CEREBROVASCULA

R DISEASE (CVD)

APRIL ARRA DAMGO

ALEX MAGNO JR.

BSN3C
Re fe rs to an y fu n c ti o n al
ab n o rmal i ty o f th e C NS c au s e d
by i n terfere n c e w i th th e n o rmal
bl o o d s u ppl y to th e b rai n .
I t e n compas s e s c o n d i ti o n s th at
i mp ai r th e fl o w o f b l o o d to th e
brai n , wh i c h c an l e ad to a
vari ety of p ro b l e ms , i n c l u d i n g
s tro kes , tran s i e n t i s c h e mi c
attacks (TI As ), an d o th e r re l ate d
i s s u es .
C VD res u l ts b l o o d v e s s e l s to
loose e l as ti c i ty , b e c o me
h ard en ed, an d develop
ath e romatou s d e p o s i ts or
pl aq u es , which may b e th e
s o u rc e of an e mb o l u s .
CEREBROVASCULA
R ACCIDENT (CVA)
ALSO KNOWN AS
“STROKE”

I t i s a s u d d e n l o s s o f b rai n
fu n c ti on re s u l ti n g f ro m a
di s ru pti on o f b l o o d s u p p l y to a
part of th e b rai n , l e ad i n g to a
l o s s of brai n f u n c ti o n
Th e con di ti o n c an re s u l t i n e i th e r
i s c h emi a du e to a b l o c kag e o f
bl o o d fl ow re s u l ti n g to i s c h em i c
str o ke or h e mo rrh ag e d u e to
bl e e di n g re s u l ti n g to
hem orrhag i c s tr o ke .
SCHEMIC STROKE

C o mmon l y re f e rre d to as “b rai n

attack”, i s a s u d d e n l o s s o f
fu n c ti on re s u l ti n g f ro m
di s ru pti on o f b l o o d s u p p l y to a
part of th e b rai n .
SCHEMIC STROKE

Th e term b rai n attac k h as b e e n

u s e d to s u g g e s t to h e al th c are
prac ti ti on ers an d th e p u b l i c th at
a s troke i s an u r g en t h e al th
care i s s u e s i mi l ar to a h e art
attack .
SCHEMIC STROKE

Th e re are 2 ty p e s :
1.T h rombo ti c S tro ke
2.E mbol i s m/ E mb o l i c S tro ke
SCHEMIC STROKE -
THROMBOTIC
A c lot is formed in a blood
ves sel supplying the brain
w i th blood fl ow.
SCHEMIC STROKE -
EMBOLISM/EMBOLIC
T here’s a traveling blood
c l o t that comes from the
other part of the body and
l ands in the brain.
HEMORRHAGIC STROKE

I t o c cu rs wh en a bl o o d v ess el i n th e
b r a i n r uptu res , l eadi n g to bl eedi n g
wi t h i n th e brai n or s u rro u n di n g
t i s s u es . Th i s cau s es i n creas ed
i n t r a cran i al press u re an d can f u rth er
d a m age brai n cel l s .
HEMORRHAGIC STROKE

I t i s cau sed ch i efl y by u n co n tro l l ed

h y p erten s i o n an d o th er co n di ti o n s
s u ch as an eu ry sm s, o r arteri o v eno u s
m a l f o rm ati o n s.
Th e s everi ty o f a s tro ke d e p e n d s
on th e l ocati o n an d ex te n t o f th e
brai n ti s s u e aff e c te d , w i th
po s s i bl e ou tc o me s ran g i n g f ro m
fu l l rec ove ry to p e rman e n t
n e u rol ogi cal i mp ai rme n t.
ANATOMY
AND
PHYSIOLOGY
LOBES
OF
THE
BRAIN
 BLOOD SUPPLY TO THE BRAIN

T h e brai n i s s u ppl i ed mai n l y by 2

a r t er i es : INTE R NAL CAR OTID ARTERY
a n d VERTE B R OB ASIL AR ARTERY.
BLOOD-BRAIN
BARRIER
(BBB)
PATHOPHYSIOLOGY
 PREDISPOSING FACTORS

- UNCONTROLLED HYPERTENSION
- CARDIAC ARRHYTMIAS
- OBESITY
- FREQUENT CONSUMPTION OF FATTY FOODS
- SMOKING
- DRUG/ALCOHOL ABUSE
- ADVANCED AGE

CEREBRAL CIRCULATION
BECOMES IMPAIRED

BLOOD CLOT IN
THE BLOOD VESSEL TEAR IN THE VESSEL WALL
(THROMBOSIS AND EMBOLISM)

BLOCKAGE IN ARTERY RUPTURE OF BLOOD VESSEL

 OXYGEN AND BLOOD ACCUMULATING AROUND
NUTRIENT SUPPLY THE BRAIN (BLEEDING)

CELL INJURY
INTRACRANIAL PRESSURE (ICP)
(ISCHEMIA)

NEURONAL DEATH IN COMPRESSION OF BRAIN TISSUE &

AFFECTED AREA BLOOD FLOW

CELLULAR INJURY FROM ICP

INFLAMMATORY RESPONSE LEADS TO INFLAMMATION
AND EDEMA
-HEMIPARESIS -HEMIPLEGIA
- APHASIA - HEADACHE
- VISION LOSS - N/V
- COGNITIVE - ALTERED
IMPAIRMENT NEUROLOGICAL DEFICITS NEUROLOGICAL DEFICITS CONSCIOUSNESS
ISCHEMIC STROKE HEMORRHAGIC STROKE

DISRUPTION OF BLOOD SUPPLY

IN THE BRAIN
 SIGNS &
SYMPTOM
S
 SIGNS AND SYPTOMS

• Hemiparesis / Hemiplegia
• Aphas ia / Dys phasia
• S udden los s of vis ion / Double
vis ion
• At axia
• S evere headache
• Vertigo
S i g ns and symptoms depend
on what side of the brain
the stroke occured and how
much damage there i s.
 CONTRALATERAL CONTROL

Re f e rs to the co nc e p t t h a t e a c h sid e of the

b ra i n controls t h e op p o si t e ( contra la te ra l)
sid e of t he b od y. T hi s me a n s t h a t the rig ht
he mi s p he re of t h e b ra i n t y p i ca lly cont rols
mot or functions , s e ns a t i on , a nd othe r
fun ct i ons on th e l e ft si d e o f t h e b od y , a nd
v ice v e rsa .
 HISTORY &
PHYSICAL
EXAMINATION
 HISTORY OF PRESENT ILLNESS

T h e mo s t i mpo r tan t part o f th e h i sto ry

i s t o determi n e when th e s y mpto ms
b eg a n . The acro n y m FAST i s u sef u l to
a s s es s fo r s i gns o f s tro ke:

• Fa ce: As k i f th e pati en t ’s f ace i s

d ro o pi ng o r as y mm etri cal .
 HISTORY OF PRESENT ILLNESS

• A rm: As k i f th ere’s weakn es s o r

n u mbn ess i n o n e arm (i .e., i n abi l i ty
t o r ai s e bo th arms ).
• S p eech : A sk i f th e pati en t h as
s l u rred s peech or di ffi cu l ty
s p eaki n g.
• Ti me: E mph asi z e th e u rgen cy to
 SYMPTOMS

S p eci fi c s y mpto ms s u ch as s udden

n u m b n ess , weakn es s , di ffi cu l ty
s p ea k i n g, v i s i o n pro bl em s, bal an ce
i s s u es , or s ev ere h eadach e. Th e
p a t t ern an d n atu re o f s y mpto m s can
h el p determ i n e th e l i kel y ty pe o f stro ke
( i s c h emi c o r h em o rrh agi c).
 RISK FACTORS

Ask a b out risk f a c t ors fo r st ro ke , such a s:

• Hyp erten si on (th e m os t com m on ri s k f a ct or)

• Atri a l fi b ri l l ati on or oth e r ca rdi a c arrh y th m i a s
• Di ab e tes m el l i tu s
• Hyp erl i pi de m i a
• Sm oki n g
• Fa m i l y h i s tory of s troke or oth e r c a rd i ov a s c u l a r
e ve n ts
• Previ o us t ransi ent i schemic attacks (TIAs) o r st roke
 MEDICATIONS

As k about the us e of anticoagulants

( w a rfarin, direct oral anticoagulants
like dabigatran) or antiplatelet
med ications (aspirin, clopidogrel), as
t hes e can infl uence the type of s troke
( is c hemic vs . hemorrhagic) and
t rea t ment options .
 PAST MEDICAL HISTORY

• H i sto r y o f Vasc u l ar Di se ase

• H i sto r y o f H y pe r te n si o n
• Ne u ro l o gi c H i sto r y
 HISTORY OF VASCULAR DISEASE

• At heroscleros is (plaque buildup in

a rteries) can increas e the ris k of
is chemic s troke.
• His tory of heart diseas e, including
myocardia l infarction or atrial
fi brillation, which can lead to clot
formation and embolic stroke.
 HISTORY OF HYPERTENSION

• Uncontrolled high blood pres sure is

a major risk factor for both
is chemic and hemorrhagic s trokes .
It increases the ris k of both
c erebral ischemia (due to narrowing
of blood ves s els ) and intracerebral
hemorrhage (due to rupture of s mall
 NEUROLOGIC HISTORY

• Pa st hist ory of ne u ro l o g i c a l d e fi cit s or

s i g ns of p re v i ou s T I As ( o fte n ca lle d
" mini-stroke s " ) , w hi c h ma y ind ica te a
h i g he r risk of fu l l -b l ow n s t ro ke.
• H i s tory of c e re b ra l a ne urysms,
a rt e riov e nou s ma l fo rma t i on s ( AVM s), or
a ny p re vious b ra i n s urg e ri e s or stroke s.
 PHYSICAL EXAMINATION

T he p hysica l ex a mi n a t i o n o f a st roke
p a t i e nt is foc us e d on a sse ssing
ne urol og ica l f un ct i o n , le ve l of
co n sc i ousne ss, a n d p o t e n t i a l si gns of
incre a se d intra cra ni a l p re ss ure . It is
cru ci a l t o q uickl y d e t e rmi n e t h e se v e rity of
ne urol og ica l d e fi c i t s a nd i d e nt ify the
re g i on of the bra i n t h a t mi g h t b e a ff e cte d .
 LEVEL OF CONSCIOUSNESS

• A ssess the patient’s G la sgow C oma Sca le

(G CS) score to eva lu a te con sciou sn e ss le v e l.
A redu ced G CS ca n indica te sign ifi ca n t b ra i n
in ju ry or increa sed intra cra nial p re ssu re .

• Look for signs of disorien ta tion , con fu sion ,

or letha rgy, w hich ma y indica te gl oba l
cerebra l dysfun ction.
 NEUROLOGICAL EXAMINATION

Th e n e u ro l o gi c al ex am asse sse s
mo to r fu n c ti o n , se n so r y pe rc e pti o n ,
c o o rdi n ati o n , re fl exe s, an d c r an i al
n e r v e fu n c tio n .
CRANIAL NERVE
FUNCTION

• A ssess for fa cia l a symmetry (d roopin g of

on e side of the fa ce), w hich ca n in di ca t e
in volvemen t of th e fa cia l nerv e (C ra n ia l
N erve V I I ).

• Pu pilla ry response: Ch eck for pu pi l di la tion

or a symmetry, w hich cou ld in d ica te bra in
h ern iation or a h emorrh a gic stroke .
CRANIAL NERVE
FUNCTION

• Vi sual fi el ds and a c u i ty:

H emiano pi a (l o s s o f vi s i o n i n h al f
o f the vi su a l fi el d) c o u l d su gges t a
s tro ke i nvo l vi n g th e o pti c trac t o r
o c cipital lo be.
MOTOR FUNCTION

• Ch e ck for h emipa resis (w eakn e ss on on e

side of th e body) or hemiplegia (pa ra l y sis of
on e side). This ma y suggest da ma ge to th e
motor cortex or descendin g mot or pa th w a y s
(e.g., corticospin a l tra ct).

• Strength testing: A sk th e pa tie n t to ra ise

both arms or legs a n d assess if th e re ’s
w eakness on on e side.
SENSORY FUNCTION

• Ask t he p a t i e n t t o cl o se t he ir e y e s a nd
re p ort se nsa t i o ns s uc h a s l i g ht touch or
p i nprick in t h e a rms , l e g s , a nd fa ce .
S e nsory d e fi c i t s on on e s i d e of t he b ody
s ug g e st a le si o n i n t h e p a ri e ta l lob e or
o t he r se nso ry p a t h w a y s.
COORDINATION
AND GAIT

• Test coordin ation by ha vin g th e p a tie n t

touch their n ose w ith th eir fi ng e r (on e side
a t a time). La ck of coordina tion , or a ta x i a ,
ma y suggest cerebella r involveme n t.
• Test gait if the pa tient is ab le to w a lk.
Diffi culty in w alkin g or ma in ta in in g ba la n c e
could indica te a stroke in v olv in g th e
cerebellum or bra instem.
 REFLEXES

• Hyperactive refl exes may s ugges t

up per motor neuron damage (e.g., a
les ion in the brain or s pinal cord),
w hereas diminis hed or abs ent
refl exes may s ugges t lower motor
neuron involvement.
 SPEECH AND
LANGUAGE
• A ssess apha sia (diffi cu lty speakin g or
u ndersta ndin g la n gu age), w hich ca n occu r in
strokes a ff ecting th e left hemisphe re of th e
bra in , pa rticu la rly in th e Broca ’s a re a (motor
speech) or Wern icke’s area (la ngua g e
compreh ension ).

• A sk th e pa tien t to repeat simple w ord s or

sen ten ces to a ssess speech fl u en cy a n d
SPEECH AND
LANGUAGE

• Dysarthria (sl u rred sp eech) may

o ccur in p a ti en ts with b rainstem
stro kes o r i n th o se who have
weakness of th e muscles
resp o nsib l e fo r sp eech .
 SIGNS OF INCREASED
INTRACRANIAL PRESSURE (ICP)

• H e a d a che , na u se a , v omiting , a nd
a l t e re d me n t a l s t a t u s c a n b e signs of
e l e v a t e d ICP, e sp e c i a l l y i n he morrha gic
s t roke .

• Cu shing ’ s t ri a d : Wi d e ne d p ulse
p re ssure , b ra d y c a rd i a , a n d irre g ula r
re sp ira tions —i n d i ca t i v e o f a la t e sig n of
DIAGNOSTICS &
LABORATORIES
 IMAGING STUDIES FOR
CONFIRMING STROKE
DIAGNOSIS

Imaging s tu di es are cri ti cal to

d et ermi n e wh eth er th e pati en t h as h ad
a s t ro ke, as wel l as th e ty pe o f s tro ke
( i s c h emi c vs. h emo rrh a gi c), i ts
l o c a t i o n , an d i ts s ev eri ty.
 IMAGING STUDIES FOR
CONFIRMING STROKE
DIAGNOSIS

The two most co m mo n i m agi n g

t ec h n i qu es u sed are:

a . CT Scan (Co mpu ted To mo graph y )

b . M R I (M agn eti c Res o n an ce Imagi n g)
CT SCAN AKA ‘CAT SCAN’

• First-line imagin g in emergen cy se tt in g s.

• CT w ithout contra st is typica lly don e in iti a l ly
becau se it ca n quickly detect h e morrh a g ic
stroke (bleedin g in the bra in ).
• I n the case of isch emic stroke, t h e ch a n ge s
ma y n ot be visible in the fi rst few h ou rs, a n d
ea rly isch emic cha n ges (such a s tissu e
swelling or soften ing) might n ot a p pe a r
immedia tely.
CT SCAN
MACHINE
 MRI

• M R I i s mo re s en sitive for d etec ti n g is c h emic

s trokes , es p eci a lly in th e ea r ly sta ges (w i th in
h ou r s o f o n s et).
• Di ff u s i o n -w ei g h ted ima g in g (DW I) in M R I c a n
d etec t a rea s of a c u te is ch emia (res tr ic ted blood
fl ow ) ver y ea r ly, even before s ymptoms a re fu ll y
a p pa ren t.
• M R I i s a l s o exc ellen t for d etec ti n g b r a in tis s u e
d a ma g e a n d i d en tifyin g th e sp ec ifi c loca tion of
th e s tro ke (c or tex, b r a in stem, c erebel lu m, etc . ).
MRI MACHINE
O t h er u s ed di agn o s ti cs are:

• Ca ro ti d U l tras o u nd
• E l ec troc a rd iog ra m (E C G )
• E c h oca rd iog ra m
 LABORATORY TESTS

I n a d di ti o n to i magi n g, l abo rato ry tes ts

may be co ndu cted to i den ti fy
u n d er l y i n g cau s es or co n tri bu ti n g
f a c t o r s , s uch as :

• B l o o d gl u co se l ev el s
• Li p id p rofi le
• C om p lete b lood c ou n t (C BC )
 MEDICAL
MANAGEMENT
T h e go al o f treatmen t i n ISCHE M IC
S T R O K E i s to res to re bl o o d fl o w to th e
a ff ec ted area as qu i ckl y as po ss i bl e to
p rev en t f ur ther damage.
 1.T h ro mbo l y si s
( Ti s s u e P l as mi n o gen Acti v ato r - tPA)

• tPA is a c lot-busting drug that can dissolve the

clot and restore blood fl ow if administered
within a 3-4. 5 hour window from the onset of
symptoms (the earlier, the better).

• I t is gi ven i ntravenously, but it’s only

eff ecti ve for i sc hemic strokes (not
hemorrhagi c strokes).
• tPA can reduc e disability but also carries a
risk of bl eedi ng (hemorrhage), so careful
screening is necessary.

• Altepl ase (Ac tivase) is the DOC for ischemic

stroke.
2 . M ec h an i cal Th ro m becto my

• For large vessel oc clusions (e.g. , in the

middle c erebral artery), mec hani cal
thrombec tomy may be performed to
physic ally remove the clot.
3 . A n t i pl atel et Therapy

• After th e a c u te phase, patients with ischemic stroke

are ty pi c a l l y sta rted on antiplatelet drugs (aspirin or
clopidogrel ) to reduce the risk of another stroke.
4 . A n t i co agu l ati o n

• For strokes c aused by cardioembolic sources

(e.g., atri al fi brillation), antic oagulants (e.g.,
warfari n, direc t oral antic oagulants [DOACs])
may b e presc ribed to prevent future clots from
formi ng.
Fo r HE M OR R H AG IC STR OK E, wh ere
b l eed i n g o ccu rs wi th i n th e brai n o r
a ro u n d i t, tPA i s n o t u s ed. Th e
t rea t men t f o cu s is on co n tro l l i ng
b l eed i n g and redu ci n g i n tracran i al
p res s u re (ICP ).
1.A n t i h y perten s i v es

• Labetal ol or Nicardipine are often used to

lower bl ood pressure in patients with
hemorrhagi c stroke, as elevated blood
pressure c an worsen bleeding and increase
I CP.
2 . Rev ers al o f An ti co agul an ts (i f
a pp l i c a bl e)

• I f the patient i s on anticoagulants (e.g. ,

warfari n or d irect oral anticoagul ants like
rivaroxaban), reversal agents are used:

• Vitami n K and Fresh Frozen Plasma (FFP) for

warfari n.
• I daruc iz umab (Praxbind) for dabigatran.
3 . S u rg i cal In terv en ti o n

• For large or li fe-threatening bleeds (e.g. ,

intrac erebral hemorrhage or subdural
hematoma), surgic al evacuation of the blood
c lot may be necessary to relieve pressure on
the brain and prevent further damage.

• Craniotomy (removal of part of the skull) may

be req ui red to remove the hematoma.
4 . Co n t ro l o f H y perten si o n

• Blood p ressure is carefully c ontrolled in the

acute phase, often aiming to keep systolic
blood pressure below 160 mmHg to reduce the
risk of further bleeding.
POST STROKE
MANAGEMENT
Aft er the ac ut e ph a s e o f a s t ro ke, i t ’ s
c ru c i a l to fo c u s o n preven t i n g a s ec o n d
stro ke. Thi s i n v o l ves m a n a gi n g r i s k
fac t o r s and a ddres s i n g th e u n der l y i n g
c au s es o f the s t ro ke.
a. Lifestyle Modifi cations

• Diet a nd Exercise: Encouraging a hea rt -

healt hy diet (low in salt, sugar, and fa t) a nd
regula r physical activity.
• Smoking Cessation: Smoking is a ma jor
stroke risk fa ctor, so cessation is key.
• Limiting Alcohol: Excessive alcohol int ake is
associa ted wit h increased stroke risk, so
modera te drinking or abstaining is advised.
b. Medica l Ma na gement

• Blood Pressure Control: Antihypertensive

medica tions (e.g., ACE inhibitors, di uretics,
beta -blockers) are used to mainta in blood
pressure within a target range.
• Cholesterol Management: Statins may be
prescribed t o reduce cholesterol and prevent
atherosclerosis.
b. Medica l Ma na gement

• Antipla telet or Anticoagulant Thera py:

• Aspirin or clopidogrel for patients a t risk of
ischemi c stroke.
• Anticoa gulants (e.g., warfarin, DOACs) for
pa tient s with atrial fi brillation or other
ca rdioembolic stroke causes.
REHABILITATION
AFTER STROKE
TYPES:

• Physi ca l Therapy (PT):

Focuses on i mproving strength, coordina tion,
a nd mot or skills, particularly for pat ient s
with hemiparesis or hemiplegia.

• Occupa tiona l Therapy (OT):

H elps pat ient s regain skills needed for dai ly
living, such as dressing, eating, a nd writing.
TYPES:

• Speech and Language Therapy:

Assist s with improving communica tion skills
for pat ients with aphasia or speech
diffi culties.

• Neuropsychological Therapy:
H elps pat ient s with cognitive impa irments
(e. g. , memory, attention, problem-solving)
a fter stroke.
 NURSING
INTERVENTIONS
a. Airwa y a nd Breathing Management

• Ensure a irwa y and breathing, ma nage vita l

signs, perform frequent neurologica l
assessments, and administer medicat ions a s
ordered (e. g. , tPA, antihypertensives).
b. Prevent Complications

• Prevent aspiration : E n su re th at th e patien t does n ot

eat or drink until a swallowin g assessmen t by a
speech therapist is per formed. If dysph agia is
present, provide th icken ed liqu ids or en teral feedin g
via NG or PEG tube if n eeded.

• Prevent deep vein th rombosis ( DVT ) : Apply

compression stock in gs or sequ en tial compression
devices (SCDs), en cou rage ear ly mobiliz ation if th e
patient is stable, an d admin ister an ticoagu lan ts as
prescribed.
c . Fa c i l i tate Reh a bi l i t a t i o n

• Encourage mobility, perform range- of-

moti on exercises, support speech and
cog nitive therapy, and assist with
activities of daily living (ADLs).
d. Prev ent Rec u rren c e

• Ed ucate patients and families on risk

factor modifi cation, medication
ad herence, and lifestyle changes to
prevent future strokes.
e. Provide Emot ional and Psychological Support

• Ad dress mental health needs, encourage

parti cipation in support groups, and
provide family education.
 THANK YOU!
MATUTULOG
NA PO KAMI <3