5 Major Stroke SyndromesRecognition, Action & Outcomes

Louise Jenkins RN, CEN, TNS, MBA

Southwest Washington Medical Center

Vancouver, Washington

Time is Brain . . .

Learning Objectives

1. Identify the five major stroke syndromes

2. Describe symptomology associated with each

3. Be familiar with assessment to identify them

4. Be familiar with rapid response to stroke

5. Identify major stroke prognostic indicators

Two stroke typesFocal Brain Dysfunction

Diffuse Brain Dysfunction

Middle Cerebral (MCA)

Anterior Cerebral (ACA) Anterior

Communicating (ACOM)

Basilar Artery

Vertebral Artery

Internal Carotid (ICA)

Posterior Cerebral (PCA)

Brain Anatomy Basics

Brainstem• Funnel/connector between cerebrum & spinal cord• Nerves to face/head• Primitive centers

Cerebellum• Coordination center

Cerebral Cortex• Gray matter•“Computer center” Left → language Right → attention

Cerebral Sub cortex• Deep white matter, “wires”• Grey matter, “balls” - motor modifier - sensory relay

5 Major Stroke Syndromes

1. Left Hemisphere

2. Right Hemisphere

3. Brainstem

4.Cerebellum5. Hemorrhage

Right visual field deficit

Aphasia

Receptive &/or

Expressive•Right

Hemiparesis

•Right

Hemisensory

Loss

Left gaze

Deviation

(preference)

Typical signs

•Right side affected

•Aphasia

• Left Gaze deviation

Left (Dominant) Hemisphere

Left (Dominant) Hemisphere Stroke: Common Pattern

•Aphasia •Right hemiparesis •Right-sided sensory loss •Right visual field defect •Poor right conjugate gaze •Dysarthria •Difficulty reading, writing, or calculating

Right gaze

Deviation

(Preference)

Left visual field deficit

Left Hemiparesis

Left Hemi-sensoryLoss

Right (Non-dominant) Hemisphere

Right (Non-dominant) Hemisphere Stroke: Common Pattern 

•Neglect of left visual field •Extinction of left-sided stimuli •Left hemiparesis •Left-sided sensory loss •Left visual field defect •Poor left conjugate gaze •Dysarthria •Spatial disorientation

A “pearl” about gaze…

Typically:

A stroke patient will gaze toward the (brain) side of their stroke

A patient with seizures will gaze away from the (brain) side of their seizure.

Brainstem

Quadparesis

Sensory lossto all 4limbs

CrossedSigns:One side of

face & contralateral side of body

Hemiparesis

Hemisensory loss

-Nausea-Vomiting-Dysarthria-Dysphagia

Brainstem

•↓ Consciousness

•Nausea/vomiting

•Hiccups

•Abnormal respirations

Oropharyngeal weakness:- Dysarthria- dysphagia

VertigoTinnitus

Eye movement abnormalities:

-Diplopia

-Dysconjugate gaze

-Gaze deviation (palsy)

Cerebellum

Ipsilateral limb ataxia Truncal or

gait ataxia

(Imbalance with wide-based gait)

-N/V-Vertigo-Nystagmus

Stroke Syndromes by Anatomy: Cortical strokes Middle cerebral artery

contralateral hemiparesis and sensory loss, face and upper extremity more involved contralateral hemianopsia aphasia gaze abnormalities extinction on simultaneous touching, apraxia

Anterior cerebral artery contralateral hemiparesis and sensory loss, lower extremity more involved disconnection syndrome

Posterior cerebral artery contralateral hemianopsia locked In syndrome

For your reading enjoyment . . .

Hemorrhage & the Brain Coverings• Cranium: hard container

enclosing brain

• Meninges: 3 layered cloth-like covering of the brain and spinal cord

• Both ICH & SAH: Suddenly increase ICP

• SAH: irritates meninges

Hemorrhage S/S

Both ICH & SAH:• Headache• Nausea/vomiting• ↓ consciousness

ICH:• Focal sign, such as

Hemiparesis

SAH:• Intolerance to light• Neck stiffness/pain

Left DominantHemisphere

Right Non-dominant

Hemisphere

Brainstem Cerebellum ICH/SAH

Aphasia

Left gaze deviation

Right visual field deficit

Right Hemiparesis

Right sensory loss

Right gaze deviation

Left neglect

Left visual field deficit

Left Hemiparesis

Left sensory loss

Hemi or Quad paresis

Hemi or Quad sensory loss

Crossed signsright face/left bodyleft face/right bodyNausea / vomiting

DysarthriaDysphagia

Abnormal respirations

Decreased LOC

Truncal/gait ataxia

Limb ataxia

Nausea/vomiting

Headache

Neck stiffness/pain

Light intolerance

Nausea/vomiting

Decreased LOC

SUMMARY

Some Stroke MimicsThese can result in focal cerebral dysfunction

Condition Comments

Hypoglycemia Treat with D50

Seizure w/postictal state

Staring/limb shaking at onset? Todd's paralysis

Migraine Previous similar events?

Can cause focal event

Tumor Onset over weeks to months (possible bleed)

Abscess Onset over weeks to months

SDH Post-trauma?

Bells Palsy 7th CN effect

Conversion Reaction

Patient must be taken serious- when ruled in, causative factor should be investigated

Neuro AssessmentsGlasgow Coma Scale• Valuable for ↓ level of consciousness- NOT focal injury

• Is quantitative exam for diffuse injury

NIHSS• Reproductive, quantifies stroke deficits (0-42)

• Admission value predicts outcome

> 10 = likely d/c to rehab or NH

>15 = poor prognosis if no RX

> 20 = Increased change of post tPA ICH

• Useful for specialist clinicians at key intervals

• Impractical for all staff nurses as regular RN exam

• Does NOT NEED A PHYSICIAN ORDER!

FAST assessment

What does FAST take into account?(F) Motor/Function

Face droop/swallow safety thought(A) Motor/ coordination Arm drift(S) Mental status & understanding Speech, follow commands, (add

asking name month= LOC

(T) = Time of onset

Do not delay notification of patient change in function or neuro status

ACT response1. RN/RT respond2. FAST/NIHSS exam3. Non-contrast head CT stat4. Get Neurology involved

(ask them to)5. Possible transfer to critical

care for intervention.

Note: Remain with the ACT

responders– you know the patient’s “norm” and history-- they do not.

PCP: Notify per SBAR format

S: ..has a change in function of right hand.

B: right hand was working normal until 3:15

A: This sudden change cannot be explained, she has risk factors for stroke (cholesterol elevated, smokes), It is 3:25 now, 10 minutes since I noted this.

R: I would like to get a stat non-contrast head CT, when can

we expect to see you, and can we get a stat Neurology consult?

Neurology or

Emergency Physician have authority to assess

and determine tPA eligibility

IV tPA = GOLD STANDARD

3 hours from sympton onset

IA tPA

6 hours from sympton onset

MERCI Retriever or Penumbra

8-12 hours from symptom onset-

May be used post-op since little to no thrombolytic is used

Neuro Interventions

Available

A Word (or two) about NIHSS

• NIHSS is needed for all R/O stroke, stroke or tia patients.

• NIHSS is an assessment- You do NOT need a physician order to do it. It is considered excellent nursing care.

• Know your clinical specialists who will do accurate NIHSS for patients on all units.

5P’s of Stroke

• Parenchyma

• Pipes

• Perfusion

• Penumbra

• Preventing Complications

“Terms” & I do not mean college..

Lets figure this out…

Component Examination

LOC I am 7th4, it’s Dethember, you note he does not look toward the right when you speak to him from that side

Face Smile is equal, raises brow equally

Arms Inability to resist gravity with right arm & leg

Speech words are appropriate but slurred and hard to understand

Time Onset: noted it when he awoke 11 hours ago

Stroke Syndrome?

Patient is 74Month is December

Left (dominant) hemisphereOut of time window for acute intervention. Needs complicaiton prevention, secondary

stroke prevention & stroke educaiton

Another Component Examination

LOC I am 61, it’s April

Face smile equal bilaterally, brows raise equally

Arms no drift, does have trouble pinpointing her nose when she goes to scratch it.

Speech clear, does C/O a lot of nausea and room spinning vividly

Time noted after her shower 35 minutes ago

Stroke Syndrome?

Patient is 61 Month is April

CerebellumPhysician assessment warranted right away- may

be eligible for acute intervention

Why not another…Component Examination

LOC Bretaehfu ….. I ….Maxer

Face right face droop brows and smile, drools from right side mouth

Arms unable to hold left arm or leg up for test → it falls to the bed

Speech uses inappropriate words, difficult to understand them. Actively vomiting and is yawning frequently

Time Wife found him this way when she came to visit. You saw him last 2 hours ago when you came on duty

Stroke Syndrome?

Patient age 49

Month is January

BrainstemPhysician assessment warranted right away-

may be eligible for acute intervention

Come on… one morePatient is 55

Month is July

Component Examination

LOC I don’t know…. Ummmm…… 50 something…..

Face symmetrical grimace

Arms no drift, rubs neck and forehead

Speech Uses 1-2 word responses, appropriate, but slow, C/O frontal HA

Time She says it started after her PT session– about 30 minutes ago

Stroke Syndrome?

HemorrhagePhysician assessment warranted right away-

CT needed to identify if ICH or SAH

oops, I lied…another..Component Examination

LOC I’m 68, it is June 24th

Face smile and brows are symmetrical. You note that he does not move his right eye past midline when he watches you

Arms Left arm is flaccid, left leg has drift, he does not feel you touch his left arm when you apply the BP cuff.

Speech clear and appropriate

Time He has no idea, she took a nap and woke like this. She went to sleep at 1:30pm, it is 2:40 pm

Stroke Syndrome?

Right (nondominant) hemispherePhysician assessment warranted right away-

may be eligible for acute intervention

Patient is 68

Month is June

noun 

1. indication of course of disease:  an indicator used in making a

prognosis concerning a disease

2. prediction: a prediction as to how a

situation will develop

Prognostic indicators: Poor

•Dysphasia

•Homonymous hemianopsia

•Poor arm and leg power

•Apraxia

•Neglect

• Denial

• Spatial perception

problems

• Initial

unconsciousness

• Prior history of stroke

Increased Short-Term Mortality

• History of congestive heart failure

• Angina and myocardial infarction

• Delay in acute hospital admission

• Poor orientation

• Increased cranial nerve deficits

• Paralyzed conjugate gaze

• Increased WBC count

Increased Long-Term Mortality

• ST elevation and disorientation upon hospital discharge

• Poor motor persistence

• Half-hour recall

• Left versus right hemiplegia

• Diabetes mellitus

• Poor upper extremity motor recovery and control

• Prolonged onset to rehabilitation

Increased Mortality After a Stroke

• Acute congestive heart failure

• Glucose level greater than 140 mg/dL

• Nonlacunar versus lacunar stroke

o This study also noted a correlation of stroke recurrence with a

history of alcohol abuse, hypertension, and elevated blood

glucose levels in the first 48 hours after admission.

Better Outcomes associated with:

• Age younger than 65 years

• Smaller lesion on CT scanning

• Orientation at admission

• Functional improvement correlates with

lower NIHSS scores

• Specialized care i.e. Stroke Unit

His / Her Brainhttp://www.exn.ca/brain/

A subject of serious research by a number of scientists is understanding of how men's and women's brains work.

The body of research has taught us that men are generally better at spatial perception, while women excel at verbal fluency, as well, in many other categories there seems to be a better performer between the sexes.