12.2 Cerebrovascular Disorders and Brain Injury

Cerebrovascular disorders can wreak havoc on the brain. Ischemic strokes starve neurons of oxygen, while hemorrhagic strokes cause bleeding and pressure. Both types lead to cell death and neurological deficits, with risk factors like hypertension and diabetes playing key roles.

Primary brain injuries occur immediately from trauma, while secondary injuries develop over time. Understanding these mechanisms is crucial for effective management. Nurses play a vital role in assessment, intervention, and rehabilitation, working to minimize damage and maximize recovery potential.

Cerebrovascular Disorders

Ischemic vs hemorrhagic stroke

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Top images from around the web for Ischemic vs hemorrhagic stroke

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  Frontiers | Hemorrhagic Transformation in Ischemic Stroke and the Role of Inflammation View original

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• 

  Frontiers | Pathophysiology of Long Non-coding RNAs in Ischemic Stroke View original

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  2.2 Stroke and Loss of Blood Flow as an Acute Injury to the Brain – Neuroscience: Canadian 1st ... View original

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  Frontiers | Hemorrhagic Transformation in Ischemic Stroke and the Role of Inflammation View original

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  Frontiers | Pathophysiology of Long Non-coding RNAs in Ischemic Stroke View original

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• Ischemic Stroke
  • Pathophysiology
    • Blockage of blood flow to brain tissue starves neurons of oxygen and glucose leading to cell death
    • Caused by thrombosis (local clot formation) or embolism (clot traveling from elsewhere)
  • Risk factors
    • Hypertension damages blood vessel walls increasing risk of clot formation
    • Diabetes accelerates atherosclerosis and impairs blood flow
    • Atrial fibrillation promotes clot formation in the heart
    • High cholesterol contributes to plaque buildup in arteries
    • Smoking narrows blood vessels and increases blood clotting tendency
  • Clinical manifestations
    • Sudden onset of neurological deficits correlating to affected brain area
    • Hemiparesis or hemiplegia (weakness or paralysis on one side of the body)
    • Aphasia (language impairment) or dysarthria (slurred speech)
    • Visual disturbances (partial or complete loss of vision in one or both eyes)
• Hemorrhagic Stroke
  • Pathophysiology
    • Rupture of blood vessels in the brain causes bleeding and increased intracranial pressure
    • Intracerebral (within brain tissue) or subarachnoid (between brain and skull) hemorrhage
  • Risk factors
    • Hypertension weakens blood vessel walls over time
    • Aneurysms (weakened bulging areas in artery walls)
    • Arteriovenous malformations (abnormal blood vessel connections)
    • Anticoagulant therapy increases bleeding risk
  • Clinical manifestations
    • Severe headache often described as "worst headache of life"
    • Altered level of consciousness ranging from confusion to coma
    • Nausea and vomiting due to increased intracranial pressure
    • Seizures caused by irritation of brain tissue

Primary and secondary brain injury

• Primary Brain Injury
  • Mechanisms
    • Direct trauma to brain tissue from impact or penetrating injuries
    • Shearing forces cause axonal damage during rapid acceleration/deceleration
    • Contusions (bruising) of brain tissue against skull
    • Hematomas (blood collections) compress brain tissue
  • Impact on neurological function
    • Immediate neuronal damage disrupts normal signaling pathways
    • Disruption of brain circuits impairs specific functions (motor, sensory, cognitive)
    • Focal or diffuse deficits depending on injury location and severity
• Secondary Brain Injury
  • Mechanisms
    • Cerebral edema (brain swelling) reduces blood flow and increases pressure
    • Increased intracranial pressure compromises blood supply to brain tissue
    • Hypoxia (lack of oxygen) leads to further cell death
    • Ischemia (reduced blood flow) starves brain tissue of nutrients
    • Inflammation triggers cascades of cellular damage
  • Impact on patient outcomes
    • Delayed neuronal death occurs hours to days after initial injury
    • Worsening of initial deficits as secondary injury progresses
    • Potential for long-term disability due to cumulative effects of primary and secondary injury

Management and Treatment

Nursing care for cerebrovascular disorders

• Assessment
  • Neurological examination
    • Glasgow Coma Scale assesses level of consciousness (eye, verbal, motor response)
    • Pupillary response indicates brainstem function
    • Motor function evaluates strength and coordination
  • Vital signs monitoring tracks blood pressure, heart rate, and respiratory rate
  • Neuroimaging studies interpretation (CT, MRI) identifies type and location of stroke or injury
• Interventions
  • Airway management ensures adequate oxygenation and ventilation
  • Blood pressure control prevents further bleeding or ischemia
  • Intracranial pressure monitoring guides treatment decisions
  • Medication administration
    • Thrombolytics (tPA) for ischemic stroke dissolve clots
    • Anticonvulsants prevent seizures and reduce secondary brain injury
  • Positioning and mobility prevent complications (pressure ulcers, pneumonia)
• Rehabilitation strategies
  • Physical therapy improves strength, balance, and mobility
  • Occupational therapy focuses on activities of daily living
  • Speech and language therapy addresses communication and swallowing difficulties
  • Cognitive rehabilitation targets memory, attention, and executive function

Early intervention in stroke management

• Time-sensitive nature of stroke treatment
  • "Time is brain" concept emphasizes urgency of treatment
  • Importance of rapid triage and diagnosis to initiate appropriate interventions
• Benefits of early intervention
  • Improved tissue salvage in ischemic stroke through timely reperfusion
  • Prevention of hematoma expansion in hemorrhagic stroke reduces secondary injury
  • Reduction of secondary injury in traumatic brain injury through prompt management
• Recognition of stroke symptoms
  • FAST acronym (Face drooping, Arm weakness, Speech difficulty, Time to call emergency)
  • Public education on stroke warning signs improves early recognition
• Prompt treatment options
  • Thrombolysis within 3-4.5 hours for ischemic stroke improves outcomes
  • Endovascular thrombectomy for large vessel occlusions extends treatment window
  • Neurosurgical interventions for certain hemorrhagic strokes (evacuation, clipping)
• Long-term impact of early treatment
  • Reduced disability and improved functional outcomes enhance quality of life
  • Enhanced potential for neuroplasticity and recovery through early rehabilitation
  • Decreased burden on healthcare systems and caregivers due to better outcomes