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Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
A subarachnoid hemorrhage is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue covering the brain (meninges).
*
The most common cause is rupture of a bulge (aneurysm) in an artery.
*
Usually, rupture of an artery causes a sudden, severe headache, often followed by a brief loss of consciousness.
*
Computed tomography, sometimes a spinal tap, and angiography are done to confirm the diagnosis.
*
Drugs are used to relieve the headache and to control blood pressure, and surgery is done to stop the bleeding.
A subarachnoid hemorrhage is a life-threatening disorder that can rapidly result in serious, permanent disabilities. It is the only type of stroke more common among women than among men.
Causes
Subarachnoid hemorrhage usually results from head injuries. However, hemorrhage due to a head injury causes different symptoms and is not considered a stroke.
Subarachnoid hemorrhage is considered a stroke only when it occurs spontaneously—that is, when the hemorrhage does not result from external forces, such as an accident or a fall. A spontaneous hemorrhage usually results from the sudden rupture of an aneurysm in a cerebral artery. Aneurysms are bulges in a weakened area of an artery's wall. Aneurysms typically occur where an artery branches. Aneurysms may be present at birth (congenital), or they may develop later, after years of high blood pressure weaken the walls of arteries. Most subarachnoid hemorrhages result from congenital aneurysms.
Less commonly, subarachnoid hemorrhage results from rupture of an abnormal connection between arteries and veins (arteriovenous malformation) in or around the brain. An arteriovenous malformation may be present at birth, but it is usually identified only if symptoms develop. Rarely, a blood clot forms on an infected heart valve, travels (becoming an embolus) to an artery that supplies the brain, and causes the artery to become inflamed. The artery may then weaken and rupture.
Did You Know...
Symptoms
Before rupturing, an aneurysm usually causes no symptoms unless it presses on a nerve or leaks small amounts of blood, usually before a large rupture (which causes headache). Then it produces warning signs, such as the following:
*
Headache, which may be unusually sudden and severe (sometimes called a thunderclap headache)
*
Facial or eye pain
*
Double vision
*
Loss of peripheral vision
The warning signs can occur minutes to weeks before the rupture. People should report any unusual headaches to a doctor immediately.
A rupture usually causes a sudden, severe headache that peaks within seconds. It is often followed by a brief loss of consciousness. Almost half of affected people die before reaching a hospital. Some people remain in a coma or unconscious. Others wake up, feeling confused and sleepy. They may also feel restless. Within hours or even minutes, people may again become sleepy and confused. They may become unresponsive and difficult to arouse. Within 24 hours, blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), causing a stiff neck as well as continuing headaches, often with vomiting, dizziness, and low back pain. Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures.
About 25% of people have symptoms that indicate damage to a specific part of the brain, such as the following:
*
Weakness or paralysis on one side of the body (most common)
*
Loss of sensation on one side of the body
*
Difficulty understanding and using language (aphasia—see Brain Dysfunction: Aphasia)
Severe impairments may develop and become permanent within minutes or hours. Fever is common during the first 5 to 10 days.
A subarachnoid hemorrhage can lead to several other serious problems:
*
Hydrocephalus: Within 24 hours, the blood from a subarachnoid hemorrhage may clot. The clotted blood may prevent the fluid surrounding the brain (cerebrospinal fluid) from draining as it normally does. As a result, blood accumulates within the brain, increasing pressure within the skull. Hydrocephalus may contribute to symptoms such as headaches, sleepiness, confusion, nausea, and vomiting and may increase the risk of coma and death.
*
Vasospasm: About 3 to 10 days after the hemorrhage, arteries in the brain may contract (spasm), limiting blood flow to the brain. Then, brain tissues may not get enough oxygen and may die, as in ischemic stroke. Vasospasm may cause symptoms similar to those of ischemic stroke, such as weakness or loss of sensation on one side of the body, difficulty using or understanding language, vertigo, and impaired coordination.
*
A second rupture: Sometimes a second rupture occurs, usually within a week.
Diagnosis
If people have a sudden, severe headache that peaks within seconds or that is accompanied by any symptoms suggesting a stroke, they should go immediately to the hospital. Computed tomography (CT) is done to check for bleeding. A spinal tap (lumbar puncture) is done if CT is inconclusive or unavailable. It can detect any blood in the cerebrospinal fluid. A spinal tap is not done if doctors suspect that pressure within the skull is increased. Cerebral angiography (see Brain Dysfunction: Aphasia) is done as soon as possible to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding. Magnetic resonance angiography or CT angiography may be used instead.
Prognosis
About 35% of people die when they have a subarachnoid hemorrhage due to an aneurysm because it results in extensive brain damage. Another 15% die within a few weeks because of bleeding from a second rupture. People who survive for 6 months but who do not have surgery for the aneurysm have a 3% chance of another rupture each year. The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography because the defect has already sealed itself off. In such cases, the outlook is very good.
Some people recover most or all mental and physical function after a subarachnoid hemorrhage. However, many people continue to have symptoms such as weakness, paralysis, or loss of sensation on one side of the body or aphasia.
Treatment
People who may have had a subarachnoid hemorrhage are hospitalized immediately. Bed rest with no exertion is essential. Analgesics such as opioids (but not aspirin Some Trade Names
BAYER
or other nonsteroidal anti-inflammatory drugs, which can worsen the bleeding) are given to control the severe headaches. Stool softeners are given to prevent straining during bowel movements. Nimodipine, a calcium channel blocker, is usually given by mouth to prevent vasospasm and subsequent ischemic stroke. Doctors take measures (such as giving drugs and adjusting the amount of intravenous fluid given) to keep blood pressure at levels low enough to avoid further hemorrhage and high enough to maintain blood flow to the damaged parts of the brain. Occasionally, a piece of plastic tubing (shunt) may be placed in the brain to drain cerebrospinal fluid away from the brain. This procedure relieves pressure and prevents hydrocephalus.
For people who have an aneurysm, a surgical procedure is done to isolate, block off, or support the walls of the weak artery and thus reduce the risk of fatal bleeding later. These procedures are difficult, and regardless of which one is used, the risk of death is high, especially for people who are in a stupor or coma. The best time for surgery is controversial and must be decided based on the person's situation. Most neurosurgeons recommend operating within 24 hours of the start of symptoms, before hydrocephalus and vasospasm develop. If surgery cannot be done this quickly, the procedure may be delayed 10 days to reduce the risks of surgery, but then bleeding is more likely to recur because the waiting period is longer.
A commonly used procedure, called neuroendovascular surgery, involves inserting coiled wires into the aneurysm. The coils are placed using a catheter that is inserted into an artery and threaded to the aneurysm. Thus, this procedure does not require that the skull be opened. By slowing blood flow through the aneurysm, the coils promote clot formation, which seals off the aneurysm and prevents it from rupturing. Neuroendovascular surgery can often be done at the same time as cerebral angiography, when the aneurysm is diagnosed.
Less commonly, a metal clip is placed across the aneurysm. This procedure prevents blood from entering the aneurysm and eliminates the risk of rupture. The clip remains in place permanently. Most clips that were placed 15 to 20 years ago are affected by the magnetic forces and can be displaced during magnetic resonance imaging (MRI). People who have these clips should inform their doctor if MRI is being considered. Newer clips are not affected by the magnetic forces.
A subarachnoid hemorrhage is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue covering the brain (meninges).
*
The most common cause is rupture of a bulge (aneurysm) in an artery.
*
Usually, rupture of an artery causes a sudden, severe headache, often followed by a brief loss of consciousness.
*
Computed tomography, sometimes a spinal tap, and angiography are done to confirm the diagnosis.
*
Drugs are used to relieve the headache and to control blood pressure, and surgery is done to stop the bleeding.
A subarachnoid hemorrhage is a life-threatening disorder that can rapidly result in serious, permanent disabilities. It is the only type of stroke more common among women than among men.
Causes
Subarachnoid hemorrhage usually results from head injuries. However, hemorrhage due to a head injury causes different symptoms and is not considered a stroke.
Subarachnoid hemorrhage is considered a stroke only when it occurs spontaneously—that is, when the hemorrhage does not result from external forces, such as an accident or a fall. A spontaneous hemorrhage usually results from the sudden rupture of an aneurysm in a cerebral artery. Aneurysms are bulges in a weakened area of an artery's wall. Aneurysms typically occur where an artery branches. Aneurysms may be present at birth (congenital), or they may develop later, after years of high blood pressure weaken the walls of arteries. Most subarachnoid hemorrhages result from congenital aneurysms.
Less commonly, subarachnoid hemorrhage results from rupture of an abnormal connection between arteries and veins (arteriovenous malformation) in or around the brain. An arteriovenous malformation may be present at birth, but it is usually identified only if symptoms develop. Rarely, a blood clot forms on an infected heart valve, travels (becoming an embolus) to an artery that supplies the brain, and causes the artery to become inflamed. The artery may then weaken and rupture.
Did You Know...
Symptoms
Before rupturing, an aneurysm usually causes no symptoms unless it presses on a nerve or leaks small amounts of blood, usually before a large rupture (which causes headache). Then it produces warning signs, such as the following:
*
Headache, which may be unusually sudden and severe (sometimes called a thunderclap headache)
*
Facial or eye pain
*
Double vision
*
Loss of peripheral vision
The warning signs can occur minutes to weeks before the rupture. People should report any unusual headaches to a doctor immediately.
A rupture usually causes a sudden, severe headache that peaks within seconds. It is often followed by a brief loss of consciousness. Almost half of affected people die before reaching a hospital. Some people remain in a coma or unconscious. Others wake up, feeling confused and sleepy. They may also feel restless. Within hours or even minutes, people may again become sleepy and confused. They may become unresponsive and difficult to arouse. Within 24 hours, blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), causing a stiff neck as well as continuing headaches, often with vomiting, dizziness, and low back pain. Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures.
About 25% of people have symptoms that indicate damage to a specific part of the brain, such as the following:
*
Weakness or paralysis on one side of the body (most common)
*
Loss of sensation on one side of the body
*
Difficulty understanding and using language (aphasia—see Brain Dysfunction: Aphasia)
Severe impairments may develop and become permanent within minutes or hours. Fever is common during the first 5 to 10 days.
A subarachnoid hemorrhage can lead to several other serious problems:
*
Hydrocephalus: Within 24 hours, the blood from a subarachnoid hemorrhage may clot. The clotted blood may prevent the fluid surrounding the brain (cerebrospinal fluid) from draining as it normally does. As a result, blood accumulates within the brain, increasing pressure within the skull. Hydrocephalus may contribute to symptoms such as headaches, sleepiness, confusion, nausea, and vomiting and may increase the risk of coma and death.
*
Vasospasm: About 3 to 10 days after the hemorrhage, arteries in the brain may contract (spasm), limiting blood flow to the brain. Then, brain tissues may not get enough oxygen and may die, as in ischemic stroke. Vasospasm may cause symptoms similar to those of ischemic stroke, such as weakness or loss of sensation on one side of the body, difficulty using or understanding language, vertigo, and impaired coordination.
*
A second rupture: Sometimes a second rupture occurs, usually within a week.
Diagnosis
If people have a sudden, severe headache that peaks within seconds or that is accompanied by any symptoms suggesting a stroke, they should go immediately to the hospital. Computed tomography (CT) is done to check for bleeding. A spinal tap (lumbar puncture) is done if CT is inconclusive or unavailable. It can detect any blood in the cerebrospinal fluid. A spinal tap is not done if doctors suspect that pressure within the skull is increased. Cerebral angiography (see Brain Dysfunction: Aphasia) is done as soon as possible to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding. Magnetic resonance angiography or CT angiography may be used instead.
Prognosis
About 35% of people die when they have a subarachnoid hemorrhage due to an aneurysm because it results in extensive brain damage. Another 15% die within a few weeks because of bleeding from a second rupture. People who survive for 6 months but who do not have surgery for the aneurysm have a 3% chance of another rupture each year. The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography because the defect has already sealed itself off. In such cases, the outlook is very good.
Some people recover most or all mental and physical function after a subarachnoid hemorrhage. However, many people continue to have symptoms such as weakness, paralysis, or loss of sensation on one side of the body or aphasia.
Treatment
People who may have had a subarachnoid hemorrhage are hospitalized immediately. Bed rest with no exertion is essential. Analgesics such as opioids (but not aspirin Some Trade Names
BAYER
or other nonsteroidal anti-inflammatory drugs, which can worsen the bleeding) are given to control the severe headaches. Stool softeners are given to prevent straining during bowel movements. Nimodipine, a calcium channel blocker, is usually given by mouth to prevent vasospasm and subsequent ischemic stroke. Doctors take measures (such as giving drugs and adjusting the amount of intravenous fluid given) to keep blood pressure at levels low enough to avoid further hemorrhage and high enough to maintain blood flow to the damaged parts of the brain. Occasionally, a piece of plastic tubing (shunt) may be placed in the brain to drain cerebrospinal fluid away from the brain. This procedure relieves pressure and prevents hydrocephalus.
For people who have an aneurysm, a surgical procedure is done to isolate, block off, or support the walls of the weak artery and thus reduce the risk of fatal bleeding later. These procedures are difficult, and regardless of which one is used, the risk of death is high, especially for people who are in a stupor or coma. The best time for surgery is controversial and must be decided based on the person's situation. Most neurosurgeons recommend operating within 24 hours of the start of symptoms, before hydrocephalus and vasospasm develop. If surgery cannot be done this quickly, the procedure may be delayed 10 days to reduce the risks of surgery, but then bleeding is more likely to recur because the waiting period is longer.
A commonly used procedure, called neuroendovascular surgery, involves inserting coiled wires into the aneurysm. The coils are placed using a catheter that is inserted into an artery and threaded to the aneurysm. Thus, this procedure does not require that the skull be opened. By slowing blood flow through the aneurysm, the coils promote clot formation, which seals off the aneurysm and prevents it from rupturing. Neuroendovascular surgery can often be done at the same time as cerebral angiography, when the aneurysm is diagnosed.
Less commonly, a metal clip is placed across the aneurysm. This procedure prevents blood from entering the aneurysm and eliminates the risk of rupture. The clip remains in place permanently. Most clips that were placed 15 to 20 years ago are affected by the magnetic forces and can be displaced during magnetic resonance imaging (MRI). People who have these clips should inform their doctor if MRI is being considered. Newer clips are not affected by the magnetic forces.
Asuhan Keperawatan Stroke
Definisi
Menurut WHO stroke adalah adanya tanda-tanda klinik yang berkembang cepat akibat gangguan fungsi otak fokal (atau global) dengan gejala-gejala yang berlangsung selama 24 jam atau lebih yang menyebabkan kematian tanpa adanya penyebab lain yang jelas selain vaskuler. (Hendro Susilo, 2000)
askep stroke hemorrhagic
Stroke adalah sindrom klinis yang awal timbulnya mendadak, progresif, cepat berupa defisit neurologis vokal atau global yang berlangsung 24 jam atau lebih atau langsung menimbulkan kematian. Semata-mata disebabkan oleh peredaran darah otak non traumatik. (Mansjoer A. Dkk)
Stroke adalah kehilangan fungsi otak secara mendadak yang diakibatkan oleh gangguan suplai darah ke bagian otak. (Brunner & Sudarth, 2000)
Stroke adalah kehilangan fungsi otak yang diakibatkan oleh berhentinya suplai darah kebagian otak. (Brunner & Sudarth, 2002)
Stroke adalah cedera otak yang berkaitan dengan obstruksi aliran darah otak. (Elizabeth J. Corwin, 2002)
Stroke adalah defisit neurologis yang mempunyai awitan mendadak atau berlangsung 24 jam sebagai akibat dari cerebrovaskular desease (CVD) atau penyakit cerebrovaskular. (Hudak and Gallo)
Stroke merupakan manifestasi neurologis yang umum yang timbul secara mendadak sebagai akibat adanya gangguan suplai darah ke otak. (Depkes RI 1996)
Timbulnya lesi iskemik atau lesi perdarahan didalam pembuluh darah intrakranial. (Brenda Walters Holloway)
Stroke adalah manifestasi klinik dari gangguan fungsi serebral baik lokal maupun menyeluruh. (WHO dikutip Harsono)
Stroke/penyakit serebrovaskuler menunjukan adanya beberapa kelainan otak baik secara fungsional maupun struktural yang disebabkan oleh keadaan patologis dari pembuluh darah serebral atau dari seluruh sistem pembuluh darah otak. (Marilyn E. Doenges)
Stroke atau serebrovaskuler accident adalah gangguan suplai darah normal ke otak yang sering terjadi dengan tiba-tiba dan menyebabkan fatal neurologik defisit. (Igrativicius, 1995)
Gangguan peredaran darah diotak atau dikenal dengan CVA ( Cerebro Vaskuar Accident) adalah gangguan fungsi syaraf yang disebabkan oleh gangguan aliran darah dalam otak yang dapat timbul secara mendadak ( dalam beberapa detik) atau secara cepat ( dalam beberapa jam ) dengan gejala atau tanda yang sesuai dengan daerah yang terganggu.(Harsono,1996, hal 67)
Stroke atau cedera cerebrovaskuler adalah kehilangan fungsi otak yang diakibatkan oleh berhentinya suplai darah ke bagian otak sering ini adalah kulminasi penyakit serebrovaskuler selama beberapa tahun. (Smeltzer C. Suzanne, 2002, hal 2131)
Perdarahan intracerebral adalah disfungsi neurologi fokal yang akut dan disebabkan oleh perdarahan primer substansi otak yang terjadi secara spontan bukan oleh karena trauma kapitis, disebabkan oleh karena pecahnya pembuluh arteri, vena dan kapiler. (UPF, 1994)
Etiologi Stroke
Penyebab Stroke antara lain :
1. Trombosis ( bekuan cairan di dalam pembuluh darah otak )
2. Embolisme cerebral ( bekuan darah atau material lain )
3. Iskemia ( Penurunan aliran darah ke area otak)
(Smeltzer C. Suzanne, 2002, hal 2131)
Faktor Resiko Stroke
1. Faktor yang tidak dapat dirubah (Non Reversible)
* Jenis kelamin : Pria lebih sering ditemukan menderita stroke dibanding wanita.
* Usia : Makin tinggi usia makin tinggi pula resiko terkena stroke.
* Keturunan : Adanya riwayat keluarga yang terkena stroke
2. Faktor yang dapat dirubah (Reversible)
* Hipertensi
* Penyakit jantung
* Kolesterol tinggi
* Obesitas
* Diabetes Melitus
* Polisetemia
* Stress Emosional
3. Kebiasaan Hidup
* Merokok,
* Peminum Alkohol,
* Obat-obatan terlarang.
* Aktivitas yang tidak sehat: Kurang olahraga, makanan berkolesterol.
Manifestasi Klinis
Gejala - gejala stroke muncul akibat daerah tertentu tak berfungsi yang disebabkan oleh terganggunya aliran darah ke daerah tersebut. Gejala itu muncul bervariasi, bergantung bagian otak yang terganggu.Gejala-gejala itu antara lain bersifat:
a. Sementara
Timbul hanya sebentar selama beberapa menit sampai beberapa jam dan hilang sendiri dengan atau tanpa pengobatan. Hal ini disebut Transient ischemic attack (TIA). Serangan bisa muncul lagi dalam wujud sama, memperberat atau malah menetap.
b.Sementara, namun lebih dari 24 jam
Gejala timbul lebih dari 24 jam dan ini disebut reversible ischemic neurologic defisit (RIND)
c. Gejala makin lama makin berat (progresif)
Hal ini disebabkan gangguan aliran darah makin lama makin berat yang disebut progressing stroke atau stroke inevolution
d. Sudah menetap/permanen
(Harsono,1996, hal 67)
Gangguan yang muncul :
Defisit Neurologis:
1. Homonimus hemianopsia ( kehilangan setengah lapang penglihatan).
* Tidak menyadari orang / objek ditempat kehilangan penglihatan, mengabaikan salah satu sisi tubuh, kesulitan menilai jarak.
2. Kehilangan penglihatan perifer.
* Kesulitan melihat pada malam hari, tidak menyadari objek atau batas objek
3. Diplopia : penglihatan ganda.
Defisit Motorik
1. Hemiparese
* kelemahan wajah, lengan dan kaki pada sisi yang sama.
2. Hemiplegia
* Paralisis wajah, lengan dan kaki pada sisi yang sama.
3. Ataksia
* Berjalan tidak mantap, tegak, tidak mampu menyatukan kaki, perlu dasar berdiri yang luas.
4. Disartria
* Kesulitas dalam membentuk kata
5. Disfagia
* Kesulitan dalam menelan
Defisit Sensori
1. Afasia ekspresif
* Ketidakmampuan menggunakan simbol berbicara
2. Afasia reseptif
* Tidak mampu menyusun kata-kata yang diucapkan
3. Afasia global
* Kombinasi baik afasia reseptif dan ekspresif
Defisit Kognitif
* Kehilangan memori jangka pendek dan jangka menengah
* Penurunan lapang perhatian
* Kerusakan kemampuan untuk berkonsentrasi
* Alasan abstrak buruk
* Perubahan penilaian
Defisit Emosional
* Kehilangan control diri
* Labilitas emosional
* Penurunan toleransi pada situasi yang menimbulkan stress
* Menarik diri, rasa takut, bermusuhan dan marah
* Perasaan isolasi
Pemeriksaan Penunjang Stroke
1. CT Scan
Memperlihatkan adanya edema , hematoma, iskemia dan adanya infark
2. Angiografi serebral
Membantu menentukan penyebab stroke secara spesifik seperti perdarahan atau obstruksi arteri
3. Pungsi Lumbal
- Menunjukan adanya tekanan normal
- Tekanan meningkat dan cairan yang mengandung darah menunjukan adanya perdarahan
4. MRI : Menunjukan daerah yang mengalami infark, hemoragik.
5. EEG: Memperlihatkan daerah lesi yang spesifik
6. Ultrasonografi Dopler : Mengidentifikasi penyakit arteriovena
7. Sinar X kepala : Menggambarkan perubahan kelenjar lempeng pineal
(DoengesE, Marilynn,2000 hal 292)
Penatalaksanaan Stroke
1. Diuretika : untuk menurunkan edema serebral .
2. Anti koagulan: mencegah memberatnya trombosis dan embolisasi.
(Smeltzer C. Suzanne, 2002, hal 2131)
Komplikasi Stroke
Hipoksia Serebral
Penurunan darah serebral
Luasnya area cedera
(Smeltzer C. Suzanne, 2002, hal 2131)
Pengkajian Stroke
1. Aktivitas dan istirahat
Data Subyektif:
- Kesulitan dalam beraktivitas ; kelemahan, kehilangan sensasi atau paralisis.
- Mudah lelah, kesulitan istirahat ( nyeri atau kejang otot )
Data obyektif:
- Perubahan tingkat kesadaran
- Perubahan tonus otot ( flaksid atau spastic), paraliysis ( hemiplegia ) , kelemahan umum.
- Gangguan penglihatan
2. Sirkulasi
Data Subyektif:
- Riwayat penyakit jantung ( penyakit katup jantung, disritmia, gagal jantung , endokarditis bacterial ), polisitemia.
Data obyektif:
- Hipertensi arterial
- Disritmia, perubahan EKG
- Pulsasi : kemungkinan bervariasi
- Denyut karotis, femoral dan arteri iliaka atau aorta abdominal
3. Integritas ego
Data Subyektif:
- Perasaan tidak berdaya, hilang harapan
Data obyektif:
- Emosi yang labil dan marah yang tidak tepat, kesedihan , kegembiraan
- Kesulitan berekspresi diri
4. Eliminasi
Data Subyektif:
- Inkontinensia, anuria
- Distensi abdomen ( kandung kemih sangat penuh ), tidak adanya suara usus ( ileus paralitik )
5. Makan/ minum
Data Subyektif:
- Nafsu makan hilang
- Nausea / vomitus menandakan adanya PTIK
- Kehilangan sensasi lidah , pipi , tenggorokan, disfagia
- Riwayat DM, peningkatan lemak dalam darah
Data obyektif:
- Problem dalam mengunyah ( menurunnya reflek palatum dan faring )
- Obesitas ( faktor resiko )
6. Sensori neural
Data Subyektif:
- Pusing / syncope ( sebelum CVA / sementara selama TIA )
- Nyeri kepala : pada perdarahan intra serebral atau perdarahan sub arachnoid.
- Kelemahan, kesemutan/kebas, sisi yang terkena terlihat seperti lumpuh/mati
- Penglihatan berkurang
- Sentuhan : kehilangan sensor pada sisi kolateral pada ekstremitas dan pada muka ipsilateral ( sisi yang sama )
- Gangguan rasa pengecapan dan penciuman
Data obyektif:
- Status mental ; koma biasanya menandai stadium perdarahan , gangguan tingkah laku (seperti: letargi, apatis, menyerang) dan gangguan fungsi kognitif
- Ekstremitas : kelemahan / paraliysis ( kontralateral pada semua jenis stroke, genggaman tangan tidak seimbang, berkurangnya reflek tendon dalam ( kontralateral )
- Wajah: paralisis / parese ( ipsilateral )
- Afasia ( kerusakan atau kehilangan fungsi bahasa, kemungkinan ekspresif/ kesulitan berkata-kata, reseptif / kesulitan berkata-kata komprehensif, global / kombinasi dari keduanya.
- Kehilangan kemampuan mengenal atau melihat, pendengaran, stimuli taktil
- Apraksia : kehilangan kemampuan menggunakan motorik
- Reaksi dan ukuran pupil : tidak sama dilatasi dan tak bereaksi pada sisi ipsi lateral
7. Nyeri / kenyamanan
Data Subyektif:
- Sakit kepala yang bervariasi intensitasnya
Data Obyektif:
- Tingkah laku yang tidak stabil, gelisah, ketegangan otot / fasial
8. Respirasi
Data Subyektif:
- Perokok ( faktor resiko )
Tanda:
- Kelemahan menelan/ batuk/ melindungi jalan napas
- Timbulnya pernapasan yang sulit dan / atau tak teratur
- Suara nafas terdengar ronchi /aspirasi
9.Keamanan
Data Obyektif:
- Motorik/sensorik : masalah dengan penglihatan
- Perubahan persepsi terhadap tubuh, kesulitan untuk melihat objek, hilang kewaspadaan terhadap bagian tubuh yang sakit
- Tidak mampu mengenali objek, warna, kata, dan wajah yang pernah dikenali
- Gangguan berespon terhadap panas, dan dingin/gangguan regulasi suhu tubuh
- Gangguan dalam memutuskan, perhatian sedikit terhadap keamanan, berkurang kesadaran diri
10. Interaksi sosial
Data Obyektif:
- Problem berbicara, ketidakmampuan berkomunikasi
11. Pengajaran / pembelajaran
Data Subjektif :
- Riwayat hipertensi keluarga, stroke
- Penggunaan kontrasepsi oral
12. Pertimbangan rencana pulang
- Menentukan regimen medikasi / penanganan terapi
- Bantuan untuk transportasi, shoping , menyiapkan makanan , perawatan diri dan pekerjaan rumah
(DoengesE, Marilynn,2000 hal 292)
Diagnosa Keperawatan Stroke
1. Perubahan perfusi jaringan serebral b.d terputusnya aliran darah : penyakit oklusi, perdarahan, spasme pembuluh darah serebral, edema serebral
Dibuktikan oleh :
- perubahan tingkat kesadaran , kehilangan memori
- perubahan respon sensorik / motorik, kegelisahan
- defisit sensori , bahasa, intelektual dan emosional
- perubahan tanda tanda vital
Tujuan Pasien / kriteria evaluasi ;
- terpelihara dan meningkatnya tingkat kesadaran, kognisi dan fungsi sensori / motor
- menampakkan stabilisasi tanda vital dan tidak ada PTIK
- peran klien menampakkan tidak adanya kemunduran / kekambuhan
Intervensi :
Independen
- Tentukan faktor-faktor yang berhubungan dengan situasi individu/ penyebab koma / penurunan perfusi serebral dan potensial PTIK
- Monitor dan catat status neurologist secara teratur
- Monitor tanda tanda vital
- Evaluasi pupil 9 ukuran bentuk kesamaan dan reaksi terhadap cahaya 0
- Bantu untuk mengubah pandangan , misalnya pandangan kabur, perubahan lapang pandang / persepsi lapang pandang
- Bantu meningkatkan fungsi, termasuk bicara jika klien mengalami gangguan fungsi
- Kepala dielevasikan perlahan lahan pada posisi netral .
- Pertahankan tirah baring , sediakan lingkungan yang tenang , atur kunjungan sesuai indikasi
Kolaborasi
- Berikan oksigen sesuai indikasi
- Berikan medikasi sesuai indikasi :
* Antifibrolitik, misal aminocaproic acid ( amicar )
* Antihipertensi
* Vasodilator perifer, misal cyclandelate, isoxsuprine.
* Manitol
2. Ketidakmampuan mobilitas fisik b.d kelemahan neuromuscular, ketidakmampuan dalam persespi kognitif
Dibuktikan oleh :
- Ketidakmampuan dalam bergerak pada lingkungan fisik : kelemahan, koordinasi, keterbatasan rentang gerak sendi, penurunan kekuatan otot.
Tujuan Pasien / kriteria evaluasi ;
- tidak ada kontraktur, foot drop.
- Adanya peningkatan kemampuan fungsi perasaan atau kompensasi dari bagian tubuh
- Menampakkan kemampuan perilaku / teknik aktivitas sebagaimana permulaanya
- Terpeliharanya integritas kulit
Intervensi
Independen
- Rubah posisi tiap dua jam ( prone, supine, miring )
- Mulai latihan aktif / pasif rentang gerak sendi pada semua ekstremitas
- Topang ekstremitas pada posisi fungsional , gunakan foot board pada saat selama periode paralysis flaksid. Pertahankan kepala dalam keadaan netral
- Evaluasi penggunaan alat bantu pengatur posisi
- Bantu meningkatkan keseimbangan duduk
- Bantu memanipulasi untuk mempengaruhi warna kulit edema atau menormalkan sirkulasi
- Awasi bagian kulit diatas tonjolan tulang
Kolaboratif
- Konsul kebagian fisioterapi
- Bantu dalam meberikan stimulasi elektrik
- Gunakan bed air atau bed khusus sesuai indikasi
3. Gangguan komunikasi verbal b.d gangguan sirkulasi serebral, gangguan neuromuskuler, kehilangan tonus otot fasial / mulut, kelemahan umum / letih.
Ditandai :
- Gangguan artikulasi
- Tidak mampu berbicara / disartria
- Ketidakmampuan modulasi wicara , mengenal kata , mengidentifikasi objek
- Ketidakmampuan berbicara atau menulis secara komprehensip
Tujuan / kriteria evaluasi
- Pasien mampu memahami problem komunikasi
- Menentukan metode komunikasi untuk berekspresi
- Menggunakan sumber bantuan dengan tepat
Intervensi
Independen
- Bantu menentukan derajat disfungsi
- Bedakan antara afasia denga disartria
- Sediakan bel khusus jika diperlukan
- Sediakan metode komunikasi alternatif
- Antisipasi dan sediakan kebutuhan klien
- Bicara langsung kepada klien dengan perlahan dan jelas
- Bicara dengan nada normal
Kolaborasi :
- Konsul dengan ahli terapi wicara
4. Perubahan persepsi sensori b.d penerimaan perubahan sensori transmisi, perpaduan ( trauma / penurunan neurology), tekanan psikologis ( penyempitan lapangan persepsi disebabkan oleh kecemasan)
Ditandai ;
- Disorientasi waktu, tempat , orang
- Perubahan pola tingkah laku
- Konsentrasi jelek, perubahan proses pikir
- Ketidakmampuan untuk mengatakan letak organ tubuh
- Perubahan pola komunikasi
- Ketidakmampuan mengkoordinasi kemampuan motorik.
Tujuan / kriteria hasil :
- Dapat mempertahakan level kesadaran dan fungsi persepsi pada level biasanya.
- Perubahan pengetahuan dan mampu terlibat
- Mendemonstrasikan perilaku untuk kompensasi
Intervensi
Independen
- Kaji patologi kondisi individual
- Evaluasi penurunan visual
- Lakukan pendekatan dari sisi yang utuh
- Sederhanakan lingkungan
- Bantu pemahaman sensori
- Beri stimulasi terhadap sisa sisa rasa sentuhan
- Lindungi klien dari temperatur yang ekstrem
- Pertahankan kontak mata saat berhubungan
- Validasi persepsi klien
5. Kurang perawatan diri b.d kerusakan neuro muskuler, penurunan kekuatan dan ketahanan, kehilangan kontrol /koordinasi otot
Ditandai dengan :
- Kerusakan kemampuan melakukan AKS misalnya ketidakmampuan makan, mandi, memasang/melepas baju, kesulitan tugas toiletng
Kriteria hasil:
- Melakukan aktivitas perwatan diri dalam tingkat kemampuan sendiri
- Mengidentifikasi sumber pribadi /komunitas dalam memberikan bantuan sesuai kebutuhan
- Mendemonstrasikan perubahan gaya hidup untuk memenuhi kenutuhan perawatan diri
Intervensi:
- Kaji kemampuan dan tingkat kekurangan (dengan menggunakan skala 1-4) untuk memenuhi kebutuhan sehari-hari
- Hindari melakukan sesuatu untuk kllien yang dapat dilakukan sendiri, tetapi berikan bantuan sesuai kebutuhan
- Kaji kemampuan klien untuk berkomunikasi tentang kebutuhannya untuk menghindari dan atau kemampuan untuk menggunakan urinal, bedpan.
- Identifikasi kebiasaan defekasi sebelumnya dan kembalikan pada kebiasaan pola normal tersebut. Kadar makanan yang berserat, anjurkan untuk minum banyak dan tingkatkan aktivitas.
- Berikan umpan balik yang positif untuk setiap usaha yang dilakukan atau keberhasilannya.
Kolaborasi;
- Berikan supositoria dan pelunak feses
- Konsultasikan dengan ahli fisioterapi/okupasi
6. Ketidakefektifan bersihan jalan napas b.d kerusakan batuk, ketidakmampuan mengatasi lendir
Kriteria hasil:
- Klien memperlihatkan kepatenan jalan napas
- Ekspansi dada simetris
- Bunyi napas bersih saat auskultasi
- Tidak terdapat tanda distress pernapasan
- GDA dan tanda vital dalam batas normal
Intervensi:
- Kaji dan pantau pernapasan, reflek batuk dan sekresi
- Posisikan tubuh dan kepala untuk menghindari obstruksi jalan napas dan memberikan pengeluaran sekresi yang optimal
- Penghisapan sekresi
- Auskultasi dada untuk mendengarkan bunyi jalan napas setiap 4 jam
- Berikan oksigenasi sesuai advis
- Pantau BGA dan Hb sesuai indikasi
8. Gangguan pemenuhan nutrisi b.d penurunan reflek menelan, kehilangan rasa ujung lidah
Ditandai dengan:
- Keluhan masukan makan tidak adekuat
- Kehilangan sensasi pengecapan
- Rongga mulut terinflamasi
Kriteria evaluasi:
- Klien dapat berpartisipasi dalam intervensi spesifik untuk merangsang nafsu makan
- BB stabil
- Klien mengungkapkan pemasukan adekuat
Intervensi;
- Pantau masukan makanan setiap hari
- Ukur BB setiap hari sesuai indikasi
- Dorong klien untuk makan diit tinggi kalori kaya nutrisi sesuai program
- Kontrol faktor lingkungan (bau, bising), hindari makanan terlalu manis, berlemak dan pedas. Ciptakan suasana makan yang menyenangkan
- Identifikasi klien yang mengalami mual muntah
Kolaborasi:
- Pemberian anti emetik dengan jadwal reguler
- Vitamin A,D,E dan B6
- Rujuk ahli diit
- Pasang /pertahankan slang NGT untuk pemberian makanan enteral
(DoengesE, Marilynn,2000 hal 293-305)
Daftar Pustaka
1. Long C, Barbara, Perawatan Medikal Bedah, Jilid 2, Bandung, Yayasan Ikatan Alumni Pendidikan Keperawatan Pajajaran, 1996
2. Tuti Pahria, dkk, Asuhan Keperawatan pada Pasien dengan Ganguan Sistem Persyarafan, Jakarta, EGC, 1993
3. Pusat pendidikan Tenaga Kesehatan Departemen Kesehatan, Asuhan Keperawatan Klien Dengan Gangguan Sistem Persarafan , Jakarta, Depkes, 1996
4. Smeltzer C. Suzanne, Brunner & Suddarth, Buku Ajar Keperawatan Medikal Bedah, Jakarta, EGC ,2002
5. Marilynn E, Doengoes, 2000, Rencana Asuhan Keperawatan, Edisi 3, Jakarta, EGC, 2000
6. Harsono, Buku Ajar : Neurologi Klinis,Yogyakarta, Gajah Mada university press, 1996
Intracerebral Hemorrhage
Intracerebral Hemorrhage
An intracerebral hemorrhage is bleeding within the brain.
*
Intracerebral hemorrhage usually results from chronic high blood pressure.
*
The first symptom is often a severe headache.
*
Diagnosis is based on symptoms and results of a physical examination and imaging tests.
*
Treatment may include vitamin K, transfusions, and, rarely, surgery to remove the accumulated blood.
Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher percentage of deaths due to stroke. Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage.
Causes
Intracerebral hemorrhage most often results when chronic high blood pressure weakens a small artery, causing it to burst. Using cocaine or amphetamines can cause temporary but very high blood pressure and hemorrhage. In some older people, an abnormal protein called amyloid accumulates in arteries of the brain. This accumulation (called amyloid angiopathy) weakens the arteries and can cause hemorrhage.
Less common causes include blood vessel abnormalities present at birth, injuries, tumors, inflammation of blood vessels (vasculitis), bleeding disorders, and use of anticoagulants in doses that are too high. Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage.
Symptoms
An intracerebral hemorrhage begins abruptly. In about half of the people, it begins with a severe headache, often during activity. However, in older people, the headache may be mild or absent. Symptoms suggesting brain dysfunction develop and steadily worsen as the hemorrhage expands. Some symptoms, such as weakness, paralysis, loss of sensation, and numbness, often affect only one side of the body. People may be unable to speak or become confused. Vision may be impaired or lost. The eyes may point in different directions or become paralyzed. The pupils may become abnormally large or small. Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes.
Diagnosis
Doctors can often diagnose intracerebral hemorrhages on the basis of symptoms and results of a physical examination. However, computed tomography (CT) or magnetic resonance imaging (MRI) is also done. Both tests can help doctors distinguish a hemorrhagic stroke from an ischemic stroke. The tests can also show how much brain tissue has been damaged and whether pressure is increased in other areas of the brain. The blood sugar level is measured because a low blood sugar level can cause symptoms similar to those of stroke.
Prognosis
Intracerebral hemorrhage is more likely to be fatal than ischemic stroke. The hemorrhage is usually large and catastrophic, especially in people who have chronic high blood pressure. More than half of the people who have a large hemorrhage die within a few days. Those who survive usually recover consciousness and some brain function over time. However, most do not recover all lost brain function.
Treatment
Treatment of intracerebral hemorrhage differs from that of an ischemic stroke. Anticoagulants (such as heparin and warfarin Some Trade Names
COUMADIN
), thrombolytic drugs, and antiplatelet drugs (such as aspirin Some Trade Names
BAYER
) are not given because they make bleeding worse. If people who are taking an anticoagulant have a hemorrhagic stroke, they may need a treatment that helps blood clot such as
*
Vitamin K, usually given intravenously
*
Transfusions of platelets
*
Transfusions of blood that has had blood cells and platelets removed (fresh frozen plasma)
*
Intravenous administration of a synthetic product similar to the proteins in blood that help blood to clot (clotting factors)
Surgery to remove the accumulated blood and relieve pressure within the skull, even if it may be life-saving, is rarely done because the operation itself can damage the brain. Also, removing the accumulated blood can trigger more bleeding, further damaging the brain and leading to severe disability. However, this operation may be effective for hemorrhage in the pituitary gland or in the cerebellum. In such cases, a good recovery is possible.
Stroke Ischemic
An ischemic stroke is death of an area of brain tissue (cerebral infarction) resulting from an inadequate supply of blood and oxygen to the brain due to blockage of an artery.
*
Ischemic stroke usually results when an artery to the brain is blocked, often by a blood clot or a fatty deposit due to atherosclerosis.
*
Symptoms occur suddenly and may include muscle weakness, paralysis, lost or abnormal sensation on one side of the body, difficulty speaking, confusion, problems with vision, dizziness, and loss of balance and coordination.
*
Diagnosis is usually based on symptoms and results of a physical examination, imaging tests, and blood tests.
*
Treatment may include drugs to break up blood clots or to make blood less likely to clot and surgery, followed by rehabilitation.
*
About one third of people recover all or most of normal function after an ischemic stroke.
Causes
An ischemic stroke typically results from blockage of an artery that supplies the brain, most commonly a branch of one of the internal carotid arteries.
Commonly, blockages are blood clots (thrombi) or pieces of fatty deposits (atheromas, or plaques) due to atherosclerosis. Such blockages often occur in the following ways:
*
By forming in and blocking an artery: An atheroma in the wall of an artery may accumulate more fatty material and become large enough to block the artery. Or a blood clot can form and block the artery when an atheroma ruptures (Atherosclerosis: How Atherosclerosis DevelopsFigures). Clots tend to form on a ruptured atheroma because the atheroma narrows the artery and slows blood flow through it, like a clogged pipe slows the flow of water. Slow-moving blood is more likely to clot. A large clot can block enough blood flowing through the narrowed artery that brain cells supplied by that artery die.
*
By traveling to another artery: A blood clot in the heart, a piece of an atheroma, or a blood clot in the wall of an artery can break off and travel through the bloodstream (becoming an embolus). The embolus may then lodge in an artery that supplies the brain and block blood flow there. (Embolism refers to blockage of arteries by materials that travel through the bloodstream to another part of the body.) Such blockages are more likely to occur where arteries are already narrowed by fatty deposits.
Several conditions besides rupture of an atheroma can trigger or promote the formation of blood clots, increasing the risk of blockage by a blood clot, such as the following:
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Heart-related problems: Blood clots may form in the heart or on a heart valve (including artificial valves). Strokes due to such blood clots are most common among people who have recently had heart surgery and people who have a heart valve disorder or an abnormal heart rhythm (arrhythmia), especially a fast, irregular heart rhythm called atrial fibrillation.
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Blood disorders: Some disorders, such as an excess of red blood cells (polycythemia), make blood thick, increasing the risk of blood clots. Some disorders, such as antiphospholipid syndrome and a high homocysteine level in the blood (hyperhomocysteinemia), make blood more likely to clot.
*
Oral contraceptives: Taking oral contraceptives, particularly those with a high estrogen dose, increases the risk of blood clots.
Another common cause of ischemic strokes is a lacunar infarction. In lacunar infarction, one of the small arteries deep in the brain becomes blocked by a mixture of fat and connective tissue—a blood clot is not the cause. This disorder is called lipohyalinosis and tends to occur in older people with diabetes or poorly controlled high blood pressure. Lipohyalinosis is different from atherosclerosis, but both disorders can cause blockage of arteries. Only a small part of the brain is damaged in lacunar infarction.
Rarely, small pieces of fat from the marrow of a broken long bone, such as a leg bone, are released into the bloodstream. These pieces can clump together and block an artery. The resulting disorder, called fat embolism syndrome, may resemble a stroke.
An ischemic stroke can also result from any disorder that reduces the amount of blood or oxygen supplied to the brain, such as severe blood loss or very low blood pressure. Occasionally, an ischemic stroke occurs when blood flow to the brain is normal but the blood does not contain enough oxygen. Disorders that reduce the oxygen content of blood include a severe deficiency of red blood cells (anemia), suffocation, and carbon monoxide poisoning. Usually, brain damage in such cases is widespread (diffuse), and coma results.
An ischemic stroke can occur if inflammation of blood vessels (vasculitis) or infection (such as herpes simplex) narrows blood vessels that supply the brain. Migraine headaches or drugs such as cocaine and amphetamines can cause spasm of the arteries, which can narrow the arteries supplying the brain and cause a stroke.
Clogs and Clots: Causes of Ischemic Stroke
When an artery that carries blood to the brain becomes clogged or blocked, an ischemic stroke can occur. Arteries may be blocked by fatty deposits (atheromas, or plaques) due to atherosclerosis. Arteries in the neck, particularly the internal carotid arteries, are a common site for atheromas. Arteries may also be blocked by a blood clot (thrombus). Blood clots may form on an atheroma in an artery. Clots may also form in the heart of people with a heart disorder. Part of a clot may break off and travel through the bloodstream (becoming an embolus). It may then block an artery that supplies blood to the brain, such as one of the cerebral arteries.
Symptoms
Usually, symptoms occur suddenly and are often most severe a few minutes after they start because most ischemic strokes begin suddenly, develop rapidly, and cause death of brain tissue within minutes to hours. Then, most strokes become stable, causing little or no further damage. Strokes that remain stable for 2 to 3 days are called completed strokes. Sudden blockage by an embolus is most likely to cause this kind of stroke.
Less commonly, symptoms develop slowly. They result from strokes that continue to worsen for several hours to a day or two, as a steadily enlarging area of brain tissue dies. Such strokes are called evolving strokes. The progression of symptoms and damage is usually interrupted by somewhat stable periods, during which the area temporarily stops enlarging or some improvement occurs. Such strokes are usually due to the formation of clots in a narrowed artery.
Many different symptoms can occur, depending on which artery is blocked and thus which part of the brain is deprived of blood and oxygen Brain Dysfunction: Dysfunction by Location). When the arteries that branch from the internal carotid artery (which carry blood along the front of the neck to the brain) are affected, the following are most common:
*
Blindness in one eye
*
Inability to see out of the same side in both eyes
*
Abnormal sensations, weakness, or paralysis in one arm or leg or on one side of the body
When the arteries that branch from the vertebral arteries (which carry blood along the back of the neck to the brain) are affected, the following are most common:
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Dizziness and vertigo
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Double vision
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Generalized weakness on both sides of the body
Many other symptoms, such as difficulty speaking (for example, slurred speech), impaired consciousness (such as confusion), loss of coordination, and urinary incontinence, can occur.
Severe strokes may lead to stupor or coma. In addition, strokes, even milder ones, can cause depression or an inability to control emotions. For example, people may cry or laugh inappropriately.
If symptoms, particularly impaired consciousness, worsen during the first 2 to 3 days, the cause is often swelling due to excess fluid (edema) in the brain. Symptoms usually lessen within a few days, as the fluid is absorbed. Nonetheless, the swelling is particularly dangerous because the skull does not expand. The resulting increase in pressure can cause the brain to shift, further impairing brain function, even if the area directly damaged by the stroke does not enlarge. If the pressure becomes very high, the brain may be forced downward in the skull, through the rigid structures that separate the brain into compartments. The resulting disorder is called herniation (see Head Injuries:IntroductionFigures).
Strokes can lead to other problems. If swallowing is difficult, people may not eat enough and become malnourished. Food, saliva, or vomit may be inhaled (aspirated) into the lungs, resulting in aspiration pneumonia. Being in one position too long can result in pressure sores and lead to muscle loss. Not being able to move the legs can result in the formation of blood clots in deep veins of the legs and groin (deep vein thrombosis). Clots can break off, travel through the bloodstream, and block an artery to a lung (a disorder called pulmonary embolism). People may have difficulty sleeping. The losses and problems resulting from the stroke may make people depressed.
Diagnosis
Audio
Turbulent Blood Flow
Turbulent Blood Flow
Doctors can usually diagnose an ischemic stroke based on the history of events and results of a physical examination. Doctors can usually identify which artery in the brain is blocked based on symptoms (see Brain Dysfunction:IntroductionFigures). For example, weakness or paralysis of the left leg suggests blockage of the artery supplying the area on the right side of the brain that controls the left leg's muscle movements.
Computed tomography (CT) is usually done first. CT helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities. Doctors also measure the blood sugar level to rule out a low blood sugar level (hypoglycemia), which can cause similar symptoms. If available, diffusion magnetic resonance imaging (MRI), which can detect ischemic strokes within minutes of their start, may be done next.
Identifying the precise cause of the stroke is important. If the blockage is a blood clot, another stroke is very likely unless the underlying disorder is corrected. For example, if blood clots result from an abnormal heart rhythm, treating that disorder can prevent new clots from forming and causing another stroke. Tests for causes may include the following:
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Electrocardiography (ECG) to look for abnormal heart rhythms
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Continuous ECG monitoring (done at home or in the hospital—see Symptoms and Diagnosis of Heart and Blood Vessel Disorders: Continuous Ambulatory Electrocardiography) to record the heart rate and rhythm continuously for 24 hours (or more), which may detect abnormal heart rhythms that occur unpredictably or briefly
*
Echocardiography to check the heart for blood clots, pumping or structural abnormalities, and valve disorders
*
Imaging tests—color Doppler ultrasonography, magnetic resonance angiography, CT angiography, or cerebral (standard) angiography—to determine whether arteries, especially the internal carotid arteries, are blocked or narrowed
*
Blood tests to check for anemia, polycythemia, blood clotting disorders, vasculitis, and some infections (such as heart valve infections and syphilis) and for risk factors such as high cholesterol levels or diabetes
Imaging tests enable doctors to determine how narrowed the carotid arteries are and thus to estimate the risk of a subsequent stroke or TIA. Such information helps determine which treatments are needed.
For cerebral angiography, a thin, flexible tube (catheter) is inserted into an artery, usually in the groin, and threaded through the aorta to an artery in the neck. Then, a dye is injected to outline the artery. Thus, this test is more invasive than other tests that provide images of the brain's blood supply. However, it provides more information (see Common Imaging Tests: Angiography). Cerebral angiography may be done before atheromas are removed surgically or when vasculitis is suspected.
Rarely, a spinal tap (lumbar puncture) is done—for example, after CT, when doctors still need to determine whether strokelike symptoms are due to an infection or whether a subarachnoid hemorrhage is present (see Stroke (CVA): Subarachnoid Hemorrhage). This procedure is done only if doctors are sure that the brain is not under excess pressure (usually determined by CT or MRI).
Prognosis
About 10% of people who have an ischemic stroke recover almost all normal function, and about 25% recover most of it. About 40% of people have moderate to severe impairments requiring special care, and about 10% require care in a nursing home or other long-term care facility. Some people are physically and mentally devastated and unable to move, speak, or eat normally. About 20% of people who have a stroke die in the hospital. The proportion is higher among older people. About 25% of people who recover from a stroke have another stroke within 5 years. Subsequent strokes impair function further.
During the first few days after an ischemic stroke, doctors usually cannot predict whether a person will improve or worsen. Younger people and people who start improving quickly are likely to recover more fully. About 50% of people with one-sided paralysis and most of those with less severe symptoms recover some function by the time they leave the hospital, and they can eventually take care of their basic needs. They can think clearly and walk adequately, although use of the affected arm or leg may be limited. Use of an arm is more often limited than use of a leg. Most impairments still present after 12 months are permanent.
Treatment
People who have any symptom suggesting an ischemic stroke should go to an emergency department immediately. The earlier the treatment, the better are the chances for recovery.
The first priority is to restore the person's breathing, heart rate, blood pressure (if low), and temperature to normal. An intravenous line is inserted to provide drugs and fluids when needed. If the person has a fever, it may be lowered using acetaminophen Some Trade Names
TYLENOL
, ibuprofen Some Trade Names
ADVILMOTRIN
, or a cooling blanket. An increase in body temperature by even a few degrees can dramatically worsen brain damage due to an ischemic stroke. Generally, doctors do not immediately treat high blood pressure unless it is very high (over 220/120 mm Hg) because, when arteries are narrowed, blood pressure must be higher than normal to push enough blood through them to the brain. However, very high blood pressure can injure the heart, kidneys, and eyes and must be lowered.
If a stroke is very severe, drugs such as mannitol may be given to reduce swelling and the increased pressure in the brain. Some people need a ventilator to breathe adequately.
Specific treatment of stroke may include drugs to break up blood clots (thrombolytic drugs), drugs to make blood less likely to clot (antiplatelet drugs and anticoagulants), and surgery, followed by rehabilitation.
Thrombolytic (Fibrinolytic) Drugs: In certain circumstances, a drug called tissue plasminogen activator (tPA) is given intravenously to break up clots and help restore blood flow to the brain. Because tPA can cause bleeding in the brain and elsewhere, it should not be given to people with certain conditions, such as the following:
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A past occurrence of a hemorrhagic stroke, a bulge (aneurysm) in an artery to the brain, other structural abnormalities in the brain, or a brain tumor
*
A seizure when the stroke began
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A tendency to bleed
*
Recent major surgery
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Recent bleeding (hemorrhage) in the gastrointestinal or urinary tract
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A recent head injury or other serious trauma
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A very high or very low blood sugar level
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A heart infection
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Current use of an anticoagulant ( warfarin Some Trade Names
COUMADIN
)
*
A large ischemic stroke
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Blood pressure that remains high after treatment with an antihypertensive drug
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Symptoms that are resolving quickly
Before tPA is given, CT is done to rule out bleeding in the brain. To be effective and safe, tPA, given intravenously, must be started within 3 hours of the beginning of an ischemic stroke. After 3 hours, most of the damage to the brain cannot be reversed, and the risk of bleeding outweighs the possible benefit of the drug. However, pinpointing when the stroke began may be difficult. So doctors assume that the stroke began the last time a person was known to be well. For example, if a person awakens with symptoms of a stroke, doctors assume the stroke began when the person was last seen awake and well. Thus, tPA can be used in only a few people who have had a stroke.
If people arrive at the hospital 3 to 6 hours (occasionally, up to 18 hours) after the stroke began, they may be given tPA or another thrombolytic drug. But the drug must be given through a catheter instead. For this treatment, doctors make an incision in the skin, usually in the groin, and insert a catheter into an artery. The catheter is then threaded through the aorta and other arteries, to the clot. The clot is partly broken up with the catheter wire and then injected with tPA. This treatment is usually available only at specialized stroke centers.
Antiplatelet Drugs and Anticoagulants: If a thrombolytic drug cannot be used, most people are given aspirin Some Trade Names
BAYER
(an antiplatelet drug) as soon as they get to the hospital. If symptoms seem to be worsening, anticoagulants such as heparin are occasionally used, but their effectiveness has not been proved. Antiplatelet drugs make platelets less likely to clump and form clots. Anticoagulants inhibit proteins in blood that help it to clot (clotting factors).
Regardless of the initial treatment, long-term treatment usually consists of aspirin Some Trade Names
BAYER
or another antiplatelet drug to reduce the risk of blood clots and thus of subsequent strokes (see Stroke (CVA): Prevention). People who have atrial fibrillation or a heart valve disorder are given anticoagulants (such as warfarin Some Trade Names
COUMADIN
) instead of antiplatelet drugs, which do not seem to prevent blood clots from forming in the heart. Occasionally, people at high risk of another stroke are given both aspirin Some Trade Names
BAYER
and warfarin Some Trade Names
COUMADIN
.
If people have been given a thrombolytic drug, doctors usually wait at least 24 hours before antiplatelet drugs or anticoagulants are started because these drugs add to the already increased risk of bleeding in the brain. Anticoagulants are not given to people who have uncontrolled high blood pressure or who have had a hemorrhagic stroke.
Surgery: Once an ischemic stroke is completed, surgical removal of atheromas or clots (endarterectomy) in an internal carotid artery may be done. Carotid endarterectomy can help if all of the following are present:
*
The stroke resulted from narrowing of a carotid artery by more than 70%.
*
Some brain tissue supplied by the affected artery still functions after the stroke.
*
The person's life expectancy is at least 5 years.
In such people, carotid endarterectomy may reduce the risk of subsequent strokes. It also reestablishes the blood supply to the affected area, but it cannot restore lost function because some brain tissue is dead.
For carotid endarterectomy, a general anesthetic or a local anesthetic (to numb the neck area) may be used. If people remain awake during the operation, the surgeon can better evaluate how the brain is functioning. The surgeon makes an incision in the neck over the area of the artery that contains the blockage and an incision in the artery. The blockage is removed, and the incisions are closed. For a few days afterwards, the neck may hurt, and swallowing may be difficult. Most people can stay in the hospital 1 or 2 days. Heavy lifting should be avoided for about 3 weeks. After several weeks, people can resume their usual activities.
Carotid endarterectomy can trigger a stroke because the operation may dislodge clots or other material that can then travel through the bloodstream and block an artery. However, after the operation, the risk of stroke is lower for several years than it is when drugs are used.
In other narrowed arteries, such as the vertebral arteries, endarterectomy may not be possible because the operation is riskier to perform in these arteries than in the internal carotid arteries.
People should find a surgeon who is experienced doing this operation and who has a low rate of serious complications (such as heart attack, stroke, and death) after the operation. If people cannot find such a surgeon, the risks of endarterectomy outweigh its expected benefits.
Stents: If endarterectomy is too risky, a less invasive procedure can be done: A wire mesh tube (stent) with an umbrella filter may be placed in the carotid artery. The stent helps keep the artery open, and the filter catches blood clots and prevents them from reaching the brain and causing a stroke. The filter is similar to one used to prevent pulmonary embolism (see Venous Disorders: Umbrellas: One Way to Prevent Pulmonary EmbolismFigures). After a local anesthetic is given, a catheter is inserted through a small incision into a large artery near the groin or in the arm and is threaded to the internal carotid artery in the neck. A dye that can be seen on x-rays (radiopaque dye) is injected, and x-rays are taken so that the narrowed area can be located. After the stent and filter are placed, the catheter is removed. People remain awake for the procedure, which usually takes 1 to 2 hours. The procedure appears to be as safe as endarterectomy and is almost as effective in preventing strokes and death.
Other Treatments: Another option being studied is a tiny corkscrew-shaped device that is attached to a catheter, threaded to the clot, and used to snag the clot. The clot is then drawn out through the catheter. This treatment may be useful for people who cannot be given tPA.
Treatment of Problems Due to Strokes: Measures to prevent aspiration pneumonia (see Pneumonia: Aspiration Pneumonia) and pressure sores (see Pressure Sores: Prevention) are started early. Heparin, injected under the skin, may be given to help prevent deep vein thrombosis (see Venous Disorders: Deep Vein Thrombosis (DVT)). People are closely monitored to determine whether the esophagus, bladder, and intestines are functioning. Often, other disorders such as heart failure, abnormal heart rhythms, and lung infections must be treated. High blood pressure is often treated after the stroke has been stabilized.
Because a stroke often causes mood changes, especially depression, family members or friends should inform the doctor if the person seems depressed. Depression can be treated with drug therapy and psychotherapy (see Mood Disorders: Prognosis and Treatment).
Last full review/revision November 2007 by Elias A. Giraldo, MD
*
Ischemic stroke usually results when an artery to the brain is blocked, often by a blood clot or a fatty deposit due to atherosclerosis.
*
Symptoms occur suddenly and may include muscle weakness, paralysis, lost or abnormal sensation on one side of the body, difficulty speaking, confusion, problems with vision, dizziness, and loss of balance and coordination.
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Diagnosis is usually based on symptoms and results of a physical examination, imaging tests, and blood tests.
*
Treatment may include drugs to break up blood clots or to make blood less likely to clot and surgery, followed by rehabilitation.
*
About one third of people recover all or most of normal function after an ischemic stroke.
Causes
An ischemic stroke typically results from blockage of an artery that supplies the brain, most commonly a branch of one of the internal carotid arteries.
Commonly, blockages are blood clots (thrombi) or pieces of fatty deposits (atheromas, or plaques) due to atherosclerosis. Such blockages often occur in the following ways:
*
By forming in and blocking an artery: An atheroma in the wall of an artery may accumulate more fatty material and become large enough to block the artery. Or a blood clot can form and block the artery when an atheroma ruptures (Atherosclerosis: How Atherosclerosis DevelopsFigures). Clots tend to form on a ruptured atheroma because the atheroma narrows the artery and slows blood flow through it, like a clogged pipe slows the flow of water. Slow-moving blood is more likely to clot. A large clot can block enough blood flowing through the narrowed artery that brain cells supplied by that artery die.
*
By traveling to another artery: A blood clot in the heart, a piece of an atheroma, or a blood clot in the wall of an artery can break off and travel through the bloodstream (becoming an embolus). The embolus may then lodge in an artery that supplies the brain and block blood flow there. (Embolism refers to blockage of arteries by materials that travel through the bloodstream to another part of the body.) Such blockages are more likely to occur where arteries are already narrowed by fatty deposits.
Several conditions besides rupture of an atheroma can trigger or promote the formation of blood clots, increasing the risk of blockage by a blood clot, such as the following:
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Heart-related problems: Blood clots may form in the heart or on a heart valve (including artificial valves). Strokes due to such blood clots are most common among people who have recently had heart surgery and people who have a heart valve disorder or an abnormal heart rhythm (arrhythmia), especially a fast, irregular heart rhythm called atrial fibrillation.
*
Blood disorders: Some disorders, such as an excess of red blood cells (polycythemia), make blood thick, increasing the risk of blood clots. Some disorders, such as antiphospholipid syndrome and a high homocysteine level in the blood (hyperhomocysteinemia), make blood more likely to clot.
*
Oral contraceptives: Taking oral contraceptives, particularly those with a high estrogen dose, increases the risk of blood clots.
Another common cause of ischemic strokes is a lacunar infarction. In lacunar infarction, one of the small arteries deep in the brain becomes blocked by a mixture of fat and connective tissue—a blood clot is not the cause. This disorder is called lipohyalinosis and tends to occur in older people with diabetes or poorly controlled high blood pressure. Lipohyalinosis is different from atherosclerosis, but both disorders can cause blockage of arteries. Only a small part of the brain is damaged in lacunar infarction.
Rarely, small pieces of fat from the marrow of a broken long bone, such as a leg bone, are released into the bloodstream. These pieces can clump together and block an artery. The resulting disorder, called fat embolism syndrome, may resemble a stroke.
An ischemic stroke can also result from any disorder that reduces the amount of blood or oxygen supplied to the brain, such as severe blood loss or very low blood pressure. Occasionally, an ischemic stroke occurs when blood flow to the brain is normal but the blood does not contain enough oxygen. Disorders that reduce the oxygen content of blood include a severe deficiency of red blood cells (anemia), suffocation, and carbon monoxide poisoning. Usually, brain damage in such cases is widespread (diffuse), and coma results.
An ischemic stroke can occur if inflammation of blood vessels (vasculitis) or infection (such as herpes simplex) narrows blood vessels that supply the brain. Migraine headaches or drugs such as cocaine and amphetamines can cause spasm of the arteries, which can narrow the arteries supplying the brain and cause a stroke.
Clogs and Clots: Causes of Ischemic Stroke
When an artery that carries blood to the brain becomes clogged or blocked, an ischemic stroke can occur. Arteries may be blocked by fatty deposits (atheromas, or plaques) due to atherosclerosis. Arteries in the neck, particularly the internal carotid arteries, are a common site for atheromas. Arteries may also be blocked by a blood clot (thrombus). Blood clots may form on an atheroma in an artery. Clots may also form in the heart of people with a heart disorder. Part of a clot may break off and travel through the bloodstream (becoming an embolus). It may then block an artery that supplies blood to the brain, such as one of the cerebral arteries.
Symptoms
Usually, symptoms occur suddenly and are often most severe a few minutes after they start because most ischemic strokes begin suddenly, develop rapidly, and cause death of brain tissue within minutes to hours. Then, most strokes become stable, causing little or no further damage. Strokes that remain stable for 2 to 3 days are called completed strokes. Sudden blockage by an embolus is most likely to cause this kind of stroke.
Less commonly, symptoms develop slowly. They result from strokes that continue to worsen for several hours to a day or two, as a steadily enlarging area of brain tissue dies. Such strokes are called evolving strokes. The progression of symptoms and damage is usually interrupted by somewhat stable periods, during which the area temporarily stops enlarging or some improvement occurs. Such strokes are usually due to the formation of clots in a narrowed artery.
Many different symptoms can occur, depending on which artery is blocked and thus which part of the brain is deprived of blood and oxygen Brain Dysfunction: Dysfunction by Location). When the arteries that branch from the internal carotid artery (which carry blood along the front of the neck to the brain) are affected, the following are most common:
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Blindness in one eye
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Inability to see out of the same side in both eyes
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Abnormal sensations, weakness, or paralysis in one arm or leg or on one side of the body
When the arteries that branch from the vertebral arteries (which carry blood along the back of the neck to the brain) are affected, the following are most common:
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Dizziness and vertigo
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Double vision
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Generalized weakness on both sides of the body
Many other symptoms, such as difficulty speaking (for example, slurred speech), impaired consciousness (such as confusion), loss of coordination, and urinary incontinence, can occur.
Severe strokes may lead to stupor or coma. In addition, strokes, even milder ones, can cause depression or an inability to control emotions. For example, people may cry or laugh inappropriately.
If symptoms, particularly impaired consciousness, worsen during the first 2 to 3 days, the cause is often swelling due to excess fluid (edema) in the brain. Symptoms usually lessen within a few days, as the fluid is absorbed. Nonetheless, the swelling is particularly dangerous because the skull does not expand. The resulting increase in pressure can cause the brain to shift, further impairing brain function, even if the area directly damaged by the stroke does not enlarge. If the pressure becomes very high, the brain may be forced downward in the skull, through the rigid structures that separate the brain into compartments. The resulting disorder is called herniation (see Head Injuries:IntroductionFigures).
Strokes can lead to other problems. If swallowing is difficult, people may not eat enough and become malnourished. Food, saliva, or vomit may be inhaled (aspirated) into the lungs, resulting in aspiration pneumonia. Being in one position too long can result in pressure sores and lead to muscle loss. Not being able to move the legs can result in the formation of blood clots in deep veins of the legs and groin (deep vein thrombosis). Clots can break off, travel through the bloodstream, and block an artery to a lung (a disorder called pulmonary embolism). People may have difficulty sleeping. The losses and problems resulting from the stroke may make people depressed.
Diagnosis
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Turbulent Blood Flow
Turbulent Blood Flow
Doctors can usually diagnose an ischemic stroke based on the history of events and results of a physical examination. Doctors can usually identify which artery in the brain is blocked based on symptoms (see Brain Dysfunction:IntroductionFigures). For example, weakness or paralysis of the left leg suggests blockage of the artery supplying the area on the right side of the brain that controls the left leg's muscle movements.
Computed tomography (CT) is usually done first. CT helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities. Doctors also measure the blood sugar level to rule out a low blood sugar level (hypoglycemia), which can cause similar symptoms. If available, diffusion magnetic resonance imaging (MRI), which can detect ischemic strokes within minutes of their start, may be done next.
Identifying the precise cause of the stroke is important. If the blockage is a blood clot, another stroke is very likely unless the underlying disorder is corrected. For example, if blood clots result from an abnormal heart rhythm, treating that disorder can prevent new clots from forming and causing another stroke. Tests for causes may include the following:
*
Electrocardiography (ECG) to look for abnormal heart rhythms
*
Continuous ECG monitoring (done at home or in the hospital—see Symptoms and Diagnosis of Heart and Blood Vessel Disorders: Continuous Ambulatory Electrocardiography) to record the heart rate and rhythm continuously for 24 hours (or more), which may detect abnormal heart rhythms that occur unpredictably or briefly
*
Echocardiography to check the heart for blood clots, pumping or structural abnormalities, and valve disorders
*
Imaging tests—color Doppler ultrasonography, magnetic resonance angiography, CT angiography, or cerebral (standard) angiography—to determine whether arteries, especially the internal carotid arteries, are blocked or narrowed
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Blood tests to check for anemia, polycythemia, blood clotting disorders, vasculitis, and some infections (such as heart valve infections and syphilis) and for risk factors such as high cholesterol levels or diabetes
Imaging tests enable doctors to determine how narrowed the carotid arteries are and thus to estimate the risk of a subsequent stroke or TIA. Such information helps determine which treatments are needed.
For cerebral angiography, a thin, flexible tube (catheter) is inserted into an artery, usually in the groin, and threaded through the aorta to an artery in the neck. Then, a dye is injected to outline the artery. Thus, this test is more invasive than other tests that provide images of the brain's blood supply. However, it provides more information (see Common Imaging Tests: Angiography). Cerebral angiography may be done before atheromas are removed surgically or when vasculitis is suspected.
Rarely, a spinal tap (lumbar puncture) is done—for example, after CT, when doctors still need to determine whether strokelike symptoms are due to an infection or whether a subarachnoid hemorrhage is present (see Stroke (CVA): Subarachnoid Hemorrhage). This procedure is done only if doctors are sure that the brain is not under excess pressure (usually determined by CT or MRI).
Prognosis
About 10% of people who have an ischemic stroke recover almost all normal function, and about 25% recover most of it. About 40% of people have moderate to severe impairments requiring special care, and about 10% require care in a nursing home or other long-term care facility. Some people are physically and mentally devastated and unable to move, speak, or eat normally. About 20% of people who have a stroke die in the hospital. The proportion is higher among older people. About 25% of people who recover from a stroke have another stroke within 5 years. Subsequent strokes impair function further.
During the first few days after an ischemic stroke, doctors usually cannot predict whether a person will improve or worsen. Younger people and people who start improving quickly are likely to recover more fully. About 50% of people with one-sided paralysis and most of those with less severe symptoms recover some function by the time they leave the hospital, and they can eventually take care of their basic needs. They can think clearly and walk adequately, although use of the affected arm or leg may be limited. Use of an arm is more often limited than use of a leg. Most impairments still present after 12 months are permanent.
Treatment
People who have any symptom suggesting an ischemic stroke should go to an emergency department immediately. The earlier the treatment, the better are the chances for recovery.
The first priority is to restore the person's breathing, heart rate, blood pressure (if low), and temperature to normal. An intravenous line is inserted to provide drugs and fluids when needed. If the person has a fever, it may be lowered using acetaminophen Some Trade Names
TYLENOL
, ibuprofen Some Trade Names
ADVILMOTRIN
, or a cooling blanket. An increase in body temperature by even a few degrees can dramatically worsen brain damage due to an ischemic stroke. Generally, doctors do not immediately treat high blood pressure unless it is very high (over 220/120 mm Hg) because, when arteries are narrowed, blood pressure must be higher than normal to push enough blood through them to the brain. However, very high blood pressure can injure the heart, kidneys, and eyes and must be lowered.
If a stroke is very severe, drugs such as mannitol may be given to reduce swelling and the increased pressure in the brain. Some people need a ventilator to breathe adequately.
Specific treatment of stroke may include drugs to break up blood clots (thrombolytic drugs), drugs to make blood less likely to clot (antiplatelet drugs and anticoagulants), and surgery, followed by rehabilitation.
Thrombolytic (Fibrinolytic) Drugs: In certain circumstances, a drug called tissue plasminogen activator (tPA) is given intravenously to break up clots and help restore blood flow to the brain. Because tPA can cause bleeding in the brain and elsewhere, it should not be given to people with certain conditions, such as the following:
*
A past occurrence of a hemorrhagic stroke, a bulge (aneurysm) in an artery to the brain, other structural abnormalities in the brain, or a brain tumor
*
A seizure when the stroke began
*
A tendency to bleed
*
Recent major surgery
*
Recent bleeding (hemorrhage) in the gastrointestinal or urinary tract
*
A recent head injury or other serious trauma
*
A very high or very low blood sugar level
*
A heart infection
*
Current use of an anticoagulant ( warfarin Some Trade Names
COUMADIN
)
*
A large ischemic stroke
*
Blood pressure that remains high after treatment with an antihypertensive drug
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Symptoms that are resolving quickly
Before tPA is given, CT is done to rule out bleeding in the brain. To be effective and safe, tPA, given intravenously, must be started within 3 hours of the beginning of an ischemic stroke. After 3 hours, most of the damage to the brain cannot be reversed, and the risk of bleeding outweighs the possible benefit of the drug. However, pinpointing when the stroke began may be difficult. So doctors assume that the stroke began the last time a person was known to be well. For example, if a person awakens with symptoms of a stroke, doctors assume the stroke began when the person was last seen awake and well. Thus, tPA can be used in only a few people who have had a stroke.
If people arrive at the hospital 3 to 6 hours (occasionally, up to 18 hours) after the stroke began, they may be given tPA or another thrombolytic drug. But the drug must be given through a catheter instead. For this treatment, doctors make an incision in the skin, usually in the groin, and insert a catheter into an artery. The catheter is then threaded through the aorta and other arteries, to the clot. The clot is partly broken up with the catheter wire and then injected with tPA. This treatment is usually available only at specialized stroke centers.
Antiplatelet Drugs and Anticoagulants: If a thrombolytic drug cannot be used, most people are given aspirin Some Trade Names
BAYER
(an antiplatelet drug) as soon as they get to the hospital. If symptoms seem to be worsening, anticoagulants such as heparin are occasionally used, but their effectiveness has not been proved. Antiplatelet drugs make platelets less likely to clump and form clots. Anticoagulants inhibit proteins in blood that help it to clot (clotting factors).
Regardless of the initial treatment, long-term treatment usually consists of aspirin Some Trade Names
BAYER
or another antiplatelet drug to reduce the risk of blood clots and thus of subsequent strokes (see Stroke (CVA): Prevention). People who have atrial fibrillation or a heart valve disorder are given anticoagulants (such as warfarin Some Trade Names
COUMADIN
) instead of antiplatelet drugs, which do not seem to prevent blood clots from forming in the heart. Occasionally, people at high risk of another stroke are given both aspirin Some Trade Names
BAYER
and warfarin Some Trade Names
COUMADIN
.
If people have been given a thrombolytic drug, doctors usually wait at least 24 hours before antiplatelet drugs or anticoagulants are started because these drugs add to the already increased risk of bleeding in the brain. Anticoagulants are not given to people who have uncontrolled high blood pressure or who have had a hemorrhagic stroke.
Surgery: Once an ischemic stroke is completed, surgical removal of atheromas or clots (endarterectomy) in an internal carotid artery may be done. Carotid endarterectomy can help if all of the following are present:
*
The stroke resulted from narrowing of a carotid artery by more than 70%.
*
Some brain tissue supplied by the affected artery still functions after the stroke.
*
The person's life expectancy is at least 5 years.
In such people, carotid endarterectomy may reduce the risk of subsequent strokes. It also reestablishes the blood supply to the affected area, but it cannot restore lost function because some brain tissue is dead.
For carotid endarterectomy, a general anesthetic or a local anesthetic (to numb the neck area) may be used. If people remain awake during the operation, the surgeon can better evaluate how the brain is functioning. The surgeon makes an incision in the neck over the area of the artery that contains the blockage and an incision in the artery. The blockage is removed, and the incisions are closed. For a few days afterwards, the neck may hurt, and swallowing may be difficult. Most people can stay in the hospital 1 or 2 days. Heavy lifting should be avoided for about 3 weeks. After several weeks, people can resume their usual activities.
Carotid endarterectomy can trigger a stroke because the operation may dislodge clots or other material that can then travel through the bloodstream and block an artery. However, after the operation, the risk of stroke is lower for several years than it is when drugs are used.
In other narrowed arteries, such as the vertebral arteries, endarterectomy may not be possible because the operation is riskier to perform in these arteries than in the internal carotid arteries.
People should find a surgeon who is experienced doing this operation and who has a low rate of serious complications (such as heart attack, stroke, and death) after the operation. If people cannot find such a surgeon, the risks of endarterectomy outweigh its expected benefits.
Stents: If endarterectomy is too risky, a less invasive procedure can be done: A wire mesh tube (stent) with an umbrella filter may be placed in the carotid artery. The stent helps keep the artery open, and the filter catches blood clots and prevents them from reaching the brain and causing a stroke. The filter is similar to one used to prevent pulmonary embolism (see Venous Disorders: Umbrellas: One Way to Prevent Pulmonary EmbolismFigures). After a local anesthetic is given, a catheter is inserted through a small incision into a large artery near the groin or in the arm and is threaded to the internal carotid artery in the neck. A dye that can be seen on x-rays (radiopaque dye) is injected, and x-rays are taken so that the narrowed area can be located. After the stent and filter are placed, the catheter is removed. People remain awake for the procedure, which usually takes 1 to 2 hours. The procedure appears to be as safe as endarterectomy and is almost as effective in preventing strokes and death.
Other Treatments: Another option being studied is a tiny corkscrew-shaped device that is attached to a catheter, threaded to the clot, and used to snag the clot. The clot is then drawn out through the catheter. This treatment may be useful for people who cannot be given tPA.
Treatment of Problems Due to Strokes: Measures to prevent aspiration pneumonia (see Pneumonia: Aspiration Pneumonia) and pressure sores (see Pressure Sores: Prevention) are started early. Heparin, injected under the skin, may be given to help prevent deep vein thrombosis (see Venous Disorders: Deep Vein Thrombosis (DVT)). People are closely monitored to determine whether the esophagus, bladder, and intestines are functioning. Often, other disorders such as heart failure, abnormal heart rhythms, and lung infections must be treated. High blood pressure is often treated after the stroke has been stabilized.
Because a stroke often causes mood changes, especially depression, family members or friends should inform the doctor if the person seems depressed. Depression can be treated with drug therapy and psychotherapy (see Mood Disorders: Prognosis and Treatment).
Last full review/revision November 2007 by Elias A. Giraldo, MD
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