Identify the vessel, recognize the

By Susan Tocco, MSN, CNS, CNRN, CCNS

EARLY

Stroke signs and symptoms vary with the affected blood vessel. Heres what you need to know when assessing suspected stroke victims.

stroke
Effects of a complete MCA stroke The hallmarks of an MCA stroke are the focus of most public-awareness messages and prehospital stroke assessment toolsfacial asymmetry, arm weakness, and speech deficits. Complete MCA strokes typically cause: hemiplegia (paralysis) of the contralateral side, affecting the lower part of the face, arm, and hand while largely sparing the leg contralateral (opposite-side) sensory loss in the same areas contralateral homonymous hemianopiavisual-field deficits affecting the same half of the visual field in both eyes. MCA strokes affect the face and arm more severely than the leg, so make sure to focus your assessment on the face and arm. Ask the patient to smile. If your patient cant follow this or other commands, apply a noxious stimulus to induce a grimace, and observe for asymmetry of the lower part of the face. Next, assess hand and arm strength. If your patient is uncooperative, observe spontaneous movement and look for differences between the right and left sides. Also check for a palmar drift or hand or arm weakness. Right side vs. left side Laterality of an MCA stroke determines additional signs and symptoms. If the stroke affects the left (or dominant) brain hemisphere, the patient may experience aphasia
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RECOGNITION and treatment of stroke can improve patient outcomes significantly. Its essential that nurses in all settings know how to recognize signs and symptoms of stroke, and alert the stroke team or activate 911 immediately. Stroke is a neurovascular condition affecting blood vessels in the brain. The two basic types of stroke are ischemic and hemorrhagic. In ischemic stroke, occlusion of a cerebral artery causes damage to the brain tissue dependent on blood supply from the affected vessel. In hemorrhagic stroke, a cerebral artery leaks blood, which damages adjacent brain tissue. Basics of the brains blood supply are relatively easy to remember. The carotid arteries supply the anterior portion of the brain, which includes most of the cerebrum. The vertebral arteries, housed in the cervical vertebral column, merge to form the basilar artery feeding the posterior portion of the brain, which houses the cerebellum and brain stem. (See Arteries supplying the cerebrum.) This article discusses the major cerebral blood vessels and the functional areas each vessel suppliesknowledge that helps you focus your neurologic assessment. Then it describes how patient assessment differs by suspected stroke location. The American Stroke Association recommends clinicians perform neurologic asAmerican Nurse Today

sessments at least every 4 hours on patients with acute strokes. More frequent assessment may be needed for a patient who is unstable, has fluctuating signs or symptoms, or has received thrombolytics.

Strokes of the middle cerebral artery

The largest vessel branching off the internal carotid artery, the middle cerebral artery (MCA) is the most common cerebral occlusion site. For this reason, signs and symptoms of MCA strokes are the most important to remember. (See Major arteries supplying the brain.) The MCA feeds an enormous territory of brain, including the frontal, temporal, and parietal lobes and the brains deep structuresbasal ganglia and internal capsule. The MCA has a main stem and several branches arising from it. Occlusion of the main stem affects the entire territory of brain supplied by the MCA. Distribution of the MCA is so large that a stroke of the main stem puts the victim at risk for severe disability or death. In contrast, occlusion of an MCA branch damages a smaller brain territory and causes less severe disability. (As an analogy, if a traffic accident occurs on a large interstate, the effect is severe, potentially disrupting an entire region or city. But an accident that blocks only a side street has a much smaller impact.)

Volume 6, Number 9

Arteries supplying the cerebrum

Understanding which areas of the brain are supplied by each blood vessel helps you identify the location of your patients stroke during your examination. This color-coded illustration shows the vascular territories of major cerebral arteries. Cortical vascular territories

Anterior cerebral artery Middle cerebral artery Posterior cerebral artery

(partial or total loss of the ability to communicate through language). Aphasia may be expressive (difficulty converting thoughts into language), receptive (difficulty understanding verbal and written language), or both. To quickly assess for expressive aphasia, ask the patient to name common objects, such as a pen, a watch, or a key. Throughout the exam, note how the patient converses with you. Does he or she have difficulty naming objects or expressing thoughts? To quickly assess for receptive aphasia, ask the patient to follow commands; for example, Show me two fingers on your left hand or Open and close your eyes. Note whether the patient follows these commands. Does he or she simply nod or shake the head in response to a yes or no question? Be aware that patients with receptive aphasia can understand nonverbal
10 American Nurse Today

communication, including the stress and intonation patterns of speech; this may allow them to give the correct response. Most people are left-hemisphere dominant, meaning the speech/ language center is in the brains left side. Thus, expect a patient with right-sided weakness to have aphasia, and focus your exam accordingly. A small percentage of left-handed persons have righthemisphere dominance. If your patient has left-sided weakness and aphasia, ask which is the dominant hand to better understand his or her signs and symptoms. With a stroke affecting the right (or nondominant) hemisphere, the patient may show signs of unilateral neglect. This complex problem involves a spectrum of manifestations, including decreased awareness or failure to attend to the left side and lack of awareness or concern about the deficits. Note whether the patient has the head turned away from the left side or seems to ignore stimuli on the left side. Neglect is most often associated with right-hemisphere strokes, so expect a patient with left-sided weakness to have neglect as welland stay especially alert for this sign.

and sensation. Keep in mind that behavioral abnormalities and incontinence also may occur. Posterior cerebral artery The posterior cerebral artery (PCA) arises from the top of the basilar artery and feeds the medial occipital lobe and inferior and medial temporal lobes. Vision is the primary function of the occipital lobe, so a stroke affecting PCA distribution commonly causes visual deficits specifically contralateral homonymous hemianopia. (While an MCA stroke also may cause this symptom, in that case the visual deficit stems from damage to the visual pathways rather than direct occipital-lobe injury.) A patient who has had a PCA stroke may report inability to see out of one eye. To investigate this complaint, have the patient cover one eye; assess vision in each of the eyes four quadrants, and repeat the exam in the other eye. Know that although patients with a right PCA stroke may report poor vision in the left eye, they actually have a visual deficit affecting the left side of the visual field of both eyes. Larger PCA strokes also may cause contralateral hemiparesis and hemisensory loss. Large left PCA strokes may result in aphasia, whereas right PCA strokes may cause neglect.

Strokes in other vessels supplying the cerebrum

Although strokes affecting the brains other vascular territories are much rarer than MCA strokes, their features are important to remember. Anterior cerebral artery The anterior cerebral artery (ACA) branches off the internal carotid artery and supplies the anterior medial portions of the frontal and parietal lobes. Its the vessel least commonly affected by strokes, so a stroke involving the ACA can easily be misdiagnosed. Classic signs of an ACA stroke are contralateral leg weakness and sensory loss. Be sure to evaluate lower-extremity strength

Vertebral-basilar strokes
A stroke affecting the vertebralbasilar circulation can affect the cerebellum, brain stem, or both. Cerebellar strokes Cerebellar strokes commonly impair balance and coordination. Assess for ataxia (incoordination) by having the patient extend the index finger and then alternately touch your finger and his or her nose. Do this on both sides. Note difficulty moving the finger in a straight line. Next, have the patient slide the heel up and down the shin of the other leg, and repeat
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Volume 6, Number 9

Major blood vessels supplying the brain

This illustration shows the major blood vessels supplying the brain. They arise from the circle of Willisthe system of communicating arteries at the base of the brain, where the carotid and vertebrobasilar arteries form a circle and where other arteries arise.

light intolerance, nausea and vomiting, and impaired level of consciousness than ischemic strokes. Generally, patients with hemorrhagic strokes are more critically ill than those with ischemic strokes.

Differentiating stroke from other conditions

Keep these key points in mind when evaluating your patient for acute stroke signs and symptoms. Determine if your patients symptoms had a sudden onset. Stroke symptoms tend to be more sudden than those of other conditions. Find out if your patient has stroke risk factors, such as hypertension, atrial fibrillation, smoking, heart failure, carotid stenosis, or coronary artery disease. (But know that patients without obvious risk factors can still have strokes.) Review the medical history. Are the patients current deficits old or new? Assess for nonstroke conditions that can cause neurologic effects, such as hypoglycemia, hyponatremia, medication, sudden blood pressure drop, and (if your patient had a seizure) a postictal state.

this on the other side. Again, note whether the patient has difficulty moving in a straight line. If possible, have the patient walk as you assess gait. Can he or she walk in a straight line, or is the gait uncoordinated? Know that cerebellar strokes also may cause vertigo, nausea and vomiting, headache, nystagmus, and slurred speech. Brain stem strokes Although rare, brain stem strokes can be devastating. Signs and symptoms differ with the specific stroke location, but may include hemiparesis or quadriplegia, sensory loss affecting either the hemibody (half of the body) or all four limbs, double vision, dysconjugate gaze, slurred speech, impaired swallowing, decreased level of consciousness, and abnormal respirations. Patients with brain stem strokes are likely to be critically ill and may require emergency intubation and mechanical ventilation.

ind out if your patient has stroke risk

factors, such as atrial fibrillation, heart failure.

cause, such as hypertension or rupture of an aneurysm or an arteriovenous malformation. Hemorrhagic strokes cause the same focal symptoms described above, depending on which artery is affected. However, they typically result in more pronounced headaches, neck pain,

hypertension, smoking, or

Time is brain
Early recognition of a stroke is essential, because a stroke cant be treated unless its recognized. Acute stroke interventions are time-sensitive. In most cases, they must be initiated within 3 to 6 hours of known onset. The ability to promptly assess stroke signs and symptoms can dramatically affect patient outcomes and reduce the risk of disability. Be your patients hero by recognizing a stroke. *
Visit www.AmericanNurseToday.com/ Archives.aspx for a list of selected references, an illustration of the functional brain areas, and information about a validated stroke assessment tool.

Hemorrhagic stroke
A hemorrhagic stroke occurs when a cerebral artery leaks blood into the brain due to a nontraumatic
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Susan Tocco is a neuroscience clinical nurse specialist at Orlando Regional Medical Center in Orlando, Florida.
American Nurse Today 11

September 2011

Functional areas of the brain

This illustration shows the brains functional areas. After a stroke, deficits in function depend on which cerebral artery is affected.
Voluntary eye movement Motor and speech production Higher intellect Self-control Inhibition Emotions Motor and speech production Motor skills development Sensation Language comprehension Vision

Memory

Auditory

Equilibrium and muscle coordination

NIH stroke scale

The National Institutes of Health Stroke Scale (NIHSS) is a validated 15-item neurologic assessment tool that can be used to evaluate the patients current status and the size of the ischemic stroke. It encompasses level of consciousness, visual-field deficits, eye movements, motor/sensory changes, ataxia, aphasia, and inattention/neglect. You can access the tool at http://www.ninds.nih.gov/doctors/ NIH_Stroke_Scale.pdf. Generally, a complete NIHSS is done in the emergency department or after the stroke patient is admitted to the unit. Some hospitals instead opt for ongoing neurologic assessments using abbreviated versions of the NIHSS (typically with fewer than 15 items). However, these versions may miss some neurologic findings, especially in patients with lower scores. Any decline in a modified NIHSS score should prompt an immediate assessment using the complete NIHSS to identify changes in the patients status.