Cerebrovascular Accident (CVA) (FL INITIAL Autonomous Practice -Differential Diagnosis)

Judy was a 76-year-old female who, with her husband, lives in a small city in a basement apartment within her daughter and son-in-law’s house. Judy has a history of diabetes and hypertension. While her daughter was away on a trip, Judy's son-in-law noticed Judy had a little bit of facial drooping and slurred speech. Upon checking her blood pressure, her son-in-law discovered Judy's blood pressure to be around 180/100 mm hg and urged Judy to go to the emergency room as he was concerned. She was having a stroke; she refused. Upon return from her trip, Judy's daughter took her to see her doctor, who then determined that Judy had an ischemic stroke.

After being diagnosed with an ischemic stroke, Judy was placed on Plavix. Her doctor also wanted her to go to rehab, which she refused. A few months after starting on Plavix, Judy fell. After the fall, she had an abrupt mental status change. She was brought to the local hospital, where she was diagnosed with a hemorrhagic stroke and was emergently transported to a higher level of care hospital where she had undergone emergency surgery.

After several months in rehabilitation, Judy came home. Her daughter and son-in-law took care of her for nine months until her death. She continued to have seizures and did not want any more life-prolonging treatments. Judy died in her home surrounded by her family.

The patient used in this case study, Judy, was not a made-up patient for this course. She was my mother-in-law.

A cerebrovascular accident (CVA), or stroke, is where the brain tissue is deprived of adequate perfusion, whether by hemorrhage or ischemia. Regardless of the cause, the state of the hypoperfusion results in brain damage to the patient. At times, the damage is minimal, with the patient having zero to a minimal residual effect. At other times, the damage is much more severe, resulting in expressive or interpretive aphasia, hemiparalysis, chronic pain syndrome, emotional debility, and co-morbidities.

The statistics in the United States surrounding CVAs are sobering. According to the most recent American Heart/Stroke Association Guidelines and information from the Centers for Disease Control (CDC), there were approximately 795,000 occurrences of strokes (Virani et al., 2020). Of that number, 610,000 were reported as new stroke cases, and 185,000 were reported as recurrent strokes (Virani et al., 2020). Of those 795,000 strokes, 87% were classified as ischemic strokes (Virani et al., 2020). The healthcare cost of strokes in 2014-2015 was $46 billion, also considered for direct healthcare costs, medications, and missed workdays (Virani et al., 2020).

There are various signs and symptoms that the stroke patient will display. According to the American Stroke Association (2021), the signs and symptoms of a stroke can be broken down into various categories. The main signs and symptoms of a stroke are listed but not limited to Loss of balance, dizziness, vision changes including blurred vision, facial drooping, severe headache, weakness, numbness, aphasia, confusion, trouble with swallowing, memory changes, and involuntary eye movements. The ‘fastest’ way to tell if a person is experiencing a stroke is to utilize the FAST acronym (Amrican Stroke Association, 2021)

• Facial Drooping: The patient will exhibit facial drooping of the eyes and/or lips.
• Arm Weakness: Arm numbness and deficits in movement and motor function.
• Speech Difficulties: Affected speech to include slurred speech and possibly aphasia.
• Time: It is time for someone to call 911. When you notice these signs, it is time to call 911.

Although both kinds of strokes deprive the brain of perfusion, they are quite different and have their own treatment modalities (American Association of Neurological Surgeons [AANS], 2021).

Prehospital care for a stroke can be just as vital as inpatient hospital care. According to the American Heart/Stroke Association Position Statement on the Nursing Care of the Stroke Patient (2021), it is up to the emergency medical services (EMS) personnel to not only properly assess and triage the stroke victim but it is also up to them to ascertain the onset of symptoms and to find out when the patient's “last known normal” (LKN) was (Ashcraft et al., 2021). This helps to identify which if any, reperfusion therapy the patient may benefit from. After performing the needed assessment, the EMS personnel will decide on preliminary treatment and which hospital to transport the patient to and initiate the transport. This decision is crucial as not every hospital is set up to deal with an acute stroke.

Once in the emergency department (ED), the ED staff will initiate the workup of the stroke patient to include an EKG, CT scan, the assessment for thrombolytic treatment, and a stroke assessment (Ashcraft et al., 2021). The non-contrast CT scan needs to be done before any other intervention (Ashcraft et al., 2021).

The stroke assessment is very important in assessing the severity of the stroke symptoms in the patient. Per the 2019 updated guidelines by the American Heart Association, there are many models of stroke scales to use, such as the prehospital scales (Powers et al., 2019):

• The Cincinnati Prehospital Stroke Scale
• The Los Angeles Pre-Hospital Stroke Scale
• The Rapid Arterial Occlusion Scale

Other Scales that can be used are the acute assessment scales:

• The Glasgow Coma Scale
• The NIH Stroke Scale
• The Modified NIH Stroke Scale
• The Intracerebral Hemorrhage Scale

One of the most widely used stroke assessment scales is the National Institute of Health Stroke Scale or NIHSS for short. The scale is composed of eleven items. Each item is given a score of 0 to 3. The total score is used objectively by healthcare professionals to essentially quantify the impairment that results following a stroke (National Institutes of Health [NIH], 2003). The higher the score, the less impaired the patient is. The items include (NIH, 2003):

1. Level of consciousness:
   • This area is broken up into three parts of responsiveness, the ability to answer orientation questions, and the ability to perform simple commands.
2. Best gaze:
   • Best gaze assesses the patients' ability to keep their gaze on the provider.
3. Visual:
   • This part assesses the presence or absence of the sense of sight.
4. Facial Palsy:
   • Facial palsy looks for uneven facial expressions.
5. Limb Motor-Arm:
   • This assesses the motor strength of the arms.
6. Limb Motor-Leg:
   • This assesses the motor strength of the legs.
7. Limb Ataxia:
   • This part assesses limb coordination.
8. Sensory Perception:
   • This test assesses the ability of the patient to differentiate between the different sensations such as a pinprick or a light touch.
9. Best Language:
   • This assessment is used to assess deficits in speech and for expressive aphasia.
10. Dysarthria:
    • This assessment tests to see if the patient has slurred speech.
11. Extinction and Inattention:
    • Commonly referred to as spatial neglect. This assessment looks at whether the patient can acknowledge or differentiate the space on the opposite side of the brain affected by the stroke.

The NIHSS should only be performed by someone certified in its use and should be done rather quickly without any coaching of the patient (NIH, 2003).

Once the patient has been admitted to the hospital, depending on the severity of the stroke, the initial treatment used for the stroke, and any co-morbidities that might be present, different treatment modalities can be used.

As stated earlier, the first thing that needs to be done within the first few minutes is a non-contrast CT of the head to determine if the stroke is ischemic or hemorrhagic. After the CT has been interpreted, the decision to use thrombolytics can be made.

The use of thrombolytics is not without its risks. There are certain indications and contraindications to its use. According to Hughes et al. (2021), Alteplase is an indicated thrombolytic product. It is also typically used for clearing IV lines within three hours of symptom onset for myocardial infarction (MI) or between 3-4.5 hours of onset for deep vein thrombosis and ischemic stroke. However, the contraindications for the medication are far more numerous than the indications for administering it. There are both relative contraindications, which would make this treatment possibly inadvisable due to risk, and absolute contraindications, which make the treatment completely inadvisable due to risk.

Absolute contraindications include but are not excluded to (Hughes et al., 2021):

• Significant trauma to the head within the past three months
• Stroke within the past three months
• Subarachnoid hemorrhage symptoms
• An arterial puncture within the past seven days that cannot be compressed
• History of:
  • Intracranial surgery
  • Hemorrhage
  • Arteriovenous malformation (AVM)
  • Aneurysm
  • Interspinal surgery
• Active internal bleeding
• Acute bleeding issues:
  • Platelet counts that are less than 100,000/mm3
  • An elevated partial thromboplastin time (PTT) at the normal upper limits from receiving heparin within 48 hours
  • Currently using an anticoagulant medication that results in an international normalized ratio (INR) of greater than 1.7 or a prothrombin (PT) of greater than 15
• A blood glucose concentration of less than 50mg/dl
• A multilobe infarction as displayed on a CT scan where the affected area is greater than one-third of a cerebral hemisphere

Although the maximum time limit for using Alteplace is 4.5 hours, newer findings suggest that the time limit may be increased. According to Oliveira-Filho and Samuels (2021), meta-analysis results from the EPITHET, EXTEND, and ECASS4 study trials suggest that patients could be treated between 4.5 to 9 hours after onset. Although these findings are preliminary, with additional future studies, this is promising information for treating ischemic stroke.

Nursing care for the stroke patient includes different phases and, in those phases, there are different priorities.

The long-term problems relating to stroke and the debility that comes after are many and need to be considered. According to Chohan et al. (2019), the list of post-stroke problems includes but are not limited to:

There have been newer developments in the intervention phase of the stroke patient. As mentioned by Rubin et al. (2014), a transformation occurred with the use of common contrast with CT angiography. This newer technique allows for the visualization of larger arteries' occlusion and the area of irreversible injury to be seen as well (Rubin et al., 2014).

The next improvement for treatment has been the increase in time allowance for the use of thrombolytics. Although mentioned earlier in the text, this is worth mentioning as different approaches are being considered for the use of thrombolytics. The first mention of a 4.5-9-hour window has been mentioned by Oliveiro-Filho and Samuels (2021). But according to Rehani et al. (2019), this window may be extended up to 24 hours. The increased time window depends on the amount of collateral circulation observed by advanced imaging studies. Although still in its early stages, the clinical trial shows promise in helping to prevent increased debility from a stroke.

The use of neuroprotectants is also being studied to help reduce the severity and improve survival. In a preliminary animal study by Zhang et al. (2021), when the neuroprotectant named NA-1 was delivered to mice by nanoparticle delivery, it reduced both the severity and mortality of a stroke. This was an improvement because when the substance was introduced without the use of a nanoparticle, the results were not as good (Zhang et al., 2021). It appears that this nanoparticle acts as an antioxidant, delivering the peptide exactly where it needs to go in acting to reduce the size of the stroke, reduce cerebral edema, and improve mortality (Zhang et al., 2021). Although in its infancy, this type of intervention could potentially make a huge difference in acute stroke intervention.

One of the biggest advancements being used currently is mechanical thrombectomy on patients with large vessel acute ischemic stroke, which according to Guo and Miao (2021) accounts for 20% of acute ischemic strokes. The procedure, usually done in an interventional lab, can be carried out with moderate sedation and can be performed up to 24 hours from the time of symptom onset (Guo & Miao, 2021). The problem with the procedure, aside from the risks and benefits inherent in any procedure, lies in the availability of providers to perform it, per Tawil and Muir (2017). But, as mentioned by Neale (2020), it is not only the right thing to do in ensuring that all prospective patients in the United States have access to the procedure, but it is also proving to be more cost-effective with better outcomes for the patient and overall reduced cost of care over the life of the patient.

Cerebrovascular accidents or strokes in the United States and across the world continue to be one of the biggest adversaries for both the patient, health care system, and for caregivers. However, it does not have to be. When the population works together to identify those experiencing a stroke, early intervention can begin sooner. When the health care system can get to the patient sooner, morbidity and mortality has the potential to decrease. Finally, when interventions can be made within a timely period, negative outcomes can be avoided, chances of long-term disability can be decreased, and overall patient outcomes post-stroke can be improved.

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