 Hello and welcome to Nursing School Explained. Today I'll be discussing a stroke also called cerebrovascular accident and the differences in ischemic and hemorrhagic strokes. I've kind of laid this out like a concept map talking about pathophysiology, signs and symptoms, risk factors, labs and diagnostics as well as treatment options and nursing care. So first of all, there are two different types of strokes. First is ischemic which accounts for about 85% of the cases and second type of stroke is hemorrhagic. So an ischemic stroke stems from a blood clot. A blood clot can be due to a thrombus which is 60% of the cases or an embolus. Now keep in mind a thrombus is something that is stagnant or stationary somewhere. Think about DVT, deep vein thrombosis as usually in the deep veins of the legs. When embolus is a blood clot that has moved. So this would be a deep vein thrombosis that has now dislodged and it's come into the pulmonary vasculature and is now a pulmonary embolus. So thrombus is stagnant versus some embolus being on the run. So these are the risk factors. So this is what's happening in an ischemic stroke and mostly this is happening because of inflammation and narrowing of the arteries of the brain due to plaque buildup. And then plaque buildup is usually just like in coronary artery plaque buildup because of cholesterol deposits, arteriosclerosis and that whole inflammation cascade that takes place because of it. Eventually the blood vessel gets so narrowed that there is a clot that builds there or an embolus dislodges from somewhere else and then dislodges and basically clogs that blood vessel preventing blood flow to tissues, to brain tissue beyond where that clot is. Resulting in ischemia which is like a blood flow and then eventually infarction which means death of cells and it happens fairly quickly. Now the second type of stroke is a hemorrhagic stroke. So this means hemorrhage meaning bleeding. Most strokes are intracranial hemorrhages which basically means bleeding in the brain and they are basically is a blood vessel where the wall gets weakened and it just ruptures and this is mostly because of uncontrolled hypertension. That's also why we call hypertension the silent killer because a lot of times it doesn't hurt to have high blood pressure. The blood vessels are weakened because of this constantly high pressure on the inside of this vessel. Eventually the wall will give out and will have an intracranial hemorrhage resulting in a hemorrhagic stroke. Now second type is a subarachnoid hemorrhage and that basically just means it's in a different space inside the cranium inside the head. There's remember there is a dura mater and then there can be epidural subdural and then there's the arachnoid membrane that's kind of a protective membrane around the brain and this subarachnoid hemorrhage typically happens when a cerebral aneurysm ruptures. So this is a cerebral aneurysm is also is a weakened blood vessel wall so we have the blood vessel and for some reason this wall is weakened and there is some turbulent blood flow and eventually this will rupture and the blood will escape the space here causing the hemorrhagic stroke. Now subarachnoid hemorrhages can also be caused by trauma so by head injuries and cocaine abuse so drug screening or assessing for drug abuse will be very important in these patients. Now moving on to signs and symptoms and as you can see I've color coded ischemic bean blue hemorrhagic stroke bleeding bean red and then in green is basically the overlap. As you can see signs and symptoms here are pretty much all in green which means that the sign of symptoms might be the same for hemorrhagic and ischemic stroke and we'll have to later on figure out which one the patient is suffering from. Signs and symptoms include headache, nausea, vomiting, altered level of consciousness that can lead to seizures, increasing blood pressure and neurological deficits most likely unit lateral weakness. There's this nice acronym called BFAST that you've probably heard about before and it stands for balance so any kind of gait abnormality where the patient all of a sudden can balance well could be an indication that there might be a stroke. Eyes, eye abnormalities, double vision, blurry vision, loss of vision any of these symptoms could be signs of increased intracranial pressure or some other intracranial pathology that might be leading us to believe that the patient is having a stroke. F stands for facial droops so the one side of the face is droopy, arm drift so when you're assessing your patient you ask them to close your eyes and hold their arms out straight and one will start to drift without them even knowing it so that's a good indication that the patient might be suffering a stroke as well as speech abnormalities meaning either slurred speech or expressive aphasia meaning they're trying to say something but they don't really know how to communicate that or receptive aphasia. We're trying to explain something to the patient and it doesn't make any sense as to how they respond they're not really comprehending the information that we're giving them and then time. Time is a big one here because for a stroke typically any hospital the if there is a hemorrhagic stroke and we'll talk about the different treatment options for different types of strokes but if there is an ischemic stroke there are three hours there's a three hour window to get the patient the medication the need to dissolve that blood clot and three hours can be it can be really pushing it after three hours sometimes the damage that's done to the brain can be so severe that it can be irreversible so time is really off the essence here so as soon as you recognize that your patient might even just have a slight change in mental status or this eye complaint blurry vision double vision that's very sudden onset and you're not sure what's going on just always err on the side of caution and be aware of the patient might be suffering a stroke because time is off the essence time is brain safe so we need to make sure we we handle this very very quickly now here are some risk factors that can lead to stroke and again I've color coded them here so definitely hypertension all the things that lead to this arthrosclerosis all these bad things that contribute to the plaque buildup can put the patient's at risk for ischemic stroke so these include hypertension heart disease diabetes smoking obesity poor diet where hemorrhagic stroke basically also hypertension as we know uncontrolled hypertension is a number one risk factor for intracranial hemorrhage diabetes also as well as poor diet and then we already talked about drug abuse with the cocaine abusers over here specifically one other risk factor for ischemic stroke is atrial fibrillation atrial fibrillation is an arrhythmia where the atria the top chambers of the heart just kind of quiver and that quivering makes the blood in the atria swash around making it more prone to blood clots and then this blood clot from the right atrium can go through the heart all the way up to the brain causing a blood clot and then ischemic stroke so atrial fibrillation is a very common risk factor for ischemic stroke as well now when we are suspected the patient has any of these signs and symptoms and we're suspecting there might be a stroke we need to act very quickly as we already discussed the first test the patient is going to get is a stat CT head without contracts because we need to figure out signs and symptoms are pretty much the same over here but ischemic versus hemorrhagic strokes treatments will be very different so we need to figure out what kind of stroke the patient is having if any and then see what kind of treatment we can give the patient to make sure that the patient's brain tissue is saved along with a stat CT we're going to be doing a cbc looking at their blood counts their platelet counts as well as their cmp to determine the liver and kidney function in anticipation of making sure that the patient has normal kidney function because we're going to be needing to give them several kinds of medications as well as pti and r because we're dealing with blood clotting versus bleeding over here so we need to know what their coagulation time is one more important very very important test that we need to be doing here is a blood glucose reason being that hypoglycemia can lead to altered level of consciousness it can lead to headaches it can lead to even neural deficits so if the patient presents with neural with um neurological deficits or altered mental status one of the first things that we always should be doing is checking the blood glucose to see if the hypoglycemia might be the cause of the signs and symptoms the patient is exhibiting but keep in mind always have somebody there with you or just do it all at the same time check your blood glucose and call that code stroke because time is of the essence we can't wait you know five ten minutes might make a big difference in the patient's neurological outcome and then additional tests for ischemic stroke after that initial acute phase is over the patient will also get an echocardiogram taking a look at their heart the valves the chambers and also um the the contractability of it an EKG to check for arrhythmias specifically atrial fibrillation a carotid ultrasound checking for stenosis or obstruction or narrowing of the carotid arteries which again makes that plaque high risk for breaking off and then dislodging into the brain tissue leading to an ischemic stroke and certainly a little bit panel because we know poor diet obesity diabetes can lead to strokes and this will be the case for both hemorrhagic and ischemic stroke and then for hemorrhagic stroke in addition we will want to do a drug screen because there's that risk for that subarachnoid hemorrhage now once we've determined mostly by that stat CT of the head or one more thing I also wrote down here later MRI and MRA so that's a magnet resonance imaging or the same with an angiogram and that basically just MRI differs from a CT scan that it's a much more in-depth picture of what's going on with the brain but an MRI usually takes fairly long somewhere between maybe 30 and 45 minutes sometimes to an hour so we cannot wait to get that test done CT is done fairly quickly within a couple of minutes and we can see if the patient has a head bleed now an ischemic stroke will not show up on an initial CAT scan so an ischemic stroke is basically diagnosed by the absence of intracranial bleeding but later if the patient suffered an ischemic stroke by doing an MRI or MRA now we can determine the extent of the ischemia or infarction how many brain cells and in what area have they really been affected from that stroke by looking at an MRI or MRA in much more detail but again that will be done later once the initial stabilization phase has been accomplished now for treatment options so if the patient has a clot we need to somehow get rid of that clot number one treatment option are thrombolytics these are the clot busters so these are basically medications that we can give the patient to break up the clot that's causing the problem now there are absolute and relative contraindications to administering these thrombolytics because if the patient for example recently had surgery they had a hip replacement and they're just healing from that if we give this clot busting medication this is an IME medication the medication doesn't distinguish what blood clot is breaking up so if we give this patient thrombolytics they might start hemorrhaging from that surgical site because not all the clots that are here are being broken up by this medication so there you can look that up separately there are relative and absolute contraindications as to when to give these medications again it'll always be up to the discretion of the provider or the physician in collaboration with the neurologist discussing with the patient if they are able to make decisions or the family to determine the risk versus benefits of administering this medication now keep in mind if the patient has a significant stroke with severe neurological deficits they're completely altered they cannot move one side of their body they have facial droop they have dysphagia they are drooling they're completely the neurological status is completely different from their usual being by administering thrombolytics in the specified time frame of the three hours symptoms will resolve sometimes they won't improve over the course of one hour two hours and the patient can have significant improvements so number one treatment for ischemic stroke is thrombolytics patient also will need a platelets and anticoagulants not only in the initial phase but also later on to prevent um clots from forming again especially if the patient has atrial fibrillation and many of these other risk factors statins will definitely need to be administered as well if the patient's lipid panel is elevated if they have high cholesterol obesity diabetes hypertension and so forth and then of course anti-hypertensives because we're going to want to keep the patient's blood pressure under control now for ischemic stroke certainly when there is bleeding in the brain we do not want to give thrombolytics that would only make the blood the bleeding worse so for an ischemic stroke mostly it's caused by the controlled hypertension so we do want to control the blood pressure that's the most important thing right away and then depending on the size of the bleed the location the neurological deficit the patient might need surgical evacuation which means surgery basically getting the bleeding stopped opening up the cranial cavity and getting in there and really stopping the bleeding or if the symptoms are not that significant and we can get blood pressure under control they might just be doing watch for waiting which is basically observe the patient very closely and see that if they're maintaining their neurostats are either getting better or worse and then determining if the patient might need surgery keep in mind brain surgery is never easy and always needs to be done by determining the patient's risk and benefits for the operation and of course that will be determined by the patient their family and or the surgeon and the team that's taking care of the patient and then most definitely will want to control the patient's blood pressure because we know hemorrhagic strokes are mostly called caused by uncontrolled hypertension now nursing care pertaining to taking care of a patient with a stroke so most definitely we will want to maintain our airway breathing and circulation if there is a patient is significantly impaired neurologically they might not be able to maintain their own airway which means they might need to be intubated breathing if there is pressure on the respiratory center of the brain it might alter their breathing and then certainly circulation blood pressure control and if there is bleeding we will want to keep a close eye on that well certainly we want to do neuro checks very frequently that means probably at least every hour if the patient gets thrombolitis it can only be given mostly by ICU or emergency room nurses because it's a very special skill and the patient needs neurological checks every 15 minutes because they can change so quickly and there is a specialized training called the NIH stroke scale where the stroke centers will follow this assessment and its special treatment training that the nurses need to undergo to be able to take care of patients and then administer medications so most likely this will be anti hypertensives anti coagulants and if the patient is in ICU they will be on a drip so they'll be very close monitoring for those and any kind of side effects and then certainly later on once this faces over we want to educate the patient and their family and support them as well now family support is important right away because their loved one is now having some significant alteration in their mental status and of course that's going to be very upsetting and devastating to the family so we'll need to support them as best as we can and then lastly we need to prepare them for rehab so if the patient has significant neurological deficits they will most likely go to some rehab facility where the goal is to get the patient back to their optimal level of functioning so they'll be working with physical therapy occupational therapy speech therapy they'll learn how to feed themselves if they've had some significant effects and they'll also support the family there on how they can help them once the patient gets home and then a lot of times home health or social workers get involved as well to support the patients when they are ready for discharge so in summary hemorrhagic versus ischemic stroke both of them are very very significant mortality rate is much higher with hemorrhagic stroke and if you have any of these signs and symptoms in one of your patients check your blood sugar and think stroke time is off the essence and we're really meant to make sure that we act very quickly to preserve the patient's um neurological status and brain tissue thank you for watching this video on um the different types of strokes please leave comments below i'll be happy to also take suggestions for review and other topics in the future and thank you for watching nursing school explained