>> Lisa: Hi, my name is Lisa Klein.
I'm a clinical nurse specialist
and I'll be going over what is a stroke.
The objectives of this presentation
will be that by the end of it,
you will be able to define what a stroke is,
recognize the signs and symptoms of a stroke,
and state the clinical tools
that are available to assess our patients for stroke.
And as far as the epidemiology of stroke,
worldwide cardiovascular diseases
are the number one cause of death globally.
There are 17 million people
that die of cardiovascular disease every year,
making stroke the second leading cause of death.
Stroke is among the leading causes of disability as well.
80% of strokes are preventable
and 10 to 18% of patients suffering a stroke
will have another stroke within a year.
Looking at some statistics for the the United Arab Emirates,
we can see that stroke is number three,
both in 2007 and in 2017
as far as what causes the most deaths.
Looking at premature causes of death in the UAE,
we can see stroke in 2007 was number five,
and we've increased to being number three in 2017.
What an actual stroke is,
is a sudden neurological deficit
that results from an abnormality
in the cerebral circulation.
It may be an abnormality in the arteries,
the veins or the way they connect with each other.
It may be an interruption of the blood flow
in an area of the brain causing ischemia
and eventual infarction
or bleeding in the brain due to a rupture of a vessel.
When it comes to strokes,
a big part of it
is when we're assessing our patients
is we can actually discern and locate
where we expect to see the lesion on diagnostic tests
like a CT scan or MRI
based on the patient's physical examples of the stroke.
So we know that the right side of the brain
controls the left side of the body and vice versa.
With regards to the cranial lobes,
in the front we have the frontal lobe.
[Indistinct] controls the motor control
and the most posterior part of that lobe,
it also controls problem solving and speech production.
We have Broca's area,
where expressive aphasia can localize from.
To the sides we have the parietal lobe
just behind the frontal lobe,
where touch perception is right behind,
is in the most anterior part of the parietal lobe,
as well as your ability for,
to know where your body is,
and place and times your body orientation
and your sensory discrimination.
Behind the parietal lobes you have is your occipital lobes,
and this is where your sight and vision come from.
Below your occipital lobe is your cerebellum,
and this is where balance or coordination stems from.
Higher up on both sides, sort of where your ears are,
that's where you have your temporal lobe,
and that's where you process hearing.
As well, Wernicke's area is in that area,
and it also little overlap
a little with the parietal lobe as well.
And that is where we have a receptive aphasia deficits.
And then we have the brainstem at the bottom
and at the base of your brain,
and this is where your involuntary responses,
your ability to breathe,
your heart rate control are all controlled there.
So that based on your patients exam,
you can sort of pinpoint where you expect to see
a stroke in your patient CT scan or MRI.
So going back to
a little bit more about the frontal and parietal lobes
is I talked about
that you have the motor and sensory strips.
So the motor strip
is the most posterior part of the frontal lobe
and the sensory strip is the most anterior part
of your parietal lobes.
And you can see that, this is a cross section
and they have actually been able to map out
where your body is controlled in your brain,
so that the, laterally it's your face is controlled,
as you move more medially, then you get to the arm,
your shoulder, your hip and your leg.
And this actually really helps us
because we can actually pinpoint
not only where we expect to see the lesion in a skin,
but we can actually know which circulation,
which artery we expect the stroke to be coming from.
So this is what we call localizing the stroke.
So the three large main areas we think about
is the anterior cerebral artery.
You can see that here in the picture to the left
and the right highlighted in blue.
I think if that is, if your patient had a Mohawk,
it's sort of your brain that be covered by that Mohawk.
And we knew from the prior picture here that the leg,
if it's in that most posterior part of the frontal lobe
can be affected
and you would expect that compared to the face and arm,
if it's here in the middle of the anterior cerebral artery.
We can see in the yellow, the middle cerebral artery.
So when we think of the middle cerebral artery
going back to this,
we can see, and expect you're gonna see more facial weakness
and maybe arm weakness
from a middle cerebral artery stroke compared to the leg
because of the vascular territory that it covers.
In the posterior part,
that's where we have our cerebrum
and our occipital lobe,
and so we can expect our vision to be affected.
And as well, we can see
it also impacts some of the temporal lobe to the side
underneath the yellow portion there,
so it may also affect some of our hearing.
When it comes to a stroke,
and taking care of patients with strokes,
everyone needs to know the signs and symptoms.
The key word here is sudden.
Strokes are not gradual increases,
but sudden onset of a headache with no known cause,
a sudden onset of weakness or numbness
on one side of the body,
a sudden onset of slurred speech,
dizziness or vertigo,
patient may experience double vision,
blurry vision or visual field deficit,
sometimes a field cut,
could be a sudden onset of difficulty
understanding or speaking,
difficulty walking,
a sudden onset of change in mental status,
or a sudden onset in issues with coordination.
Patients that have a stroke,
it doesn't mean they have all of these symptoms,
they may have one some, or even sometimes none,
but still have had a stroke.
One screening tool that is used
prior to the patients coming into the hospital frequently
is called the Cincinnati pre hospital stroke scale.
It's an acronym for F-A-S-T for the word FAST
so that you will spot a stroke
if you notice first facial drooping,
or you may notice arm weakness,
or the S would be speech difficulties.
The T here is just to remind you that brain is time,
to save stroke patients
we want them to get to the hospital as quick as possible
and call 911.
Sometimes this FAST also includes the word be,
B in front of it, BFAST.
B being for balance.
So your patient may, or a person may have balance issues,
and that could be a sign of a stroke,
or E meaning eye deficits or visual deficits.
When it comes to the face, arm and speech,
if one of these is abnormal, there's a 72% chance
or probability the person has had a stroke.
If someone has all three of them,
so their face has weakness, the arm,
and they're having speech difficulty,
there's an 85% probability the person has had a stroke.
Another screens that we use
is the National Institute of Health stroke screen.
This is an assessment tool
that quantitatively measures
stroke-related neurologic deficits.
It is, oh sorry,
it is actually an 11-item neurological exam,
and the score for this can be between zero and 42 points.
With regards to stroke severity,
a patient can have a minor stroke
if it's between zero and four.
It increases to moderate and then to a severe stroke
once it hits 21 or more points.
I'm gonna go over this stroke screen scale
in another presentation.
For intracerebral hemorrhages,
it is a five item scale for the ICH score.
And it has a 66 sensitivity,
66% sensitivity and predicting the 30-day mortality.
So we can see here it's a combination of the patient's GCS,
their age, the location of the stroke,
so being infratentorial versus supratentorial,
is whether it's above the cerebellum and brainstem
or below it.
If, depending on the size of the ICH based on the CT scan,
it's also depending on if the blood has also
gone into the ventricles.
We can see here the ICH score,
if their score is zero,
there's zero percent 30-day more time.
But as it increases once we hit four, it's at 97%,
and both five and six are at 100% mortality at 30-days.
For the initial workup when a patient comes to the hospital,
it's important to get a history and physical.
You need to find out that time of onset,
when was the patient last seen normal.
And then the physical exam will help us so that we get
the diagnostic tests of a CT scan right away,
that we can actually
recognize where we expect to see a deficit.
For ABCD's, we wanna make sure the patient's
breathing and protecting their airway,
we wanna get an IV placed in them,
especially in case we want to give them TPA
or alteplase,
and a D-stick to for dextrose,
we wanna check a patient's blood sugar,
since a patient who is hypoglycemic
may appear to look like they've had a stroke
but have not had a stroke.
We wanna get a 12-lid kg and put them on monitor.
We'll talk a bit more about what we're looking out for,
but atrial fibrillation is the number one rhythm
that we are monitoring for
that are putting patients at risk for strokes.
We also wanna collect lab work,
we wanna get a CBC, a BMP,
or we wanna get their co-bags getting their PT and PTT.
And then lastly, we wanna get that head CT.
That head CT will tell us if there is a lesion,
maybe a tumor, if there's blood,
but it won't necessarily tell us if it's a fresh stroke.
We will not see acute strokes on a dry head CT.
Coming up will be two types of stroke,
we'll go over this ischemic and hemorrhagic strokes.