulse across
synapse.

8. F. Myelin sheath: a wrapping of myelin ( a whitish fatty material) that protects
and insulates nerve fibers and enhances the speed of impulse conduction.
> Both axons and dendrites may or may not have a myelin sheath
(myelinated/unmyelinated)
> Most axons leaving the CNS are heavily myelinated by Schwann cells.
FUNCTIONAL CLASSIFICATION
a. Afferent (sensory) neurons: transmit impulses from peripheral receptors
to the CNS.
b. Efferent (motor) neurons: conduct impulses from CNS to the muscle
and glands.
c. Internuncial neurons (interneurons): connecting links between afferent
and efferent neurons.

9. Central Nervous System:
Brain and Spinal Cord

10. BRAIN
Brain:
A. Cerebrum: outermost area (cerebral
cortex) is gray matter; deeper area is
composed of white matter.
1. Two hemispheres: right and left.
2. Each hemisphere divided into four
lobes; many of the functional areas of
the cerebrum have been located in
these lobes.

11. The Brain Hemisphere

12. a. Frontal Lobe
> personality, behavior
> higher intellectual functioning
> precentral gyrus: motor function
> Broca’s area: specialized motor speech
b. Parietal Lobe
> Postcentral gyrus: register registers general sensation (e.g. touch,
pressure).
> Integrates sensory information.

13. c. Temporal Lobe
> hearing, taste, smell
> Wernickes’s Area:
sensory speech area
(understanding/formulatio
n of language)
d. Occipital lobe
> Vision
Brain Lobes

14. Brain Structure

15. 3. Corpus Callosum: large fiber tract that connects the two two cerebral
hemispheres.
4. Basal Ganglia: islands of gray matter within white matter of cerebrum
> regulate and integrate motor activity
> part of extrapyramidal system
B. Diencephalon: connecting part of the brain, between the cerebrum and the brain
stem. Contains several small structures; the thalamus and hypothalamus are most
important.
1. Thalamus
a.. Relay station for discrimination of sensory signals (e.g. pain, temperature,
touch.).
b. Controls primitive emotional responses (e.g. rage, fear.)

16. 2. Hypothalamus
a. Found immediately beneath the thalamus.
b. Plays major role in regulation of vital functions such as blood
pressure, sleep, food and water intake, and body temperature.
c. Acts as control center for pituitary gland and affects both divisions of
the autonomic nervous system.

17. C. Brainstem
1. Contains midbrain, pons, and medulla
oblongata.
2. Extends from the cerebral
hemispheres to the foramen magnum at
the base of the skull.
3. Contains nuclei of the cranial nerves
and the long ascending and descending
tracts connecting the cerebrum and the
spinal cord.
4. Contains vital centers of respiratory,
vasomotor, and cardiac functions.

18. C. Cerebellum
- coordinates muscle tone
and movements and
maintains position in space
(equilibrium)

19. Anatomy of the Brain

20. Spinal Cord
Spinal Cord:
A. Serves as a connecting link between the brain and the periphery.
B. Extends from foramen magnum to second lumbar vertebra.
C. H-shaped gray matter in the center (cell bodies) surrounded by white matter
(nerve tracts and fibers).
D. Gray Matter
1. Anterior horns: contain cell bodies giving to efferent (motor) fibers.
2. Posterior horns: contain cell bodies connecting with afferent (sensory)
fibers from dorsal root ganglion.
3. Lateral horns: in thoracic region, contain cells giving rise to autonomic
fibers of sympathetic nervous system

21.  E. White Matter
1. Ascending tracts (sensory pathways)
a. Posterior columns: carry impulses concerned with touch,
pressure, vibration, and position sense.
b. Spinocerebellar: carry impulses concerned with muscle tension
and position sense to cerebellum.
c. Lateral spinothalamic: carry impulses concerned with crude
touch and pressure.
2. Descending tracts ( motor pathways )
a. Corticospinal (pyramidal, upper motor neuron): conduct motor
impulses from motor cortex to anterior horn cells (cross in the medulla).
b. Extrpyramidal: help to maintain muscle tone and to control body
movements such as walking.

22. F. Reflex arc
1. Reflex consist of an involuntary response to a stimulus occurring
over a neural pathway called a reflex arc.
2. Not relayed to and from brain; takes place at cord levels.
3. Components
a. Sensory receptor: receivesreacts to a stimulus.
b. Afferent pathway: transmits impulses to spinal cord.
c. Interneuron: synapses with a motor neuron (anterior horn
cell).
d. Efferent pathway: transmits impulses from motor neuron
to effector.
e. Effector: muscle or organ that responds to stimulus.

23. Supporting Structures
A. Skull
1. Rigid;
numerous bones
fused together
2. Protects and
supports the
brain.

24. B. Spinal Column
1. Consists of 7 cervical,
12 thoracic, and 5 lumbar
vertebrae, as well as
sacrum and coccyx.
2. Supports the head and
protects the spinal cord.

25. C. Meninges
1. Membranes between the
skull and brain and the
vertebral column and spinal
cord.
2. Layers
a. Dura matter:
outermost layer, tough,
leathery
b. Arachnoid matter:
middle layer, weblike
c. Pia matter:
innermost layer, delicate,
clings to surface of brain.

26. 3. Area between arachnoid and pia matter is called subarachnoid space.
D. Ventricles
1. Four fluid-filled cavities connecting with one another and the spinal
canal.
2. Produce and circulate cerebrospinal fluid.

27. Cerebro Spinal Fluid (CSF)
E. Cerebrospinal Fluid
1. Surrounds brain and
spinal cord
2. Offers protection by
functioning as a shock
absorber.
3. Allows fluid shifts from
the cranial cavity to the
spinal cavity.
4. Carries nutrients to and
waste products away from
the nerve cell.

28. F. Vascular Supply
1. Two internal carotid arteries – anterior.
2. Two vertebral arteries leading to basilar artery – posterior.
3. These arteries communicate at the base of the brain through the Circle
of Willis.
4. Anterior, middle, and posterior cerebral arteries are the main arteries
for distributing blood to each hemisphere of the brain.
5. Brainstem and cerebellum are supplied by branches of the vertebral
and basilar arteries.
6. Venous blood drains into dural sinuses and then into internal jugular
veins.
G. Blood brain barrier: protective barrier preventing harmful agents from
entering the capillaries of the CNS; protects brain and spinal cord.

29. Vascular Supply

30. Circle of Willis

31. The Circle of Willis is the
joining area of several
arteries at the bottom
(inferior) side of the
brain. At the Circle of
Willis, the internal carotid
arteries branch into
smaller arteries that
supply oxygenated blood
to over 80% of the
cerebrum.

32. Peripheral Nervous System
Spinal Nerves
A. 31 pairs: carry impulses to and from spinal cord.
B. Each segment of the spinal cord contains a pair of spinal nerves (one for
each side of the body).
C. Each nerve is attached to the spinal cord by two roots.
1. Dorsal (posterior) root: contain afferent
(sensory) nerve whose cell body is in the dorsal root ganglion.
2. Ventral (anterior) root: contains efferent (motor) nerve whose nerve
fibers originate in the anterior horn cell of the spinal cord (lower
motor neuron).
Cranial Nerves
A. 12 pairs: carry impulses to and from brain
B. May have sensory, motor, or mixed functions.

33. Cranial Nerve Name Function
I Olfactory Sensory: carries impulses for sense of
smell
II Optic Sensory: carries impulses for vison
III Oculomotor Motor: muscles for pupillary constriction,
elecvation of upper eyelid; 4 out of 6
extraocular movements
IV Trochlear Motor: muscles for downward,
inward movement of the eye
V Trigeminal Mixed: Impulses form face, surface of
eyes (corneal reflex); muscles controlling
mastication
Cranial Nerves

34. Cranial Nerve Name Function
VI Abducens Motor: muscles for lateral deviation
of the eye
VII Facial Mixed: impulses for taste from anterior
tongue; muscles for facial movement
VIII Acoustic Sensory: impulses for hearing (cochlear
division) and balance (vestibular division)
IX Glossopharyngeal Mixed: impulses for sensation to
posterior tongue and pharynx;
muscles for movement of pharynx
(elevation) and swallowing

35. Cranial Nerve Name Function
X Vagus Mixed: impulses for sensation to
lower pharynx and larynx; muscles for
movement of soft palate, pharynx,
and larynx
XI Spinal
Accessory
Motor: movement of sternomastoid
muscles and upper part of trapezius
muscle
XII Hypoglossal Motor: movement of the tongue

36. Autonomic Nervous System
A. Part of the peripheral nervous system
B. Includes those peripheral nerves (both cranial and spinal)
that regulate functions occurring automatically in the body,
ANS regulates smooth muscle, cardiac muscle and glands.
C. Components
1. Sympathetic nervous system: generally accelerates
some body functions in response to stress.
2. Parasympathetic nervous system: controls normal
body functioning.

37. EFFECTS OF AUTONOMIC
NERVOUS SYSTEM ACTIVITY
Effector Sympathetic
(Adrenergic) Effects
Parasympathetic
(Cholinergic) Effects
Eye Dilates pupil (mydriasis) Constricts pupil (miosis)
Glands of head
Lacrimal
Salivary
No effect
Scantly thick, viscous
secretions; dry mouth
Stimulates secretion
Copious thin, watery secretions
Heart Increase rate and force of
contraction
Decreases rate

38. Effector Sympathetic
(Adrenergic) Effects
Parasympathetic
(Cholinergic) Effects
Blood Vessels Constricts smooth
muscles of skin,
abdominal blood vessels,
and cutaneous blood
vessels
Dilates smooth muscle of
bronchioles, blood
vessels of heart, and
skeletal muscle of heart.
No effect
Lungs Bronchodilation Bronchoconstriction

39. Effector Sympathetic
(Adrenergic) Effects
Parasympathetic
(Cholinergic) Effects
GI Tract Decreases motility
Constricts sphincters
Possibly inhibits
secretions
Inhibits activity of
gallbladder and ducts
Inhibits glycogenolysis in
liver
Increases motility
Relaxes sphincters
Stimulates secretion
Stimulates activity of
gallbladder and ducts

40. Effector Sympathetic
(Adrenergic) Effects
Parasympathetic
(Cholinergic) Effects
Adrenal Gland Stimulates secretion of
Epinephrine and
norepinephrine
No effects
Urinary Tract Relaxes detrusor muscle
Contracts trigone
sphincter (prevents
voiding)
Contracts detrusor muscle
Relaxes trigone sphincter
(allows voiding)

41. What is CVD (Stroke)?
 Stroke is the No. 1 cause of adult disability.
 80% of strokes are preventable; you can
prevent a stroke!

42. Ischemic Stroke
In everyday life, blood clotting
is beneficial. When you are
bleeding from a wound, blood
clots work to slow and
eventually stop the bleeding. In
the case of stroke, however,
blood clots are dangerous
because they can block arteries
and cut off blood flow, a
process called ischemia.

43. An ischemic stroke can
occur in two ways:
embolic and thrombotic
strokes

44. Embolic Stroke
In an embolic stroke, a blood
clot forms somewhere in the
body (usually the heart) and
travels through the bloodstream
to your brain. Once in your
brain, the clot eventually travels
to a blood vessel small enough
to block its passage. The clot
lodges there, blocking the blood
vessel and causing a stroke. The
medical word for this type of
blood clot is embolus.

45. Thrombotic Stroke
In the second type of blood-
clot stroke, blood flow is
impaired because of a
blockage to one or more of
the arteries supplying blood to
the brain. The process leading
to this blockage is known as
thrombosis. Strokes caused in
this way are called
thrombotic strokes. That's
because the medical word for
a clot that forms on a blood-
vessel deposit is thrombus.

46. Blood-clot strokes can also
happen as the result of unhealthy
blood vessels clogged with a
buildup of fatty deposits and
cholesterol. Your body regards
these buildups as multiple, tiny
and repeated injuries to the blood
vessel wall. So your body reacts
to these injuries just as it would if
you were bleeding from a
wound;it responds by forming
clots. Two types of thrombosis
can cause stroke: large vessel
thrombosis and small vessel
disease (or lacunar infarction.)

47. Large Vessel Thrombosis
Thrombotic stroke occurs most often in the large arteries, so
large vessel thrombosis is the most common and best
understood type of thrombotic stroke. Most large vessel
thrombosis is caused by a combination of long-term
atherosclerosis followed by rapid blood clot formation.
Thrombotic stroke patients are also likely to have coronary
artery disease, and heart attack is a frequent cause of death in
patients who have suffered this type of brain attack.

48. Small Vessel Disease/Lacunar Infarction
Small vessel disease, or lacunar infarction, occurs when
blood flow is blocked to a very small arterial vessel. The
term's origin is from the Latin word lacuna which means
hole, and describes the small cavity remaining after the
products of deep infarct have been removed by other cells in
the body. Little is known about the causes of small vessel
disease, but it is closely linked to hypertension (high blood
pressure).

49. Hemorrhagic Stroke
Strokes caused by the breakage or
"blowout" of a blood vessel in the
brain are called hemorrhagic
strokes. The medical word for this
type of breakage is hemorrhage.
Hemorrhages can be caused by a
number of disorders which affect
the blood vessels, including long-
standing high blood pressure and
cerebral aneurysms. There are two
types of hemorrhagic stroke
subarachnoid and intracerebral.

50. There are two types
of hemorrhagic
stroke
subarachnoid and
intracerebral.

51. An aneurysm is a weak or
thin spot on a blood vessel
wall. These weak spots are
usually present at birth.
Aneurysms develop over a
number of years and
usually don't cause
detectable problems until
they break.

52.
 In an intracerbral
hemorrhage, bleeding
occurs from vessels within
the brain itself.
Hypertension (high blood
pressure) is the primary
cause of this type of
hemorrhage.

53. Intracerebral Hemorrhage

54. . In a subarachnoid
hemmorrhage(SAH), an
aneurysm bursts in a large
artery on or near the thin,
delicate membrane
surrounding the brain.
Blood spills into the area
around the brain which is
filled with a protective
fluid,causing the brain to
be surrounded by blood-
contaminated fluid

55. Stroke Symptoms
Stroke Symptoms include:
 Sudden numbness or weakness of face, arm or leg -
especially on one side of the body.
 Sudden confusion, trouble speaking or understanding.
 Sudden trouble seeing in one or both eyes.
 Sudden trouble walking, dizziness, loss of balance or
coordination.
 Sudden severe headache with no known cause.

56. Strokes may cause temporary or permanent loses of
motor function, thought processes, memory,
speech, or sensory function. Difficulty with
swallowing and speaking, hemiplegia, and visual
field defects are also related complications of this
disease.

57. Treatment is aimed at supporting vital functions,
ensuring adequate cerebral perfusion, and
prevention of major complications or permanent
disability

58. RISK FACTORS IN STROKE
 Advance Age
 High Cholesterol
 Obesity
 Transient Ischemic Attacks (TIA).
 Diabetes Mellitus
 Oral contaceptives (especially with co-existing
hypertension, smoking, and high estrogen levels.)
 Smoking
 Elevated Blood Lipids

59. PATHOPHYSIOLOGY
CVA (stroke)
Cerebral Hemorrhage
Occlusion of Major
vessel by embolism
Other causes of
Ischemia
Cerebral Infarction
Decreased Blood Flow to the Brain
Hypoxia

60. Ischemia
Inadequate adenosine triphosphate (ATP)
Neurotransmitter depletion
Cerebral Edema
Vascular congestion
Compression of tissue

61. Impaired function
Posterior Cerebral
Artery
Middle Cerebral
Artery
Anterior Cerebral
Artery
Hemiparesis
Ataxia
Visual problems
Dysphasia
Arm paralysis
Hemianopia
Aphasia
Agnosia
Perception deficits
Confusion
Impaired thought
Contralateral paralysis
Urinary Incontinence
Sensory deficits

62. Further compression of tissuesDecreases edema
Function improved
Continued inadequate blood flowReturn of normal perfusion
CEREBRAL DEATH
Good Prognosis Poor Prognosis

63. MEDICAL MANAGEMENT
> For an ischemic stroke, treatment focuses on
restoring blood flow to the brain. If less than 3
hours have passed since your symptoms began,
doctors may use a medicine that dissolves blood
clots. Research shows that this medicine can
improve recovery from a stroke, especially if
given within 90 minutes of the first symptoms.
Other medicines may be given to prevent blood
clots and control symptoms.

64. MEDICAL MANAGEMENT
 A hemorrhagic stroke can be hard to treat. Doctors may
do surgery or other treatments to stop bleeding or reduce
pressure on the brain. Medicines may be used to control
blood pressure, brain swelling, and other problems.
 After your condition is stable, treatment shifts to
preventing other problems and future strokes. You may
need to take a number of medicines to control conditions
that put you at risk for stroke, such as high blood pressure,
high cholesterol, and diabetes. Some people need to have a
surgery to remove plaque build up from the blood vessels
that supply the brain (carotid arteries).

65. PLAN / IMPLEMENTATION
 Immediate Care
a. Maintain patent airway
b. Minimize activity
c. Keep head bed elevated 15-30 angle
d. Maintain proper body alignment
e. Keep side rails in upright position

66. PLAN / IMPLEMENTATION
 Intermediate care and Rehabilatative needs
a. position for good body alignment
b. Institute measures that facilitates swallowing
1. Allow patient to sit in upright position
2. Instruct client to use tongue actively
3. Administer liquids slowly, avoid milk based
products.
4. Place food on unaffected side of mouth
5. Provide semisolid foods. (easiest to swallow)
6. Instruct to swallow while eating; maintain
upright position for 30 – 45 minutes after eating.

67. PLAN / IMPLEMENTATION
 c. Monitor elimination patterns
 d. Provide skin care
 e. Perform passive and active ROM exercises
 f. Orient to person, time and place.
 g. Move affected extremities slowly and
gently.
 h. Teach use of supportive devices (e.g.
commode, trapeze and cane.)

68. PLAN / IMPLEMENTATION
 i. Address communication needs – face
patient and speak clearly and slowly;
give the patient time to respond; use
verbal and non verbal communication?
 j. Do not approach from visually
impaired side.

69. DISCHARGE PLAN
 Lifestyle changes that can reduce the risk of
stroke and improve overall health.
 Don't smoke. Smoking can more than double
the risk of stroke. Avoid secondhand smoke
too.

70. DISCHARGE PLAN
 Eat a heart-healthy diet that includes plenty of
fish, fruits, vegetables, beans, high-fiber grains
and breads, and olive oil. Eat less salt too.

71. DISCHARGE PLAN
 Get exercise on most, preferably all, days of
the week. Your doctor can suggest a safe
level of exercise for you.
 Stay at a healthy weight.

72. Control your cholesterol and blood pressure.
If you have diabetes, keep your blood sugar as
close to normal as possible.
DISCHARGE PLAN

73.  Limit alcohol. Having more than 2 drinks a day
increases the risk of stroke.
 Take a daily aspirin or other medicines if your doctor
advises it.
DISCHARGE PLAN

74. THANK
YOU !