NCLEX Review Guide: Stroke

Types of Stroke

• Ischemic stroke: Occurs when a blood vessel supplying blood to the brain is obstructed, accounting for approximately 87% of all strokes. The obstruction can be due to a thrombus (blood clot) that forms locally or an embolus that travels from another part of the body.
• Hemorrhagic stroke: Results from a weakened blood vessel that ruptures and bleeds into the surrounding brain tissue. The accumulated blood compresses the surrounding brain tissue, causing damage. Subdivided into intracerebral hemorrhage (bleeding within the brain) and subarachnoid hemorrhage (bleeding in the space between the brain and the subarachnoid space).
• Transient Ischemic Attack (TIA): Often called a "mini-stroke," a TIA is a temporary disruption of blood flow to part of the brain. Symptoms typically resolve within 24 hours but serve as a serious warning sign for future stroke risk.

Risk Factors

• Modifiable risk factors: Hypertension (leading risk factor), diabetes mellitus, atrial fibrillation, hyperlipidemia, smoking, physical inactivity, obesity, and excessive alcohol consumption. These factors can be controlled through lifestyle changes and medical management.
• Non-modifiable risk factors: Age (risk doubles each decade after 55), gender (higher in males until older age), race (higher in African Americans), family history, and previous stroke or TIA. These factors cannot be changed but should prompt more aggressive management of modifiable factors.

Stroke Symptoms

• FAST assessment: Face drooping (facial asymmetry), Arm weakness (inability to raise both arms equally), Speech difficulties (slurred speech or difficulty finding words), Time to call emergency services if any of these signs are present.
• Other common symptoms: Sudden severe headache with no known cause (especially in hemorrhagic stroke), sudden confusion, trouble seeing in one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, and numbness or weakness of the face, arm, or leg, especially on one side of the body.

Neurological Deficits by Location

• Middle cerebral artery (MCA): Contralateral hemiparesis and sensory loss affecting face and arm more than leg, homonymous hemianopsia (visual field defect), aphasia (if dominant hemisphere affected, usually left), and neglect syndrome (if non-dominant hemisphere affected, usually right).
• Anterior cerebral artery (ACA): Contralateral weakness and sensory loss affecting leg more than arm, urinary incontinence, and personality changes including apathy, disinhibition, or abulia (lack of willpower).
• Posterior cerebral artery (PCA): Homonymous hemianopsia, visual agnosia (inability to recognize objects), memory deficits, and occasionally cortical blindness if bilateral.
• Vertebrobasilar system: Vertigo, nausea, vomiting, diplopia, ataxia, dysarthria, dysphagia, and crossed sensory and motor deficits (ipsilateral cranial nerve deficits with contralateral motor deficits).

Immediate Assessment

• National Institutes of Health Stroke Scale (NIHSS): Standardized assessment tool used to quantify the severity of stroke. Evaluates level of consciousness, vision, facial palsy, motor strength, ataxia, sensation, language, and neglect. Higher scores indicate greater stroke severity.
• Neuroimaging: Non-contrast CT scan is the initial imaging study to differentiate between ischemic and hemorrhagic stroke. CT angiography (CTA) may be performed to identify vessel occlusion or malformations. MRI provides more detailed information but may not be immediately available.
• Laboratory studies: Complete blood count, coagulation studies (PT/INR, PTT), blood glucose, electrolytes, renal function tests, cardiac enzymes, and toxicology screen as indicated. These tests help identify contributing factors and guide treatment decisions.

Additional Diagnostic Studies

• Carotid doppler/ultrasound: Non-invasive imaging to evaluate carotid arteries for stenosis or occlusion, particularly useful in patients with anterior circulation strokes.
• Echocardiogram: Transthoracic (TTE) or transesophageal (TEE) echocardiogram to identify cardiac sources of emboli such as thrombi, valvular disease, or patent foramen ovale.
• Electrocardiogram (ECG): To identify atrial fibrillation or other cardiac arrhythmias that may contribute to cardioembolic strokes.
• Cerebral angiography: Gold standard for evaluating cerebrovascular anatomy, particularly useful for identifying aneurysms or arteriovenous malformations in hemorrhagic stroke.

Ischemic Stroke Treatment

• Thrombolytic therapy: Intravenous recombinant tissue plasminogen activator (tPA or alteplase) is the standard treatment for eligible patients within 4.5 hours of symptom onset. The dose is 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder infused over 60 minutes.
• Mechanical thrombectomy: Endovascular procedure to physically remove a clot, indicated for large vessel occlusions in the anterior circulation within 24 hours of symptom onset in selected patients. Can be performed with or without prior IV tPA administration.
• Antiplatelet therapy: Aspirin (325 mg initially, then 81-325 mg daily) is typically started within 24-48 hours after stroke onset if thrombolytics are not given or after the 24-hour post-thrombolytic period.

tPA Administration Protocol

1. Confirm eligibility based on time window and absence of contraindications
2. Calculate dose based on patient weight (0.9 mg/kg, maximum 90 mg)
3. Administer 10% of total dose as IV bolus over 1 minute
4. Infuse remaining 90% over 60 minutes
5. Monitor vital signs and neurological status: every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly until 24 hours after treatment
6. Maintain BP <180/105 mmHg for 24 hours after tPA
7. Hold anticoagulants and antiplatelets for 24 hours after tPA

Hemorrhagic Stroke Treatment

• Blood pressure management: For intracerebral hemorrhage, target systolic BP <140 mmHg in the first hours after onset. Common IV agents include labetalol, nicardipine, and clevidipine. For subarachnoid hemorrhage, maintain systolic BP <160 mmHg until the aneurysm is secured.
• Reversal of anticoagulation: For patients on warfarin, administer prothrombin complex concentrate (PCC) and vitamin K. For direct oral anticoagulants (DOACs), specific reversal agents may be used: idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors (apixaban, rivaroxaban).
• Neurosurgical intervention: May be indicated for cerebellar hemorrhages >3 cm, hemorrhages with significant mass effect or hydrocephalus, or for surgical clipping or endovascular coiling of ruptured aneurysms in subarachnoid hemorrhage.

Neurological Assessment

• Neurological checks: Perform frequent assessments using the Glasgow Coma Scale (GCS) and NIHSS. Monitor level of consciousness, pupillary response, motor function, sensory function, cranial nerve function, and vital signs. Frequency depends on patient status and hospital protocol but typically every 1-2 hours in acute phase.
• Deterioration indicators: Watch for decreasing level of consciousness, new or worsening neurological deficits, severe headache, vomiting, seizures, or significant changes in vital signs (particularly elevated BP or bradycardia with hypertension suggesting increased intracranial pressure).

Airway and Respiratory Management

• Airway protection: Position patient with head of bed elevated 30° unless contraindicated. Assess swallowing before oral intake using a formal dysphagia screening tool. Implement aspiration precautions including proper positioning during meals, thickened liquids if prescribed, and suction equipment at bedside.
• Oxygen therapy: Maintain oxygen saturation >94%. Supplemental oxygen should be provided only if hypoxemia is present, as hyperoxia may be harmful.
• Intubation considerations: Intubation may be necessary for patients with decreased level of consciousness (GCS <8), inability to protect airway, or respiratory insufficiency. Rapid sequence intubation with medications that minimize increases in intracranial pressure is preferred.

Blood Pressure Management

• Ischemic stroke parameters: For patients not receiving thrombolytics, permissive hypertension with cautious treatment only if BP exceeds 220/120 mmHg. For patients receiving tPA, maintain BP <180/105 mmHg for 24 hours after administration.
• Hemorrhagic stroke parameters: More aggressive BP control with target systolic BP <140 mmHg. IV antihypertensives with short half-lives (labetalol, nicardipine, clevidipine) are preferred for precise titration.
• Hypotension management: Hypotension should be promptly addressed as it can worsen cerebral perfusion. Isotonic fluids (normal saline) should be used for volume resuscitation, and vasopressors may be necessary if fluid resuscitation is inadequate.

Preventing Complications

• Deep vein thrombosis (DVT) prophylaxis: Implement early mobilization when appropriate. Apply intermittent pneumatic compression devices. Pharmacological prophylaxis with low molecular weight heparin or unfractionated heparin may be started 24-48 hours after ischemic stroke if bleeding risk is low, and after 48-72 hours for hemorrhagic stroke with stable imaging.
• Pressure injury prevention: Perform regular skin assessments, implement turning schedule (every 2 hours), use pressure-redistributing surfaces, maintain proper positioning, and ensure adequate nutrition and hydration.
• Bladder and bowel management: Avoid indwelling catheters when possible or remove as soon as feasible. Implement bladder training program. Monitor for constipation and implement bowel program as needed.
• Glucose management: Monitor blood glucose levels and maintain between 140-180 mg/dL. Both hyperglycemia and hypoglycemia can worsen neurological outcomes.

Early Rehabilitation

• Multidisciplinary approach: Coordinated care by physical therapy, occupational therapy, speech-language pathology, rehabilitation nursing, and neuropsychology. Assessment should begin as soon as the patient is medically stable, typically within 24-48 hours of admission.
• Positioning and mobility: Proper positioning to prevent contractures, shoulder subluxation, and pressure injuries. Position affected extremities in functional alignment using supportive devices as needed. Progress mobility as tolerated from bed mobility to sitting, standing, and ambulation with appropriate assistive devices.
• Activities of daily living (ADLs): Encourage independence in self-care activities with adaptive equipment as needed. Use affected side during activities to promote neuroplasticity and prevent learned nonuse.

Communication and Swallowing

• Aphasia management: Aphasia is an impairment in language comprehension or production resulting from damage to language centers in the brain. Establish reliable communication method (yes/no responses, communication boards, gestures). Speak in short, simple sentences and allow extra time for response. Avoid speaking loudly (unless patient has hearing impairment) or using childish language.
• Dysarthria interventions: Dysarthria is a motor speech disorder resulting from neurological injury affecting the muscles used for speech. Encourage slow, deliberate speech with adequate breath support. Teach compensatory strategies such as overarticulation and pacing.
• Dysphagia management: Dysphagia is difficulty swallowing that can lead to aspiration pneumonia, malnutrition, and dehydration. Implement recommendations from formal swallowing evaluation, which may include diet modifications (thickened liquids, pureed foods), swallowing techniques (chin tuck, double swallow), and swallowing exercises to strengthen affected muscles.

Secondary Prevention

• Antiplatelet therapy: For non-cardioembolic ischemic stroke, options include aspirin (81-325 mg daily), clopidogrel (75 mg daily), or aspirin plus extended-release dipyridamole. The specific agent depends on patient factors, stroke mechanism, and comorbidities.
• Anticoagulation: For cardioembolic stroke (particularly with atrial fibrillation), options include warfarin (target INR 2-3) or direct oral anticoagulants (apixaban, dabigatran, edoxaban, rivaroxaban). The timing of initiation after stroke depends on stroke severity and infarct size.
• Statin therapy: High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) is recommended for most ischemic stroke patients, regardless of baseline LDL cholesterol levels.
• Risk factor modification: Blood pressure control (target <130/80 mmHg for most patients), diabetes management (target HbA1c <7%), smoking cessation, weight management, regular physical activity, and limited alcohol consumption.

• Pathophysiology: Strokes are classified as ischemic (87%, caused by vessel obstruction) or hemorrhagic (13%, caused by vessel rupture). TIAs are temporary episodes that resolve within 24 hours but indicate high risk for future stroke.
• Assessment: Use the FAST method (Face, Arms, Speech, Time) for initial stroke recognition. The NIHSS provides standardized assessment of stroke severity. Different vascular territories produce distinct patterns of neurological deficits.
• Acute management: "Time is Brain" - IV tPA is indicated within 4.5 hours of symptom onset for eligible patients with ischemic stroke. Mechanical thrombectomy may be performed up to 24 hours in selected patients. Hemorrhagic stroke requires aggressive BP control and possible surgical intervention.
• Nursing care: Frequent neurological assessments, airway protection, proper positioning, swallowing evaluation before oral intake, and prevention of complications (DVT, pressure injuries, aspiration) are essential.
• Rehabilitation: Early, intensive, multidisciplinary rehabilitation improves functional outcomes. Communication disorders and dysphagia require specialized interventions.
• Secondary prevention: Includes antiplatelet or anticoagulant therapy as appropriate, statins, and aggressive risk factor modification to prevent recurrent stroke.

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