Discuss the pathophysiology of cerebrovascular accidents (CVAs)âthrombotic, embolic, hemorrhagic, and lacunarâ their incidence and prevalence, clinical manifestations, evaluation, and treatment.

Discuss the pathophysiology of cerebrovascular accidents (CVAs)âthrombotic, embolic, hemorrhagic, and lacunarâ their incidence and prevalence, clinical manifestations, evaluation, and treatment.

Cerebrovascular Accident

Cerebrovascular accident (CVA), also known as acute stroke, refers to a sudden loss of function arising from the disruption of blood supply to a portion of the brain. Acute stroke is a significant contributor to disability globally and the second leading cause of death(Kuriakose & Xiao, 2020). Stroke is the leading cause of disability and the fifth leading cause of death, with new 800,000 new cases of stroke annually in the United States, with a new case of stroke every 40 seconds (Tadi & Lui, 2021). There are several causes of stroke, with different types of the condition and underlying pathophysiology. This paper focuses on the pathophysiology of CVAs, their prevalence and incidence, clinical picture, evaluation, and treatment approaches.

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Pathophysiology

Blood flow to the brain is managed by the Circle of Willis (two vertebral arteries posteriorly and two internal carotids anteriorly). The neurovascular anatomy of the brain offers more profound insights into the manifestation of CVA. There are modifiable and nonmodifiable risk factors that play significant roles in stroke etiology. The modifiable risk factors include hypertension, carotid stenosis, unhealthy lifestyle practices such as excess alcohol consumption and tobacco smoking, obesity, transient ischemic attacks, sickle cell disease, and obesity. On the other hand, the nonmodifiable risk factors include age, sex, race, ethnicity, heredity, and fibromuscular dysplasia (Jauch et al., 2019).  Stroke is classified into two main categories, ischemic and hemorrhagic. Ischemic stroke arises from a deficiency in oxygen and bloodsupply to the brain and contributes to about 85% of the cases (Kuriakose & Xiao, 2020). Hemorrhagic stroke results from leaking or bleeding blood vessels, accounting for approximately 10-15% of stroke cases (Tadi & Lui, 2021). Regardless of the type, impaired perfusion to the brain causes an abrupt neurological outburst, leading to stroke.

Thrombotic Stroke

Ischemic stroke is subdivided into thrombotic and embolic strokes. A thrombotic stroke is caused by a blood clot that develops in the blood arteries perfusing the brain.Kuriakose and Xia (2020) state that atherosclerosis, the buildup of plaque, narrows blood vessels, affecting blood flow. An atherothrombotic plaque forms from the buildup of low-density lipoprotein cholesterol (Tadi & Lui, 2021). Eventually, the buildup constricts the vessels forming blood clots that occlude blood flow, causing a thrombotic stroke.

Embolic Stroke

An embolic stroke results from reduced blood flow to the brain due to an embolism, an obstruction of a blood vessel by foreign substances. Embolic strokes are caused by blood clots forming elsewhere in the body and travelingto the brain via the bloodstream (Kuriakose & Xiao, 2020). Embolism reduces blood flow, causing severe stress and necrosis. Necrosis disrupts the plasma membrane, leading to leakage of cellular contents and loss of neuronal function.

Hemorrhagic Stroke

It results when blood vessels perfusing the brain bleed or rupture. Kuriakose and Xia (2020) state that internal injury and excess stress to the brain cause blood vessels to rupture, producing toxic effects and the formation of an infarct. Hemorrhage also causes the pooling of blood within the brain. Consequently, pressure builds up, and cells are deprived of nutrients and oxygen, leading to further brain damage.

Lacunar Stroke

A lacunar is a form of ischemic stroke. A lacunar stroke occurs when the small penetrating arteries of the deep branches of the arteries of the Circle of Willis are blocked or impeded. The occlusion arises from micro-atheroma formation or lipohyalinosis, a process in which the media of the small vessels thicken accompanied by deposition of fibrinoid(Gore et al., 2021). These pathophysiological processes cause occlusion of the deep penetrating arteries, leading to stroke.

Incidence and Prevalence

Every 40 seconds, an individual suffers from a stroke, while a stroke-related death is every four minutes (Benjamin et al., 2017). The incidence of stroke increases with age, doubling past 55 years (Kuriakose & Xiao, 2020). The highest incidence of stroke was reported in China, with the second-highest in Eastern Europe (Johnson et al., 2019). Men are at a higher risk for stroke than women (Jauch et al., 2019). Ischemic strokes account for 85% of all cases, with hemorrhagic stroke accounting for 10-15% of the cases (Kuriakose & Xiao, 2020). Katan and Luft (2018) state that lacunar stroke accounts for 17% of ischemic strokes.

Clinical Manifestations

Patients with stroke may present with numbness, visual disturbances, trouble speaking, confusion, sudden severe headache, and loss of coordination and balance. They may also present with homonymous, diplopia, hemiplegia, hemiparesis, ataxia, dysarthria, dysphagia, aphasia, and emotional deficits (Hinkle & Cheever, 2018). Patients may also present with unique pathognomonic clinical features depending on the blood vessels affected.

Evaluation

The first diagnostic tool is an emergency computed tomography with contrast. It confirms the diagnosis and rules out bleeding. Magnetic resonance imaging is diagnostic for acute ischemic infarctions, leaving the size and location of infarcts. An echocardiogram and ECG are indicated to rule out cardiac etiologies(Tadi & Lui, 2021). Other studies to provide potential clues to etiology include complete blood count, lipid profile, GFR, platelet count, random blood sugar, blood urine nitrogen (BUN), and a coagulation panel (Jauch et al., 2019; Tadi & Lui, 2021).

Treatment

The healthcare provider must first assess the patient for stable airway, breathing, and circulation. Then, assess whether a patient is eligible for fibrinolytic therapy. The therapy dissolves clots, restoring blood flow to the affected areas (Tadi & Lui, 2021). Oxygen is administered to support adequate gaseous exchange. The nurse should also offer clinical education to patients and relatives as part of therapy. Additionally, palliative care is an essential component of stroke care.

References

Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., de Ferranti, S. D., Floyd, J., Fornage, M., Gillespie, C., Isasi, C. R., Jiménez, M. C., Jordan, L. C., Judd, S. E., Lackland, D., Lichtman, J. H., Lisabeth, L., Liu, S., Longenecker, C. T., & Mackey, R. H. (2017). Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association. Circulation, 135(10). https://doi.org/10.1161/cir.0000000000000485

Gore, M., Bansal, K., & Asuncion, R. M. D. (2021). Lacunar Stroke. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK563216/

Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed., Vol. 2). Wolters Kluwer.

Jauch, E. C., Kasab, S. A., & Stettler, B. (2019). Ischemic Stroke: Practice Essentials, Background, Anatomy. EMedicine. https://emedicine.medscape.com/article/1916852-overview#a5

Johnson, C. O., Nguyen, M., Roth, G. A., Nichols, E., Alam, T., Abate, D., Abd-Allah, F., Abdelalim, A., Abraha, H. N., Abu-Rmeileh, N. M., Adebayo, O. M., Adeoye, A. M., Agarwal, G., Agrawal, S., Aichour, A. N., Aichour, I., Aichour, M. T. E., Alahdab, F., Ali, R., & Alvis-Guzman, N. (2019). Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18(5), 439–458. https://doi.org/10.1016/s1474-4422(19)30034-1

Katan, M., & Luft, A. (2018). Global Burden of Stroke. Seminars in Neurology, 38(02), 208–211. https://doi.org/10.1055/s-0038-1649503

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International Journal of Molecular Sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609

Tadi, P., & Lui, F. (2021). Acute Stroke (Cerebrovascular Accident). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535369/

Discuss the pathophysiology of cerebrovascular accidents (CVAs)—thrombotic, embolic, hemorrhagic, and lacunar—their incidence and prevalence, clinical manifestations, evaluation, and treatment.