Neurological assessment

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Neurological assessment
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Anatomic and Physiologic Overview

• The nervous system consists of two divisions the
  central nervous system (CNS) including the brain
  and spinal cord
• peripheral nervous system, which includes
  cranial and spinal nerves.
• The peripheral nervous system can be further
  divided into the somatic, or voluntary, nervous
  system, and the autonomic, or involuntary,
  nervous system.

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• The function of the nervous system is control
  of all motor, sensory, autonomic, cognitive, and
  behavioral activities.
• The nervous system has approximately 10
  million sensory neurons that send information
  about the internal and external environment to
  the brain and 500,000 motor neurons that control
  the muscles and glands.

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• The brain itself contains more than 100 billion
  cells that link the motor and sensory pathways,
  monitor the body's processes, respond to the
  internal and external environment, maintain
  homeostasis, and direct all psychological,
  biologic, and physical activity through complex
  chemical and electrical messages

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Anatomy of the Nervous System

• Cells of the Nervous System
• The basic functional unit of the brain is the
  neuron It is composed of a cell body, a dendrite,
  and an axon.
• The axon is a long projection that carries
  impulses away from the cell body. Nerve cell
  bodies occurring in clusters are called ganglia
  or nuclei.

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• Neurotransmitters
• Neurotransmitters communicate messages from one
  neuron to another or from a neuron to a specific
  target tissue .
• (In fact, probably all brain functions are
  modulated through neurotransmitter receptor site
  activity, including memory and other cognitive
  processes

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• Many neurologic disorders are due, at least in
  part, to an imbalance in neurotransmittersthat
  is
• an increase in gamma-aminobutyric acid (GABA) in
  alcohol withdrawal seizures
• (a decrease in dopamine in Parkinson's disease
  and a decrease in acetylcholine in myasthenia
  gravis

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The Central Nervous System

• Brain
• The brain is divided into three major areas the
  cerebrum, the brain stem, and the cerebellum.
• The cerebrum is composed of two hemispheres, the
  thalamus, the hypothalamus, and the basal
  ganglia.

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• Each hemisphere has four lobes
• parietal, occipital, temporal, frontal. The
  cerebral lobes control complex problem-solving
  value judgments languageemotions
  interpretation of visual images interpretation
  of touch, pressure,temperature, position sense.

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• Each hemisphere sends and receives impulses from
  the opposite sides of the body and consists of
  four lobes "frontal, parietal, temporal and
  occipital". The lobes are composed of a substance
  known as gray matter, which mediates
  higher-level-functions such as memory,
  perception, communication, and initiation of
  voluntary movements.

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• The brain stem includes the midbrain, pons,
  medulla, Is a major sensory and motor pathway for
  impulses running to and from the cerebrum.
  Regulates body functions such as respiration,
  auditory and visual reflexes, swallowing.

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• The cerebellum is located under the cerebrum and
  behind the brain stem).
• contains the major motor and sensory pathways. It
  controls smooth, coordinated muscle movements and
  helps to maintain equilibrium.

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• The brain accounts for approximately 2 of the
  total body weight in an average young adult, the
  brain weighs approximately 1,400 g whereas in an
  average elderly person, the brain weighs
  proximately 1,200g

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• The meninges (fibrous connective tissues that
  cover the brain and spinal cord) provide
  protection, support, and nourishment to the brain
  and spinal cord. The layers of the meninges are
  the dura, arachnoid, and pia mater .

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Cerebrospinal Fluid

• CSF, a clear and colorless fluid with a specific
  gravity of 1.007, is produced in the ventricles
  and is circulated around the brain and the spinal
  cord through the ventricular system. There are
  four ventricles the right and left lateral and
  the third and fourth ventricles

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• CSF is produced in the choroid plexus of the
  lateral, third, and fourth ventricles. The
  ventricular and subarachnoid system contains
  approximately 150 mL of fluid each lateral
  ventricle normally contains 25 mL of CSF .

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• The composition of CSF is similar to other
  extracellular fluids (such as blood plasma), but
  the concentrations of the various constituents
  are different.
• The laboratory report of CSF analysis usually
  contains information on color, specific gravity,
  protein count, white blood cell count, glucose,
  and other electrolyte levels Normal CSF contains
  a minimal number of white blood cells and no red
  blood cells .

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• Cerebral Circulation
• The cerebral circulation receives approximately
  15 of the cardiac output, or 750 mL per minute.
  The brain does not store nutrients and has a high
  metabolic demand that requires the high blood
  flow.

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• The brain's blood pathway is unique because it
  flows against gravity its arteries fill from
  below, and the veins drain from above.
• In contrast to other organs that may tolerate
  decreases in blood flow because of their good
  collateral circulation, the brain has poor
  collateral blood flow, which may result in
  irreversible tissue damage when blood flow is
  occluded for even short time periods

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Spinal Cord

• The spinal cord is located in the vertebral canal
  and extends from the medulla oblongata to the
  first lumbar vertebra,and serving as the
  connection between the brain and the periphery.
• Approximately 45 cm (18 in) long and about the
  thickness of a finger,

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• The spinal cord is an H-shaped structure with
  nerve cell bodies (gray matter) surrounded by
  ascending and descending tracts (white matter)

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• The spinal cord conducts sensory impulses up
  ascending tracts to the brain, conducts motor
  impulses down descending tracts to neurons that
  stimulate glands and muscles throughout the body,
  and is responsible for simple reflex activity.
  Reflex activity involves various neural
  structures.

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Peripheral Nervous System

• The peripheral nervous system consists of 12
  pairs of cranial nerves and 31 pairs of spinal
  nerves
• These nerves are categorized as two types of
  fibers somatic and autonomic. autonomic nervous
  system mediates unconsciousness, or involuntary
  activities.
•  

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• Spinal Nerve
• The spinal cord is composed of 31 pairs of spinal
  nerves 8 cervical, 12 thoracic, 5 lumbar, 5
  sacral, and 1 coccygeal. Each spinal nerve has a
  ventral root and a dorsal root

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• Autonomic Nervous System
• The autonomic nervous system regulates the
  activities of internal organs such as the heart,
  lungs, blood vessels, digestive organs, and
  glands. Maintenance and restoration of internal
  homeostasis is largely the responsibility of the
  autonomic nervous system.

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• There are two major divisions the sympathetic
  nervous system, with predominantly excitatory
  responses, most notably the fight or flight
  response .
• and the parasympathetic nervous system, which
  controls mostly visceral functions.

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Assessment The Neurologic Examination

• Health History
• An important aspect of the neurologic assessment
  is the history of the present illness. The
  initial interview provides an excellent
  opportunity to systematically explore the
  patient's current condition and related events
  while simultaneously observing overall
  appearance, mental status, posture, movement, and
  affect.

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• Neurologic disease may be stable or progressive,
  characterized by symptom-free periods as well as
  fluctuations in symptoms
• The nurse should be aware of any history of
  trauma or falls that may have involved the head
  or spinal cord. Questions regarding the use of
  alcohol, medications, and illicit drugs are also
  relevant.

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• The history-taking portion of the neurologic
  assessment is critical and, in many cases of
  neurologic disease, leads to an accurate
  diagnosis. .

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Neurological assessment

• The Glasgow Coma Scale
• Best Eye-Opening Response
  Score
• Spontaneously
  4
• To speech
  3
• To pain
  2
• No response
  1
• Best Motor Response Score
• Obeys commands
  6
• Localizes stimuli attempt to remove noxious
  stimuli 5
  
• Withdrawal from stimulus to avoid noxious
  stimuli 4
• Abnormal flexion (decorticate)
  3
• Abnormal extension (decerebrate)
  2
• No response - flaccid
  1

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The Glasgow Coma Scale

• Best Verbal Response
  Score
• Oriented
  5
• Confused conversation
  4
• Answer not appropriate to question
  
• Inappropriate words disorganized ,random speech
• 
  3
• Incomprehensible sounds
  2
• No response
  1
• A total score of 3 to 8 suggests severe
  impairment, 9 to 12 suggests moderate impairment,
  and 13 to 15 suggests mild impairment.

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Categories of consciousness

• Alert (full consciousness) normal
• Awake may sleep more than usual or be somewhat
  confused on first awakening, but fully oriented
  when Aroused.
• Confused pt disoriented to time and place put
  usually oriented to person ,with impaired
  judgment and decision making.
• Delirious pt disoriented to time and place and
  person with loss of contact with reality and
  often has auditory or visual hallucination.
• Lethargic drowsy but follows simple
  commands when stimulated, in which the pt needs
  an increased stimulus to be awakened.
• Comatose may have no response to any
  stimulus.

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Clinical Manifestations

• Pain is considered an unpleasant sensory
  perception and emotional experience associated
  with actual or potential tissue damage or
  described in terms of such damage
• Seizures are the result of abnormal paroxysmal
  discharges in the cerebral cortex, which then
  manifest as an alteration in sensation, behavior,
  movement, perception, or consciousness

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• Dizziness and Vertigo
• Dizziness is an abnormal sensation of imbalance
  or movement.. About 50 of all patients with
  dizziness have vertigo, which is defined as an
  illusion of movement, usually rotation . Vertigo
  is usually a manifestation of vestibular
  dysfunction. It can be so severe as to result in
  disorientation, loss of equilibrium (staggering),
  and nausea and vomiting.

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• Visual Disturbances
• Lesions of the eye itself (eg, cataract), lesions
  along the pathway (eg, tumor), or lesions in the
  visual cortex (from stroke) interfere with normal
  visual acuity. Abnormalities of eye movement can
  also compromise vision by causing diplopia or
  double vision.

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• Weakness
• Weakness, specifically muscle weakness, is a
  common manifestation of neurologic disease.
• Abnormal Sensation
• Numbness, abnormal sensation, or loss of
  sensation is a neurologic manifestation of both
  central and peripheral nervous system disease

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Diagnostic Evaluation

• Computed Tomography Scanning (CT). The images
  provide cross-sectional views of the brain, with
  distinguishing differences in tissue densities of
  the skull, cortex, subcortical structures, and
  ventricles.

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• Magnetic Resonance Imaging (MRI) uses a powerful
  magnetic field (Can be performed through magnetic
  waves which stimulates nuclei of the atoms in the
  body ) to obtain images of different areas of the
  body
• An MRI scan can be performed with or without a
  contrast agent and can identify a cerebral
  abnormality earlier and more clearly than other
  diagnostic tests .

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• It is used to detect CNS tumors, infectious
  problem of the CNS
• allowing the clinician to monitor a tumor's
  response to treatment. It is particularly useful
  in the diagnosis of multiple sclerosis .

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Cerebral angiography 1-conventional angiography.
For diagnosis of cerebral aneurysm,, vasospasm,
carotid artery disease. Complication cerebral
embolus, hemorrhage or hematoma at the site of
catheter insertion, vasospasm, thrombosis,
allergic reaction.
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Electrophysiology studies
        Electroencephalogram( EEG) It is a
recording of electrical impulses generated by
brain. Purpose include detection of area of
abnormal electrical activity.      
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lumber puncture(LP)
A lumbar puncture (spinal tap) is carried out by
inserting a needle into the lumbar subarachnoid
space . The purpose of lumber puncture is to
obtain CSF sample for analysis ( subarachnoid
hemorrhage and infection). It is performed by
insertion of 20 22 gauge needle into the
subarachnoid space at L3-L4 or L4 -L5 level by
putting patient in lateral recumbent position .
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• Usually, specimens are obtained for cell count,
  culture, and glucose and protein testing. The
  specimens should be sent to the laboratory
  immediately because changes will take place and
  alter the result .

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PostLumbar Puncture Headache

• Bed rest after procedure is very important to
  prevent headache also preventing CSF.
• analgesic agents, and hydration. Occasionally,
• Other Complications of Lumbar Puncture
  Herniation of the intracranial contents results
  from shifting of tissue from one compartment of
  the brain to another, spinal epidural abscess,
  spinal epidural hematoma

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Intracranial pressure (ICP)
The main components inside the cranium are -
brain tissue (80), blood (10), and
cerebrospinal fluid (CSF (10). So that any
increase in the size of brain tissue or increase
in the volume of the CSF or problem in the blood
vessel (E.g. bleeding into the cranium) will
cause increase in the ICP.  The normal ICP in
patients should be less than 15mm Hg.
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• The effect of increase in ICP will cause
  neurological deficit (sensory, motor, level of
  consciousness) or other problem such as seizure
  so that it is important in some patient to
  monitor ICP.

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• Cerebral blood flow
• The normal cerebral blood flow (CBF) is 50ml /
  100g of brain tissue.
• Although brain makes up to 2 of the body
  weight but it required 15 to 20 of the resting
  cardiac output and 15 of the total bodys oxygen
  demands.
•    

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Assessment and diagnosis

• The main signs and symptoms of increased in ICP
• 1-    Decreased in the level of consciousness.
• 2-    Cushings triad (bradycardia, systolic
  hypertension, and bradypnea).
• 3-    Diminished brain stem reflexes.
• 4-    Papilledema.
• 5-    Decerebrate (extension to pain).
• 6-    Decorticate (flexion to pain).

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• 7-    Unequal pupil size.
• 8-    Projectile vomiting.
• 9-    Decreased pupillary reaction to light.
• 10-  Altered breathing pattern.
• 11- Headache.

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Medical and Nursing management

• 1-positioning and other nursing activities
• A-Elevation of the bed up to 30 degree will help
  to decrease ICP by encouraging the venous return.
• B-Positions that should be avoided are
  (trendelenberg, prone, extreme flexion of the hip

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• 2- hyperventilation -
• The rational to hyperventilate patient with high
  ICP is to reduce the Paco2 from its normal range
  (35-40mm Hg) to a range between 25 and 30
  mmHg.wich lead to cerebral arteries
  vasoconstriction which lead to decrease in the
  CBF and increase in the venous return.
• Also prolonged hyperventilation will lead to
  ischemia and infarction, so that the new trend is
  to maintain Paco2 in the lower side of the normal
  (35 2 cm Hg).

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• 4-    Blood pressure control -
• Maintenance of arterial blood pressure in the
  high normal range is essential in head injured
  patients.
• Sedation is required to control blood pressure
  in the initial phase.
•    If sedative fail to control blood
  pressure, antihypertensive should be administered
  (e.g.nitroprusside and nitroglycerin), also we
  will use B- blockers (e.g. labetalol or
  metoprolol) may be used to overcome the effect of
  vasodilation of antihypertensive agent.

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• 3- temperature control
• Cerebral metabolic rate increases 7 per degree
  centigrade of increase in the body temperature.
• Fever should be avoided and treated aggressively
  when occurred by using antipyretic and cooling
  device until the cause of fever to be determined
• Hypothermia 32to 35-degree C will decrease the
  ICP

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• 5-   Seizure control -
• The prophylactic use of anticonvulsant is
  important in controlling the cerebral metabolic
  needs.
• The usual medication to be used are phenytoin and
  Phenobarbital also lorazepam as a short and fast
  acting.

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• 7-Cerebrospinal fluid drainage
• 8- diuretic
• a-Osmotic diuretic.
• The widely used medication is mannitol (it will
  improve perfusion to ischemic areas of the brain
  and decrease intracerebral edema that caused by
  the injury by its osmotic effect.
• Side effect electrolyte imbalance

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• Nonosmotic diuretic -
• The most widely used is furosemide
• Maintain euvolemic state to maintain and
  optimize cerebral perfusion.

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• 9- control of metabolic demand
• There are some noxious stimuli that lead to
  increase ICP pain, presence of end tracheal
  tube, coughing suctioning, repositioning,
  bathing.
• There are many agent are used to decrease
  metabolic demand benzodiazepines( midazolam.
  Lorazepam), sedative hypnotic (propofol),
  opioid narcotic (phentanyl and morphine), and
  neuromuscular blocking agents (atracurium and
  vecuronium)

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Stroke
Is a descriptive term for the onset of acute
neurological deficit persisting for more than
24 hours and caused by interruption of blood flow
to the brain.  
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Ischemic Stroke

• An ischemic stroke, cerebrovascular accident
  (CVA), or brain attack is a sudden loss of
  function resulting from disruption of the blood
  supply to a part of the brain.

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• Modifiable risk factors for ischemic stroke
  include
• Hypertension
• atrial fibrillation
• hyperlipidemia
• obesity
• smoking
• diabetes

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Clinical Manifestations

• Numbness or weakness of the face, arm, or leg,
  especially on one side of the body
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Visual disturbances
• Difficulty walking, dizziness, or loss of balance
  or coordination
• Sudden severe headache

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• Motor, sensory, cranial nerve, cognitive, and
  other functions may be disrupted
• Motor Loss
• hemiplegia (paralysis of one side of the body)
  caused by a lesion of the opposite side of the
  brain. Hemiparesis, or weakness of one side of
  the body, is another sign.

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Communication Loss

• Other brain functions affected by stroke are
  language and communication. In fact, stroke is
  the most common cause of aphasia.
• Dysarthria (difficulty in speaking), caused by
  paralysis of the muscles responsible for
  producing speech
• Dysphasia (impaired speech) or aphasia (loss of
  speech), which can be expressive aphasia,
  receptive aphasia, or global (mixed) aphasia

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• Apraxia (inability to perform a previously
• learned action)
• Visual-perceptual dysfunctions. hemianopsia (loss
  of half of the visual field)
• Sensory Loss
• Agnosias are deficits in the ability to
  recognize previously familiar objects perceived
  by one or more of the senses.

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Assessment and Diagnosis
   1- The characteristics signs of an ischemic
stroke is a sudden onset of focal neurologic
signs persisting for more than 24 hours.    2-
Presence of hemiparesis, aphasia,
hemanopsia.    3-Change in level of
consciousness usually occur with brainstem or
cerebellar involvement ,seizure, hypoxia,
hemorrhage, increased ICP. 4-Brain CT
without contrast. 5- ECG, chest X-ray,
continuous cardiac monitoring, arterial blood
gases.
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Assessment and Diagnostic Findings

• Any patient with neurologic deficits needs a
  careful history and a complete physical and
  neurologic examination.
• The characteristics signs of an ischemic stroke
  is a sudden onset of focal neurologic signs
  persisting for more than 24 hours

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• - Presence of hemiparesis, aphasia, hemanopsia.
•  -Change in level of consciousness usually occur
  with brainstem or cerebellar involvement ,seizure
  ,hypoxia, increased ICP.

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• Initial assessment focuses on airway patency,
  which may be compromised by loss of gag or cough
  reflexes and altered respiratory pattern
  cardiovascular status (including blood pressure,
  cardiac rhythm and rate) and gross neurologic
  deficits

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• Patients may present to the acute care facility
  with temporary neurologic symptoms.
• A transient ischemic attack (TIA) is a neurologic
  deficit lasting less than 24 hours, with most
  episodes resolving in less than 1 hour

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• . A TIA is manifested by a sudden loss of motor,
  sensory, or visual function. The symptoms result
  from temporary ischemia (impairment of blood
  flow) to a specific region of the brain.
• A TIA may serve as a warning of impending stroke.
  Lack of evaluation and treatment of a patient who
  has experienced previous TIAs may result in a
  stroke and irreversible deficits

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• The initial diagnostic test for a stroke is a
  noncontrast (CT) scan performed emergently to
  determine if the event is ischemic or hemorrhagic
  .
• A 12-lead (ECG) and a carotid ultrasound are
  standard tests

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Medical Management
Thrombolytic agent( rt-PA)which is given
intravenously is recommended within 3 hours of
onset of ischemic stroke, also age should be
greater than 18 years old according to the
national institute of neurologic disorders and
stroke( NINDS).      The recommended dose is
0.9 mg / Kg up to the maximum dose of 90 mg, 10
of the dose is administered as an initial
intravenous bolus over 1 minute, the remaining
90 is administered by intravenous infusion over
60 minute.     Patient who receive
thrombolytic therapy for stroke should not
receive aspirin, heparin, warfarin, ticlodipine
for at least 24 hours after treatment.
      
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• Patients who have experienced a TIA or stroke
  should have medical management for secondary
  prevention.
• Platelet-inhibiting medications, including
  aspirin, clopidogrel (Plavix), and ticlopidine
  (Ticlid), decrease the incidence of cerebral
  infarction in patients who have experienced TIAs
  and stroke from suspected embolic or thrombotic
  causes .

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Therapy for Patients With Ischemic Stroke Not
Receiving t-PA

• Other treatments may include anticoagulant
  administration (IV heparin or low-molecular-weight
  heparin).
• Interventions during this period include measures
  to reduce ICP, such as administering an osmotic
  diuretic (eg, mannitol), maintaining the partial
  pressure of carbon dioxide (PaCO2) within the
  range of 30 to 35 mm Hg, and positioning to avoid
  hypoxia

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         Blood pressure in some cases must not
be lowered because it will affect the cerebral
perfusion pressure.       antihypertensive
therapy is considered only if the diastolic blood
pressure is greater than 120 mmHg or the systolic
BP is greater than 220mmHg.       Blood
pressure should be 180/105 mmHg to prevent
intracranial hemorrhage.       Intravenous
labetalol and nitroprusside is used to achieve BP
control.        Treatment should include
controlling cerebral edema or seizure activity.
but prophylaxis for these complication is not
recommended.
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Hemorrhagic Stroke

• Hemorrhagic strokes account for 15 to 20 of
  cerebrovascular disorders and are primarily
  caused by intracranial or subarachnoid
  hemorrhage. Hemorrhagic strokes are caused by
  bleeding into the brain tissue, the ventricles,
  or the subarachnoid space .

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 Intracerebral hemorrhage
    Is a bleeding directly into the brain
tissue.      It will destroys cerebral tissue
causes cerebral edema, and

increaseICP. Causes
include .    1- the most important cause is
hypertension     2- rupture of AVM or aneurysm.
.    3-. rupture of small artery .    4-patients
who receive anticoagulant or thrombolytic
therapy. .     5-coagulation disorders. .    
6-drug abuse .     7-hemorrhage into cerebral
infarct or brain tumor  
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• An intracerebral hemorrhage (ICH) is bleeding
  within brain tissue.
• An ICH may be associated with other brain
  injuries, particularly contusions .

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Assessment and Diagnostic Findings

• Any patient with suspected stroke should undergo
  a CT scan to determine the type of stroke, the
  size and location of the hematoma, and the
  presence or absence of ventricular blood and
  hydrocephalus.
• CT scan and cerebral angiography confirm the
  diagnosis of an intracranial aneurysm or AVM

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Clinical Manifestations

• Clinical Manifestations
• The patient with a hemorrhagic stroke can present
  with a wide variety of neurologic deficits,
  similar to the patient with ischemic stroke.

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      Medical Management
1. airway , breathing, and circulation.
2. reduction of blood pressure is necessary
to decrease ongoing bleeding, but lowering
blood pressure too much or too rapid may
compromise cerebral perfusion pressure(CPP).
3. MAP should be below 130 mmHg in patients
with a history of hypertension, and 110 mmHg
after surgical treatment of ICH. 4. if
there is increase in ICP, recommended therapy is
mannitol, hyperventilation, neuromuscular
blockade with sedation.
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• . steroids are avoided.
• surgery is required in patient with hydrocephalus
  associated with cerebellar hemorrhage that
  compress brain stem or young patient with
  moderate or large hemorrhage with clinical
  deterioration

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Subarachnoid hemorrhage

• it is the bleeding into the subarachnoid space(
  CSF circulation).
• causes of subarachnoid hemorrhage-
• 1-  rupture of cerebral aneurysm.
• 2-  Arteriovenous malformation.
• 3-  Trauma.
• Risk factors hypertension, smoking, alcohol
  abuse , and stimulants use.

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Subarachnoid hemorrhage

• Traumatic subarachnoid hemorrhage (SAH) is caused
  by bleeding into the subarachnoid space.

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Etiology

• Cerebral aneurysm rupture account 85 of
  subarachnoid hemorrhage. Also 90 of aneurysms
  are congenital.
• Rupture of cerebral aneurysm occur during the
  fifth and sixth decades of life.
• arteriovenous malformation(AVM) rupture is
  responsible for less than 10 of subarachnoid
  hemorrhage.

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• AVM are congenital tangled mass of arterial and
  venous blood vessels that shunts blood directly
  from the arterial side into the venous side

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Assessment and diagnosis

• 1-HEADACHE( WORST HEADACHE IN MY LIFE)
• 2-BRIEF LOSS OF CONSCIOUSNESS.
• 3-NAUSEA AND VOMITING
• 4-FOCAL NEUROLOGICAL DEFICIT.
• 5-STIFF NECK
• 6-PHTOPHOBIA

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DIAGNOSTIC TESTS

• 1- CT scan initially done to verify diagnosis.
• 2- lumbar puncture to take CSF sample for
  analysis if the CT scan is negative.
• 3- magnetic resonance angiogram(MRA)and magnetic
  resonance venogram(MRV).
• 4- catheterization cerebral angiography.

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Medical management

• the goal of treatment is preservation
  neurological function.
• Airway management and ventilatory assistance may
  be necessary.
• Venticulostomy is performed to control ICP if the
  patients develop deterioration in the level of
  consciousness with hydrocephalus.
• Control of blood pressure by maintaining systolic
  blood pressure no greater than 150mmHg and
  prevent hypotension.

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• prophylactic anticonvulsants must be prescribed.
• Maintain normal blood volume by giving
  intravenous fluid to expand blood volume to
  prevent vasospasm, and maintain adequate cerebral
  perfusion.
• Nimodipine cause vasodilatation of cerebral
  vessel , in doses 60 mg every 4 hours for 21 days

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