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Stroke
Angela DeVolder-Blair
The Robert B. Miller College
Pathophysiology
Dr. Theresa Dawson
April 15, 2015

Stroke
The Cleveland Clinic defines a stroke asan acute loss of neurological function due to an
abnormal perfusion of brain tissue (Cleveland Clinic, 2015). Strokes are the leading cause of
morbidity and the fourth-leading cause of death in the United States (Cleveland Clinic, 2015).
Although the brain only makes up 2% of total body weight, 20% of the oxygen we breathe is
delivered by arteries to all parts of the brain (CDC, 2015). The brain controls movements, stores
memories, thoughts, emotions, and language (CDC, 2015). It also controls many functions of the
body like breathing and digestion (CDC, 2015). A stroke occurs if the flow of oxygen-rich blood
is blocked to a portion of the brain (NIH, 2015). Within just a few minutes without oxygen, brain
cells start to die (NIH, 2015). Sudden bleeding in the brain can also cause a stroke if brain cells
are damaged (NIH, 2015).
There are essentially two types of stroke that occur, 87% are ischemic strokes and 13%
are hemorrhagic stroke (Cleveland Clinic, 2015). An ischemic stroke occurs if an artery that

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supplies blood to the brain becomes blocked and causes brain tissue death (NIH, 2015).
Atherosclerosis is a disease in which fatty substance called plaque builds up in the walls of the
arteries and hardens and narrows the arteries, which in turn limits the flow of blood to structures
like the heart and brain (NIH, 2015). Plaque that is present in an artery can crack or rupture
(NIH, 2015). Blood platelets attach to the site of the plaque injury and clump together to from
blood clots that can partially or fully block an artery (NIH, 2015). The two main arteries on each
side of the neck are called the carotid arteries and they supply blood to the brain, face, scalp, and
neck. When plaque builds up in the carotid arteries it is called carotid artery disease and is
responsible for many of the ischemic strokes and TIAs in the U.S. (NIH, 2015). A TIA or
transient ischemic attack is sometimes referred to as a mini-stroke and occurs if blood flow to
the brain is only blocked for a short time and damage to the brain cells does not remain
permanent (NIH, 2015). Patients with history of TIAs are at greater risk for developing a full
blown stroke (NIH, 2015). An embolic stroke is a type of ischemic stroke or TIA can also occur
if a blood clot or piece of the plaque breaks away from the wall of the artery and travels through
the blood stream and becomes lodged in an artery in the brain (NIH, 2015). Blood flow is
blocked and brain cells are damaged. Certain heart conditions and blood conditions can also
cause blood clots that result in stroke. In atrial fibrillation, the upper chambers of the heart
contract in a fast, irregular rhythm causing blood to pool in the heart (NIH, 2015). The pooling of
blood places patients at risk for developing blood clots in the heart and causing an embolic stroke
(NIH, 2015). A deep vein thrombosis, a clot in the arteries of the leg or arm can also break away
and cause stroke as well as a pulmonary embolism which is a blood clot in the lungs places the
patient at high risk. A thrombotic stroke occurs when a blood clot forms in one if the arteries that

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supply blood to the brain (Mayo Clinic, 2015). A clot may be caused by fatty deposits (plaque)
that build up in arteries and cause reduced blood flow (atherosclerosis) (Mayo Clinic), 2015.
A hemorrhagic stroke occurs if an artery in the brain leaks blood or ruptures (NIH, 2015).
The bleeding causes swelling of the brain and increased pressure in the skull which damages
brain cells and tissue (NIH, 2015). An intracerebral hemorrhage occurs when a blood vessel
inside the brain leaks blood or ruptures (NIH, 2015). Hypertension, aneurysms, and
arteriovenous malformations are conditions that can lead to a hemorrhagic stroke (NIH, 2015).
Aneurysms are bulges in the arteries that stretch and burst (NIH, 2015). In a subarachnoid
hemorrhage, a blood vessel on the surface of the brain leaks blood or ruptures and bleeding
occurs between the inner and middle layers of the membranes that cover the brain placing
pressure on brain tissue and results in brain tissue death (NIH, 2015).
Some risk factors for stroke are modifiable while others are simply out of the patients
control. The more risk factors a patient has, the more likely they are to develop a stroke (NIH,
2015). Patients cannot control their age and gender (NIH, 2015). Risk of stroke increases with
age but men are more likely to have a stroke at a younger age but women are more likely to die
from a stroke (NIH, 2015). Women who take birth control pills are also at higher risk of suffering
from stroke (Stroke, 2015). The patient for our case study is identified as currently taking birth
control pills. Race or ethnicity also plays a role (NIH, 2015). Strokes occur more often in African
American, Alaska Native, and American Indian adults than in Caucasian, Hispanic, or Asian
American adults (NIH, 2015). Brain aneurysms or arteriovenous malformations (AVMs may be
present at birth) are often not identified and diagnosed until they rupture (NIH, 2015). Family
history of a stroke or TIA places a patient at higher risk for suffering from a stroke or TIA and
risk for having a repeat stroke is highest right after a stroke (NIH, 2015).
Other risk factors may be possible to treat or control. High blood pressure or
hypertension is a prominent risk factor for stroke. Hypertension is defined by National Heart,

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Lung, and Blood Institute as maintaining or higher than 140/90 mmHg over time (NIH, 2015). A
diabetic or chronic kidney disease patient sustaining a blood pressure of 130/80 mmHg is
considered hypertensive (NIH, 2015). Continuous elevated blood pressure puts pressure on the
arteries and increases the risk of damage to the arteriole walls which may make the patient more
likely to develop an area for plaque to attach or a thrombus to form. Diabetes is a disease in
which the body does not make enough insulin or doesnt use insulin properly so blood sugar
levels are high (NIH, 2015). Elevated blood sugar levels can damage and weaken the arteriole
walls (Stroke, 2015). High cholesterol or hyperlipidemia is a fatty substance in the blood that is
found in food or produced by the body (Stroke, 2015). Hyperlipidemia can be controlled by diet,
exercise, or medications with a target range of cholesterol less than 200 (Stroke, 2015).
Heart disease, coronary artery disease, atrial fibrillation, or an atrial or ventricle septal
defect (when there is a hole at the septum and a blood clot can pass from the right to the left side
of the heart then pass into the arteries into the brain) all place patients at higher risk for stroke
(NIH, 2015). Heart disease is managed with diet, exercise, and medication management.
Non-modifiable medical conditions that increase the chance of stroke include sickle cell
anemia, vasculitis, and bleeding disorders (NIH, 2015).
Unhealthy lifestyle choices place patients at greater risk for stroke and can all be
modified by the patient. Smoking can damage blood vessels and increase blood pressure, alcohol
and illegal drug use including cocaine and amphetamines, unhealthy diet and lack of physical
exercise, obesity, and stress (NIH, 2015).
The history of the patient signaled some red flags. The patient is a 32 year old woman on
oral contraceptives that has just returned from a trip to Germany via airplane and symptoms
include nervousness and sudden weakness to left arm and leg. The fact that the patient is on birth
control and has been on an extended plane ride and has been sitting for hours make me start to
think about the possibility of DVT or PE development.(Deep vein thrombosis often precedes a

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pulmonary embolism). The fact that the patient is nervous or anxious also increases my suspicion
of a blood clot as that is often a symptom or something that may observed of the patient upon
assessment. The patients vital signs are within normal limits but her heart rate is a little higher
than normal for her and tachycardia is a vital sign to be concerned about with DVT or PE. A midsystolic murmur was auscultated and an atrial septal defect is suspected and confirmed with
echocardiography. Ultrasound confirms the patient has a thrombus in the veins of the left leg
which correlates with her travel history and birth control use. MRI detects an acute infarct in the
region of the right middle cerebral artery which correlates to the left sided weakness the patient
is experiencing. From the DVT the patient has developed, it is suspected that the clot traveled
from the leg to the right side of her heart and because of the atrial septal defect (hole at the
septum), the clot passed from the right to the left side of the heart and passed into the arteries and
traveled to the brain where it blocked a vessel and caused a stroke. (NIH, 2015).
A stroke is diagnosed based on signs and symptoms, medical history, physical exam, and
test results. It will be important to determine the type of stroke that has occurred so proper
treatment can begin immediately.
The type of symptoms that a patient may be experiencing depends on the area of the brain
that is affected (NIH, 2015). Symptoms may occur quickly or develop over hours or days (NIH,
2015). Signs and symptoms of a stroke include:
* Sudden weakness
* Paralysis or numbness to the face, arms or legs and often on just one side of the body
* Confusion
* Trouble speaking or understanding speech
* Vision changes
* Difficulty breathing
* Dizziness, gait instability, loss of balance or coordination, falls
* Sudden or severe headache
* Loss of consciousness
The patient shows signs and symptoms including sudden onset of weakness of the left arm and
leg and neurologic exam shows a slight sensorimotor hemiparesis on the left.

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When a patient presents with neurological complaints, a healthcare professional will

perform a complete physical head to toe exam including a NIH stroke scale and Glascow Coma
Scale. The NIH stroke scale measures several aspects of brain functioning including vision,
sensation, movement, speech, level of consciousness, and language (NIH, 2015). Points are
given for each impairment uncovered with a maximum of 42 (NIH, 2015). 0= no stroke, 1-4 =
minor stroke, 5-15 = moderate stroke, 15-20 moderate/severe stroke, 21-42 severe stroke (NIH,
2015). The Glascow Coma Scale is a common scoring method used to determine the patients
level of consciousness. The GSC measures eye opening, verbal response, and motor response
and points up to a total of 15 are given based on patient response. Mild = 13-15, Moderate = 912, Severe = 3-8. (NIH, 2015).
Diagnostic testing will be used in conjunction with physical testing to confirm a stroke. A
patient will be sent immediately for a brain CT scan (an xray) to detect any bleeding in the brain
or damage to the brain cells (NIH, 2015). MRI uses magnets and radio waves to create pictures
of structures and organs in the body (NIH, 2015). An MRI may be performed to identify brain
tissue or damage to brain cells not previously detected by CT. A CTA or MRA show blood
vessels in the brain and can pinpoint the site of the blood clot and the flow of blood through the
brain (NIH, 2015). A carotid ultrasound may be performed to show narrowing or blockage
present in the carotid arteries to the brain (NIH, 2015). A carotid angiography uses dye placed via
an artery in the groin and xrays to examine the arteries (NIH, 2015). An EKG will be performed
to detect any problems with the heart such as atrial fibrillation or myocardial infarction that led
to a stroke (NIH, 2015). Echocardiography is an ultrasound of the heart and gives information on
the shape, size, and how well the chambers and valves are working (NIH, 2015). An echo can
also detect a blood clot present in the heart or problems with the aorta (NIH, 2015). The patient
in the case study was found to have an atrial septal defect via echocardiography.

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Determining what type of stroke has occurred determines what type of treatment the
patient receives. Strokes are considered medical emergencies and every minute means brain
tissue lost.
Ischemic strokes can be treated with a medicine called tPA (tissue plasminogen activator)
given via IV within 4 hours of onset of symptoms and should be given as soon as possible (NIH,
2015). If there is a medical reason the patient is unable to receive tPA or they are outside of the 4
hour window, antiplatelet medication such as aspirin will be given. Anticoagulants will be started
to prevent blood clots from getting larger and prevent new clots from forming (NIH, 2015). If it
is determined that the patients carotid arteries are blocked, a carotid endarterectomy will be
performed to open the blockage (NIH, 2015). An intra-arterial thrombolysis places a long tube in
the patients groin and medication is delivered to the artery in the brain to break up the clot (NIH,
2015). MERCI is a device that is placed in the carotid artery and threaded to the affected artery
in the brain and then pulls the clot through the catheter (NIH, 2015).
Hemorrhagic strokes are treated with aneurysm clipping and coil embolization (NIH,
2015). Aneurysm clipping helps prevent further leaking from the aneurysm and can also prevent
bursting again (NIH, 2015). During coil embolization, a catheter is placed in the artery in the
groin and a tiny coil is pushed through the tube and into the aneurysm causing a blood clot to
form and will block blood flow (NIH, 2015).
Strokes can have many short term and long term effects for the patient and the family.
Recovery from a stroke depends on how much damage to the brain tissue occurred during the
event. Short term signs and symptoms to monitor for are signs of another stroke. Patients may
suffer from physical limitations such as immobility, inability to express themselves verbally or
emotionally, and cognitive deficits. Many patients suffering from a stroke also suffer from onset
of depression as their independence is now limited. This not only places a strain on the patient
but the caregivers as well.

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Long term effects may include blood clots, muscle weakness, difficulty swallowing,
(which can lead to aspiration pneumonia), and loss of bowel or bladder. Patients may need to
wear adult briefs and the fear of incontinence often leads to constipation and urinary tract
infections (NIH, 2015), Long term deficits increase and become more permanent - even death
when patients wait to be evaluated (NIH, 2015). Fifty percent of stroke survivors develop
depression (NIH, 2015). Patients that suffer from an ischemic stroke have a more positive
prognosis than those that suffer a hemorrhagic stroke (NIH, 2015).
Supportive roles of healthcare providers can be utilized in many ways. Support groups
are both present for patients and family members to learn to cope with the effects of the stroke.
Continuous education needs to be provided for patients placed on antiplatelet and anticoagulants
and the importance of warning signs such as bleeding and lab testing must be conveyed to the
patient (NIH, 2015). Patients may need referral to a speech therapist for speech, swallowing, and
eating problems and physical and occupational therapy to regain muscle weakness or paralysis
(NIH, 2015). Keeping open communication with stroke patients is important to determine
obstacles they are facing and the changing of those obstacles as their rehabilitation progresses.
Education must be ongoing for patients determined to be at higher risk for stroke such as
signs and symptoms, decreasing risk factors such as smoking cessation, diet, exercise, and the
importance of immediately seeking treatment for stroke like symptoms.
Clinical trials are presently being conducted by the National Heart, Lung, and Blood
Institute for ways to reduce the risk of complications such as sleep apnea or heart attack
following a stroke, ways to prevent stroke after coronary artery bypass grafting, and how a
persons genetic makeup may change the effectiveness of high blood pressure medications (NIH,
2015). Much of the research being performed relies on the willingness of volunteers who have
the diseases to take part in clinical trials (NIH, 2015).

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In the case of stroke, time lost is brain loss. It is essential that patients seek emergency
medical attention at the immediate onset of symptoms to decrease the risk of further brain
damage.

References
Centers for Disease Control and Prevention. (2015). About stroke. Retrieved from
http://www.cdc.gov/stroke/about.htm
Cleveland Clinic. (2015). Stroke. Retrieved from
www.clevelandclinicmeded.com/medicalpub/neurology
Mayo Clinic. (2015). Stroke. Retrieved from www.mayoclinic.org/diseases-conditions/stroke
Stroke.Org. (2015). Women and stroke. Retrieved from www.stroke.org/understandstroke/women-and-stroke
U.S. Department of Health and Human Services, National Institutes of Health, National Heart,
Lung, and Blood Institute. (2015). What is a stroke? Retrieved from
http://www.nhlbi.nih.gov/health/topics/strokes

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