Introduction

(Cerebrovascular Accident; Stroke)

A heterogeneous group of vascular disorders that result in brain injury.

Each year, about 750,000 Americans have a stroke, and about 150,000 of them die. Stroke is the third leading cause of death in the USA and in most other industrialized countries. At any time, there are about 2 million stroke survivors in the USA. Stroke incidence and mortality rate increase with age, especially after age 65 (see Table 44-1). About 72% of persons who have a stroke in a given year are >= 65, and > 88% of persons who die of stroke are >= 65. Prevalence in the USA is generally higher among men and blacks (see Figure 44-1).

More impressive than the mortality rates are the ways in which stroke changes the survivor's quality of life. Daily functioning in the workplace, home, and community is often reduced, and many stroke patients are impaired in their ability to walk, see, and feel. Some cannot read, recall, think, speak, or otherwise communicate as well as they could before the stroke. Dementia may result, especially if multiple lacunar infarcts occur.

The complications of stroke may be more devastating than the stroke itself. Strokes activate the body's clotting system, potentially leading to venous thromboembolism and myocardial infarction during the acute period or during convalescence. At times, determining whether the myocardial ischemia or the brain ischemia came first is difficult.

Prevention

Preventing strokes is far better than treating them. Much of prevention is best begun before old age; nonetheless, many preventive measures are still relevant for the elderly (see Table 44-2).

Because early treatment of stroke can be beneficial, all patients at risk should be taught about the early symptoms of stroke (see Table 44-3). They should be told to seek immediate medical attention if they have such symptoms, with emphasis that treatment should be started within 3 to 6 hours.

Prognosis

Recovery after a stroke has two aspects: neurologic and functional. The extent of neurologic recovery depends on the mechanism, location, and size of the lesion. In general, the smaller the lesion, the better the recovery. About 90% of neurologic recovery usually occurs within 3 months. The remaining 10% occurs more slowly. Recovery after hemorrhagic stroke is particularly slow.

Recovery depends on the personal and socioeconomic circumstances of the stroke patient as much as (if not more than) on the injury itself. The patient's physical capabilities and mental health before the stroke are important predictors of subsequent ability to cope and to work toward recovery. Depression, which is common after a stroke, may impede recovery. Patients are much more likely to return to an active, useful life if they have good resources and a living environment that facilitates independence (eg, a first-floor residence; a car or access to a driver; nearby shopping, recreational, and medical facilities; income for rehabilitation equipment and therapists). A home caregiver is extremely important to recovery.

Treatment and End-of-Life Issues

The health care team must establish an appropriate care plan as soon as possible. Early, aggressive treatment can often effect dramatic improvement. However, aggressive treatment is not warranted for all patients. For some patients, treatment is unlikely to help, because their quality of life is and will remain extremely poor. In such cases, supportive care is the focus. Advance directives (eg, living wills, durable power of attorney), if available, can help physicians determine what kind of supportive care to provide for the patient (eg, hydration, nutrition, treatment of infections and pain).

The coexistence of other serious disorders (eg, cancer, incapacitating heart or lung disease, dementia) may affect treatment decisions. Certain treatments may be contraindicated--eg, anticoagulants for patients with severe hypertension or gastrointestinal bleeding. Some treatments (eg, anticoagulants, vascular or brain surgery) have higher risks and complication rates in the elderly; however, age alone is not an absolute contraindication to treatment.

Aggressive diagnostic tests, invasive medical and surgical therapies, and prolonged bed rest often tax the spirit and vigor of elderly patients. Pneumonia, limb contractures, pressure sores, and depression are particularly common and must be prevented or treated if present. Antidepressants are particularly effective in treating the depression caused by stroke. Certain strategies can help prevent and manage stroke complications (see Table 44-4).

If a local institution is not equipped to care for stroke patients with potential for recovery, transfer to a special center is warranted. Similarly, rehabilitation is best performed in special centers.

Nursing Issues

Nurses must be vigilant in preventing sleep problems, problems with eating and feeding, incontinence, confusion, falls, and skin breakdown, which are common among patients with cerebrovascular disease and which can be serious, even fatal. Nurses must also watch for the development of depression, which is common after a stroke. A nurse usually coordinates an interdisciplinary team, helping organize arrangements for the patient's discharge and helping develop a postdischarge care plan. An interdisciplinary team is needed because cerebrovascular disease is complex and devastating and because team members can follow the patient across care settings.

Developing a postdischarge care plan that is likely to be followed is difficult. Basic issues must be considered; they include transportation to appointments, the patient's willingness to participate in rehabilitation therapy, the patient's ability to adhere to complicated drug regimens, and the patient's willingness and ability to work with caregivers such as nursing attendants in the home. The patient, family members, and home caregivers must attend discharge planning meetings. Consequently, times and locations for the meetings should accommodate these persons.