Stroke (Cerebrovascular Accident)
Key Points
- “Time is brain” — brain cells die within minutes without oxygen; early recognition and intervention are critical
- 87% of strokes are ischemic (clot occlusion); 13% are hemorrhagic (vessel rupture)
- BEFAST: Balance, Eyes, Face, Arm, Speech, Time — standardized stroke recognition mnemonic
- tPA (alteplase): Only FDA-approved for ischemic stroke; must be given within 3 hours (up to 4.5 hours select patients)
- First diagnostic test: Non-contrast CT scan — rules out hemorrhage before tPA can be given
- TIA: “Mini-stroke” — same symptoms but resolves without permanent damage; 18% stroke risk within 90 days
Pathophysiology
A stroke (cerebrovascular accident, CVA) is a sudden interruption of blood flow to the brain causing irreversible neuronal death if not treated rapidly. Over 800,000 strokes occur annually in the US; nearly 75% occur in adults over age 65.
Ischemic Stroke (87%)
Mechanism: Occlusion of a cerebral artery → loss of perfusion → neuronal death.
| Type | Mechanism | Risk Factors |
|---|---|---|
| Thrombotic | Plaque (atherosclerosis) → thrombus forms in cerebral vessel | Hypertension, atherosclerosis |
| Embolic | Clot forms elsewhere (heart, carotid), travels to brain | Atrial fibrillation (most common cardiac source), valvular disease |
| Lacunar | Small vessel occlusion in penetrating arteries | Hypertension, diabetes, high cholesterol |
| Cryptogenic | Cause undetermined; higher incidence in African Americans and Hispanics | — |
TIA (Transient Ischemic Attack): Temporary occlusion with transient stroke-like symptoms and no persistent infarction evidence; episodes often resolve within minutes and commonly within about 1 hour. Considered a warning sign of imminent stroke: 90-day stroke risk after TIA is ~18%.
Typical presentation differences:
- Ischemic thrombotic: Symptoms may evolve gradually or fluctuate before stabilizing.
- Ischemic embolic: More abrupt onset with severe deficits often present early.
- Hemorrhagic: Abrupt presentation with headache and depressed consciousness risk.
Hemorrhagic Stroke (13%)
Mechanism: Rupture of a cerebral vessel → blood accumulates → increased intracranial pressure (ICP) → brain compression and ischemia.
| Type | Location | Common Cause |
|---|---|---|
| Intracerebral hemorrhage (ICH) | Within brain tissue | Hypertension (most common), anticoagulants |
| Subarachnoid hemorrhage (SAH) | Subarachnoid space (around brain) | Ruptured aneurysm, AVM rupture |
SAH hallmark: Sudden “worst headache of my life” — thunderclap onset, often with nausea, vomiting, photophobia, nuchal rigidity.
Clinical Manifestations
BEFAST Mnemonic (Stroke Recognition)
| Letter | Assessment | Signs |
|---|---|---|
| B — Balance | Sudden loss of balance or coordination | Ataxia, falls |
| E — Eyes | Sudden vision loss or change | Hemianopia, diplopia |
| F — Face | Facial asymmetry | Facial drooping on one side |
| A — Arm | Arm weakness or drift | Hemiparesis/hemiplegia |
| S — Speech | Slurred or confused speech | Dysarthria, aphasia |
| T — Time | Time to call 911 immediately | Document “last known well” time |
Additional Symptoms by Stroke Location
- Right hemisphere: Visual/spatial deficits, impulsivity, personality changes, left-sided deficits
- Left hemisphere: Speech and language deficits (aphasia), analytic thinking impairment, right-sided deficits
- Mimic caution: Peripheral facial palsy patterns (for example Bell palsy) may resemble stroke at presentation; sudden focal deficits should still be treated as stroke until urgent workup excludes cerebrovascular cause.
Complications of CVA
Hemiparesis/hemiplegia, dysphagia, aphasia, dysarthria, homonymous hemianopsia, bladder incontinence, seizures (first 24 hours), emotional lability, aspiration risk.
Assessment and Diagnostics
Neurological Assessment Tools:
- NIHSS (NIH Stroke Scale): Standardized severity rating; higher score = more dysfunction; used to guide treatment decisions
- Glasgow Coma Scale (GCS): Level of consciousness assessment
- “Last known well” time: Most critical question — determines tPA eligibility window
- NIHSS-linked highly predictive acute findings include facial droop, arm weakness/drift, and speech abnormality.
Rapid stroke-pathway activation should include immediate transport to an accredited stroke center or activation of in-hospital stroke-team protocol.
Diagnostic Tests:
| Test | Purpose |
|---|---|
| CT scan (non-contrast) | First-line — rules out hemorrhage before tPA administration |
| MRI | Brain lesions, extent of infarction |
| Carotid Doppler ultrasound | Assesses carotid artery occlusion |
| Cardiac echocardiogram | Evaluates for cardiac embolic source (A-fib) |
| Cerebral angiogram | Identifies blockage site for endovascular therapy |
| PT, INR, aPTT | Baseline coagulation before fibrinolytic/anticoagulant therapy |
Signs of Increased Intracranial Pressure (ICP)
Increased ICP — Priority Assessment
Hemorrhagic stroke patients are at highest risk for ICP elevation within the first 72 hours.
- Earliest sign: Decreased level of consciousness
- Restlessness, agitation, confusion
- Headache, nausea/vomiting
- Seizures (especially first 24 hours)
- Severe hypertension + bradycardia (Cushing’s triad)
- Late signs: Decerebrate (extension) or decorticate (flexion) posturing
Medical Management
Ischemic Stroke — tPA (Alteplase)
tPA Administration — Time-Critical
IV alteplase (tPA) must be administered within 3 hours of stroke onset (up to 4.5 hours in select patients).
Contraindications to tPA:
- Age over 80 years
- Current anticoagulant use
- History of both stroke and diabetes
- Recent surgery or head trauma
Post-tPA: Do NOT give aspirin or anticoagulants within 24 hours of tPA.
Ongoing therapy: Aspirin 24–48 hours after onset (if tPA not used or after 24-hour waiting period); anticoagulants for A-fib-related strokes.
Endovascular therapy: Mechanical thrombectomy for large vessel occlusion — extends treatment window.
Hemorrhagic Stroke Management
- Blood pressure control: Gradual reduction to 150/90 mmHg — beta-blockers, ACE inhibitors, calcium channel blockers, or hydralazine
- Surgical intervention: For cerebellar hemorrhage >3 cm, hydrocephalus, brain stem compression
- Aneurysm/AVM: Neurosurgical clipping or coiling to stop bleeding
- Vasospasm management context: Nimodipine may be used after subarachnoid hemorrhage in selected care pathways.
Nursing Interventions (Acute Phase)
Priority Assessments:
- Neurological checks: LOC, Glasgow Coma Scale, pupillary response, motor strength
- Airway patency, respiratory status
- Vital signs — frequent monitoring
- Cardiac rhythm monitoring (detect A-fib)
- Seizure monitoring (especially first 24 hours)
- Swallowing assessment — aspiration precautions
- Sodium and intake/output trending for potential SIADH-associated fluid/electrolyte shifts
Key Nursing Interventions:
- Maintain HOB elevation 30° to reduce ICP
- Aspiration precautions (dysphagia risk): NPO until swallowing assessment completed
- Skin integrity — frequent repositioning for immobile patients
- Fall prevention — hemiparesis/hemiplegia and confusion increase risk
- Communication support — provide alternative communication strategies for aphasia
- Follow DVT prophylaxis and constipation-prevention plans (including stool-softener protocols when ordered)
- Avoid lifting or pulling on a flaccid/affected arm; protect affected extremities from dependent edema and injury
- Apply visual-field compensation strategies (approach from intact side and cue scanning toward affected field)
- Assess homonymous-hemianopsia impact on eating, hygiene, and community mobility; reinforce active head-turn scanning and postpone driving until formal visual/cognitive clearance.
- If receiving alteplase/anticoagulants, implement strict bleeding precautions
ICP-Focused Stroke Care
- Keep neck midline and avoid sudden neck/hip flexion that can increase intrathoracic pressure and ICP.
- Avoid clustering high-stimulation activities; use low-stimulus pacing to reduce ICP spikes.
- Provide oxygenation support and hyperoxygenate around suctioning when indicated.
- Use sedatives cautiously because they can mask neurologic changes.
Rehabilitation Goals: Interdisciplinary team (PT, OT, speech therapy, case management):
- Improved mobility and self-care
- Dysphagia management and aspiration prevention
- Communication optimization (speech therapy for aphasia/dysarthria)
- Emotional support for lability, coping, and depression
Health Teaching and Secondary Prevention
- Reinforce recurrent-stroke prevention: smoking cessation, blood-pressure and glucose control, lipid reduction, physical activity, diet improvement, and adherence to prescribed medications.
- Include individualized risk-counseling context, noting sex- and population-level disparities (for example women and selected American Indian/Alaska Native communities) when planning prevention follow-up.
- Teach client/caregiver stroke-warning recognition (BEFAST) and immediate emergency activation for recurrent symptoms.
- If discharged on anticoagulants, teach bleeding-risk surveillance and urgent reporting triggers.
- Teach safe use of assistive devices to reduce fall risk during recovery.
Related Concepts
- neurological-system — Cerebrovascular anatomy
- common-neurological-disorders-recognition-and-priority-care — Neurological assessment frameworks
- anticoagulants — Prevention of embolic recurrence; contraindicated during acute phase
- antihypertensives — Hypertension management as primary risk factor
- hypertension-assessment-and-management — Hemorrhagic stroke prevention
- cardiovascular-system — Atrial fibrillation as embolic source
- fall-prevention — Post-stroke fall risk management
Self-Check
- A patient arrives at the ED with sudden right-sided arm weakness and speech difficulty, “last known well” 2 hours ago. CT scan is negative for hemorrhage. What medication may be administered, and what is the time-critical consideration?
- A patient with hemorrhagic stroke who was neurologically stable suddenly becomes lethargic with bradycardia and severe hypertension. What complication do these findings suggest, and what is the priority intervention?
- A nurse is assessing a post-stroke patient and notes they are coughing during mealtime. What complication is the patient at risk for, and what nursing action is most appropriate?