Stroke/Cerebrovascular Disease Essay

Transient ischemic attack (TI

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These symptoms usually only last for a matter of minutes and TIA is also referred to as a “mini stroke.” Symptoms that do not resolve after 24 hours, however, indicate a full stroke. A person who has experienced a TIA needs to be evaluated and treated as soon as possible to minimize the chance of a further TIA or full stroke occurring.

Stroke or cerebrovascular accident (CVA)
This is an event that occurs as a result of restricted or blocked supply of blood to the brain. Most commonly, the blockage is caused by a blood clot. Starved of oxygen and nutrients, parts of the brain cells start to die which can cause brain damage or even death.Stroke/Cerebrovascular Disease Essay

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The main points to be aware of in stroke are represented by the acronym FAST where the letters stand for the following:

Face – An eye or corner of the mouth may be drooped on one side of the face. A person may drool and have a lack of expression due to paralysis of the facial muscles on one side of the face.
Arms – The person may be unable to raise their arms due to paralysis and weakness of the muscles.
Speech – Speech may be indistinct, slurred or completely absent.
Time – Medical attention must be sought as soon as possible after symptom onset, as the sooner the patient is treated, the more likely they are to recover and not suffer from brain damage.
Subarachnoid hemorrhage
This is a form of stroke that occurs when leaking blood accumulates on the surface of the brain. The leak is usually caused by an aneurysm rupturing beneath a membrane called the arachnoid, which leads to the accumulation of blood in the subarchnoid space. A subarachnoid hemorrhage can also be caused by a severe head injury or a birth defect that causes arteriovenous malformations.Stroke/Cerebrovascular Disease Essay

Vascular dementia
Vascular dementia refers to a decline in mental aptitude linked to slowly dying brain cells. Problems with the blood vessels cause a reduced supply of blood to parts of the brain, which become damaged and may eventually die off.

Stroke carries a high risk of death. Survivors can experience loss of vision and/or speech, paralysis and confusion. Stroke is so called because of the way it strikes people down. The risk of further episodes is significantly increased for people having experienced a previous stroke. The risk of death depends on the type of stroke. Transient ischaemic attacks or TIA – where symptoms resolve in less than 24 hours – have the best outcome, followed by stroke caused by carotid stenosis (narrowing of the artery in the neck that supplies blood to the brain). Blockage of an artery is more dangerous, with rupture of a cerebral blood vessel the most dangerous of all.

Annually, 15 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing a burden on family and community. Stroke is uncommon in people under 40 years; when it does occur, the main cause is high blood pressure. However, stroke also occurs in about 8% of children with sickle cell disease.Stroke/Cerebrovascular Disease Essay

High blood pressure and tobacco use are the most significant modifiable risks. For every 10 people who die of stroke, four could have been saved if their blood pressure had been regulated. Among those aged under 65, two-fifths of deaths from stroke are linked to smoking. Atrial fibrillation, heart failure and heart attack are other important risk factors. The incidence of stroke is declining in many developed countries, largely as a result of better control of high blood pressure and reduced levels of smoking. However, the absolute number of strokes continues to increase because of the ageing population.

Founded in 1907, the University of Pavia’s Clinica Neuropatologica (Clinic for Nervous and Mental Diseases) was created as an institution for the diagnosis and treatment of neuropsychiatric disorders and, in line with what was happening (or would later happen) to similar institutions, it was built outside the complex of the city’s main hospital (the San Matteo Hospital). In the years immediately following its foundation, the institute’s location was actually to prove its fortune, endowing it with those peculiar characteristics and qualities that still today identify it in the minds of the people of the city and province of Pavia; however, as was to prove the case for all clinics similarly located, this circumstance was to end up leaving the institute in “splendid” isolation, excluded from the organisational, and even cultural, developments of more recent years. The move to the new site in via Mondino, a modern and much more comfortable building, was not to succeed in resolving this problem completely, given the institute’s new orientation as, primarily, a hospital health care facility; indeed, as such, it feels acutely, and at times painfully, its isolation from hospitals in which it could fulfil the role that, correctly, is now starting to be envisaged for neurology, today and in the future.Stroke/Cerebrovascular Disease Essay

Over time there has emerged a growing contraposition between two different models, or versions, of neurology. On the one hand, we have “academic” (or classical) neurology, which, while boasting a refined diagnostic approach, remains one of the few disciplines using a semiological framework that has moved on very little, if at all, from the body of knowledge of the past century; furthermore, it also has the severe drawback of offering few or no treatment options. On the other hand, we have “emergency” neurology, which, being primarily geared at the management of critical conditions on admission to hospital or during hospitalisation, is deeply integrated with the other (more or less general) medical specialties, and has an operational approach that is at odds with the erudite, sometimes almost philosophical, case discussion that has become a feature of the first “version” of this discipline. The intensive care hospital is the right setting for the practice of emergency neurolo gy, which involves semi-intensive type care and close contact with other intensive and semi-intensive care units and departments, such as the coronary unit and emergency room or accident and emergency department. Operating in this way, the emergency neurology unit is able to “intercept” the neurological needs of patients on their admission to hospital, or at the onset of specific complications in other units of the same hospital. As such, it can be seen as the natural evolution of the model of organisation represented by the stroke unit, which is given over to the diagnosis and treatment of acute cerebrovascular diseases and is a technologically and culturally advanced area for the management of critical neurological conditions that would otherwise have to be treated in non-specialist settings, with all the attendant drawbacks and problems (low diagnostic specificity, more diagnostic tests, longer hospitalisations, uncertain impact of non-specialistic therapies). In view of these considerations, it can reasonably be asserted that stroke care has been the driving force behind the definitive development of (emergency) neurology, given that it is, precisely, changing ideas on diagnosis and treatment that have allowed the transition from a “nihilistic” to an “interventional” approach, characterised by interventions within the very first hours of the acute event, links with emergency services (but also with rehabilitation services) and, finally, the development of management outlooks that are completely new and, above all, geared at reducing mortality and disability, not only from stroke but also from other acute neurological diseases. At the present time, the “classical model” (high specialty) of neurology is still in operation in the Mondino Institute; but alongside it there is also an emergency neurology unit and a neurorehabilitation unit which has close links with a widespread territorial network. In this way the institute is able to offer a complete range of neurological services in line with the direction this discipline is taking.Stroke/Cerebrovascular Disease Essay

At first glance, this whole process may seem to have very little to do with the historical figure of Ottorino Rossi and his activities within the University of Pavia.

However, in actual fact, in Rossi’s 1906 essay “L’arteriosclerosi dei centri cerebrali e spinali”, which he wrote while still an assistant at the Clinic of Nervous and Mental Diseases of the University of Pavia (directed by Professor Casimiro Mondino), we encounter a rather unusual, or at least unexpected (i.e. not particularly “contemplative”) approach to the problem of cerebrovascular disease, which he interpreted in an essentially anatomopathological way (the only one possible at the time), also identifying some therapeutic possibilities, which were interesting not least because of their scope for further development (1).

What Rossi wrote in 1906 is clearly in line with what, in much more recent times, has been written about the approach to cardiovascular and cerebrovascular risk in the atherothrombotic patient. In short, he showed the benefit of a holistic view of the problem and accepted, in part, the more classically cardiological view of the local acute coronary event as a complication of atherosclerotic plaque rupture.Stroke/Cerebrovascular Disease Essay

Atherothrombosis is characterised by an unpredictable and sudden disintegration (rupture or fissure) of an atherosclerotic plaque; this causes platelet activation leading to thrombus formation and occlusion of the vessel where the plaque is located. It is the basic condition that determines the events leading to myocardial infarction, ischaemic stroke, peripheral artery disease and vascular death, and it is the final consequence of atherosclerosis, which, instead, develops over a period of several decades. Indeed, although the atherosclerotic process begins in an individual’s late teens or twenties, with the formation of fatty streaks and fibrous plaques, the clinical manifestations of the disease are rarely evident before the age of 40 years. Atherothrombosis is a progressive process over time that affects the entire vascular system; it is potentially fatal and it is unpredictable (as regards both the timing of the clinical event and the long-term outcomes).

Rossi’s essay did not fail to point out the pathological complications (or rather consequences) of atherosclerotic lesions of both extracranial and intracranial vessels, and here again it is possible to discern a modern approach to the problem of cerebrovascular disease, i.e. the one that focuses on altered cerebral circulation, whose role is, even today, still not fully and definitively clarified, especially with regard to the possible therapeutic approaches that it might imply.Stroke/Cerebrovascular Disease Essay

Leaving aside the obvious differences from extracranial large vessel disease, it is clearly apparent that intracranial vessels are still little studied (especially in acute settings) and rarely considered candidate sites for recanalisation procedures in ischaemic disease (mechanical or pharmacological thrombectomy); above all, no appropriate long-term therapeutic approaches (as valid as those used to treat the same condition in the major vessels) are known. Finally, appealing as the hypothesis is, the role of genetic factors in the phenotypic expression of intracranial disease has not yet been fully identified (and, with it, possible therapeutic approaches).

Leaving aside observations that are still in part sub judice, like those on vertiginous syndromes linked to atherosclerosis, Rossi’s essay also introduces the important topic of vascular cognitive decline, in other words the condition that, many years later, was to be sweepingly labelled (albeit, unfortunately, in the absence of diagnostic-therapeutic certainties) “vascular dementia”. As chapter 16 of the Italian SPREAD stroke guidelines (Psycho-Cognitive Complications) (2) clearly shows, vascular dementia can be seen as a condition in which the cognitive decline may result from a range of very diverse pathological conditions. Indeed, there exist various forms of vascular dementia: the multi-infarct form (i.e., related to multiple infarcts, even in different arterial territories, as in the case of cardioembolic stroke); the form associated with a single strategic lesion – this often involves a single acute ischaemic event –, which is characterised by the occurrence of a (sometimes peculiar) cognitive disorder resulting from an injury that interrupts (sometimes permanently) the cortico-subcortical circuits that underlie the major cognitive functions; the form associated with cerebral small-vessel disease; the acute and/or chronic hypoperfusion form, seen prevalently in conditions of chronic hypotension (iatrogenic hypotension, chronic autonomic failure, chronic heart failure) or acute prolonged hypotension (heart or carotid surgery); finally, the haemorrhagic form.Stroke/Cerebrovascular Disease Essay

Of all these, the one that has attracted the most interest on the part of researchers in recent years is undoubtedly the “small-vessel disease” form, previously also described as Binswanger’s disease.

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In reality, the definition “small-vessel disease” includes cerebral white matter disorder characterised by diffuse changes of vascular origin (leukoencephalopathy), or by the presence of diffuse lacunar or microlacunar lesions (most often asymptomatic), or by an association of the two.

From the anatomopathological point of view, these structural white matter alterations are underlain by changes in the walls of small cerebral vessels, which lead to the appearance of lipohyalinosis, microaneurysms, microatheromas and even fibrinoid necrosis.

These are conditions that can, of course, translate into a clear susceptibility to hypoperfusion phenomena (occurring, for example, as a response to arterial hypertension that would otherwise be harmful to the microcirculation and the cerebral haemodynamic, possibly leading to leukoaraiosis), haemorrhagic lesions (usually detectable on gradient echo MRI or CT as microbleeds, or larger haemorrhagic lesions, as in the case of typical spontaneous intraparenchymal bleeding), or small focal lesions definable as ischaemic lacunar infarcts, whose physiopathogenetic significance and, particularly, therapeutic implications are still debated today. Additionally, of course, cerebral atrophy alone may be present as a possible anatomopathological picture underlying the clinical manifestations of vascular dementia.Stroke/Cerebrovascular Disease Essay

All this adds up to a complex morphological picture, in which the clinical features can have very different, or excessively similar, connotations. The differential diagnosis of vascular dementia may have to be made versus other forms of dementia, such as Alzheimer’s dementia, even though numerous clinical and neuropsychological findings seem to clearly differentiate the latter.

However, it should not be forgotten that the phenotypic expression of vascular cognitive impairment, too, appears to result from a genetic background that only in some cases corresponds to a monogenic disease (CADASIL, CARASIL, CAA); in other cases it is likely that it is the combination of gene polymorphisms (in themselves insufficient to cause the disease) with vascular risk factors (hypertension, diabetes, smoking, hypercholesterolaemia), and in general with certain environmental conditions, which gives rise to a wide spectrum of clinical conditions. Ottorino Rossi’s descriptions of cases observed at the Clinic for Nervous and Mental Diseases constitute accounts of phenomena that would, many years later, be observed using more appropriate research tools. At the same time, Rossi provided descriptions, even classical ones, of alterations of sensorimotor function possibly dependent on acute-subacute vascular lesions, located both supra- and subtentorially, or in the spinal cord.Stroke/Cerebrovascular Disease Essay

Perhaps because it was following in the wake of a method oscillating between clinical observation (necessary and “compulsory”) and instrumental diagnostic investigation, the Clinica Neuropatologica where Rossi conducted his studies did not fail to equip itself, over the years, with a set (initially simple, even minimal) of instrumental tools. This was enriched in more recent times (early 1970s) with the acquisition of a brain CT scanner (the institute was one of the first in Italy to purchase one); this addition was an important step towards better understanding (and, in part, confirmation) of what had previously been described purely on the basis of anatomopathological observations.

Attempts to establish a functional approach

to vascular pathology

Thus, the whole neurology scenario was set to change and, as proved to be the case for all the branches of modern medicine, to do so in an increasingly rapid and specific manner. Moreover, the Pavia Clinica Neuropatologica had, during the ’70s, brought together, under Prof. Kauchtschischvili, a group of young researchers through whom it was ready to take up, once again, the line of investigation concerning, precisely, cerebrovascular disorders and the haemodynamic, degenerative and functional conditions that can cause them. These young researchers included, among others, Giuseppe Nappi, Marco Poloni, Giorgio Bono, Paola Bo, and Gianpaolo Papandrea. Adopting an approach characterised by openness to collaborations outside the institute, a spirit that would continue in the years that followed, they studied, among other things, cerebral transit time with radioactive tracers (in collaboration with A. Favino of the Institute of Occupational Medicine, University of Pavia).Stroke/Cerebrovascular Disease Essay

In the early 1970s, this group published papers (3-8) on the influence of smoking and other “harmful” exogenous factors, such as chronic alcohol abuse, aging and induced hypoglycaemia, on the functional status of cerebral circulation. The latter was evaluated mainly using a rheograph, a rather rudimentary instrument from whose results it was easy to intuit the involvement of purely mechanical factors capable of influencing the characteristics of the sphygmic wave which this technique claimed to depict. This instrument was used to photograph a “functional abnormality” – no longer an anatomopathological one (as in Rossi’s times) – in the context of diseases whose evolutionary pattern was already quite easy to understand. This was also the period of pharmacological studies using vasoactive substances such as ergot derivatives (vincamine) in the “treatment” of chronic disorders of cerebral circulation. These studies, in addition to rheography, also used another method that might today be considered “curious”, namely ophthalmodynamometry, i.e. the determination of blood pressure in the retinal artery through the application, to the orbit, of an inflatable balloon in order to determine the disappearance of the pressure wave, and thus the evaluation of “intracerebral” circulation (as well as of the efficacy of possible mechanisms of compensation in the presence of intracranial and/or extracranial vessel disease).Stroke/Cerebrovascular Disease Essay

Thanks to the work of the same group, it was not long before these studies of cerebral haemodynamics were embracing other methods, namely the Doppler method and angiography, allowing the description of cases with dolichobasilar and megadolichobasilar artery abnormalities (and also consideration of their possible role in hemifacial spasm, in an early interpretation of what would later more correctly be identified and described as a neurovascular conflict involving the VII cranial nerve) (9,10). At the same time, a National Research Council study – this study was coded ATS-OD2 and its aim was to conduct an instrumental assessment and follow up of patients with cerebrovascular diseases (TIA or minor strokes) observed in the acute or subacute phase – was using methods now fortunately obsolete and long since abandoned, such as EEG recording during carotid compression. This particular application of electroencephalography was, indeed, not free from risks, associated with the possible presence of unstable plaques in the compressed carotid artery. Furthermore, it was not unusual for the sinus stimulation that could derive from this procedure to cause the appearance of a worrying asystole (fortunately short-lasting). Mainly, however, it rarely expressed, in reality, the state of cerebral circulation, and its compensations, following an acute event (11,12).Stroke/Cerebrovascular Disease Essay

Finally, following the acquisition of the cerebral CT scanner, this remarkable tool of investigation also began to be applied to clinical research, particularly research into cerebrovascular diseases, both acute and chronic, through investigations geared mainly at defining clinical pictures related to chronic vascular white matter disease and at describing findings that might be considered topical today, given the fresh interest that has been shown in this disease in recent years, in part thanks to the efforts of a large number researchers, both Italian and foreign (13).

For both the institute and the working group created over many years and coordinated by Prof. Giuseppe Nappi (who co-authors this article), which was mainly oriented towards the study of functional disorders of the nervous system, particularly headaches, this period also constituted a valuable opportunity to investigate the possible links between headache and acute cerebrovascular episodes, especially minor strokes and those episodes that, at the start of the 1980s, were still known as RIAs (reversible ischaemic attacks).Stroke/Cerebrovascular Disease Essay

These investigations of the presence of headache before and/or during and/or after the onset of the ischaemic cerebrovascular symptoms constituted, for the school of the Mondino Institute of Neurology, the moment that marked a real revival of interest in vascular disease in the strict sense, even though some years were still to gothe importance of the categorisation of headaches as the point of transition between affective and cerebrovascular disorders, which, unlike the former, are hallmarked by the final (ischaemic) damage. Indeed, it is always a predisposition to develop headache that, depending on risk factors that are linked to aspects of the internal and external environment, underlies the appearance of the “complication”, and can be inserted among the comorbidities of the two classes of disorders that lie at the two ends of the spectrum.Stroke/Cerebrovascular Disease Essay

There was, in this period, no lack of experimental models simulating the relationship between migraine and vascular disease, a relationship demonstrated, for example, in the response of the cerebral endothelium to nitrates, which are known for their headache-inducing effect and also provide a reliable measure of cerebral vascular reactivity both in physiological and in pathological conditions (diabetes, carotid stenosis, etc.). A similar experimental model allowed the Mondino group to discover the clinical relevance of the use of NO donors, both in acute and in chronic cerebrovascular disease, especially in patients with traditional risk factors, such as diabetes and hypertension (16,17).

In short, the study of cerebrovascular diseases by the Pavia neurological school was well under way again, as is shown by the fact that, from its use of models, both clinical and speculative, borrowed from other interesting diseases such as those affecting the autonomic nervous system (investigated at length in this period, also within the context of various forms of primary headache), it succeeded in making connections that are still very much appreciated today; these include the interesting and useful relationship, supported by a more recent review published in Clinical Autonomic Research, between the autonomic nervous system and ischaemic stroke. Discussion of the activity of the autonomic nervous system was still serving to complement and enrich epidemiological, clinical and/or therapeutic data, providing some very interesting interpretations of pathological events that, in some cases, prompted the opening of new lines of research in the field (17,18).Stroke/Cerebrovascular Disease Essay

The relationship between the autonomic nervous system and stroke is perhaps best enshrined in a very common and increasingly frequent condition (not only among the elderly), namely, atrial fibrillation which, of course, particularly with advancing age, can cause stroke (cardioembolic). However, there exist many other relationships between ischaemic (or haemorrhagic) cerebrovascular disease and changes in vegetative functions. It was for these reasons that the Pavia neurological group, in conjunction with a group of Pavia cardiologists, founded the Italian Society of Cardioneurology, through which, in 1989, an international meeting was organised in Palmi Calabro (Reggio Calabria) which brought together specialists in both disciplines from every part of the world, and came shortly after another interesting meeting held in Pavia (19). The proceedings of this international meeting were published in the book “Neurocardiology Update” (20).Stroke/Cerebrovascular Disease Essay

A stroke unit is established at the C. Mondino Foundation

It was in the early nineties, when the institute was still located at the old site in via Palestro, that we began to develop the necessary know-how, cultural, scientific and organisational, to care for cerebrovascular patients, sometimes in the acute phase. The work, in those early years, was done without a dedicated area. In other words, it was carried out, within the various departments, by an “itinerant” medical team (stroke team). In this period, initial ideas began to take shape on the organisation of what, in 1996, was to become one of Italy’s first stroke units. An area for this unit was selected: one of the large rooms (traditionally occupied by as many as 13 beds) located within the department, at the time directed by Prof. Nappi, was transformed into anopen space designed to accommodate six closely monitored beds, a nursing area and a specially equipped bathroom.

Outside the department, in what had previously (in the old Clinica Neuropatologica) been the “verandah”, i.e. the space given over communal activities, including meals, a small area was created to house the computer equipment. Its purpose was to collect data from the stroke unit monitors, as well as from the computerised patient records that were gradually being introduced in this period, and from nursing folders. This use of advanced IT solutions and software revolutionised many aspects of the care of cerebrovascular patients in our stroke unit (workflow management, compliance with Italian SPREAD guidelines, assessment of clinical risk, and so on).Stroke/Cerebrovascular Disease Essay

The stroke unit was enthusiastically welcomed by the nursing staff, some of whom still work there today (the unit was transferred to the institute’s new site in 2003), as well as by the physicians and all those who, over the years, have made a crucial contribution to the work done there (rehabilitation therapists, physiotherapists, psychologists, social workers and bioengineers). Its inauguration provided the opportunity for a congress, held at the “old” Mondino site, which was attended by the specialists (vascular surgeons, neurosurgeons and others) who, with sacrifice and enthusiasm over many years of joint collaboration, had taken part in all the work on cerebrovascular diseases (21).

The stroke unit, thanks to its well-known organisational and management features, was a setting ideally equipped for ensuring accurate identification of a patient’s risk profile, continuous monitoring of vital signs, prompt therapeutic interventions in response to neurological and/or medical complications, standardisation of specific treatment procedures for stroke, and effective and rapid multidisciplinary consultations.Stroke/Cerebrovascular Disease Essay

At the same time, it opened the way for the development of management models for improvement of nursing and for initiatives geared at involving, and raising awareness among, the general public; examples in this regard include information campaigns carried out first in the province of Pavia and then at regional level (PRESTO and ASL MI2 projects), and projects developed for the Ministry of Health (on more advanced and effective computer-based models of care).

The intensive work carried out in recent years in the sphere of information, aimed both at the public and, in particular, at patients and their families, is illustrated by the publication (in early 2003) of the booklet entitled “The stroke patient: what do I do when he comes home?”

This booklet, born of the collaboration between all the professionals who took part in the information campaigns held at provincial level (especially those organised in rehabilitation centres), was published in no less than 100,000 copies and quickly became a “must” from which many other healthcare professionals have drawn inspiration for similar initiatives.Stroke/Cerebrovascular Disease Essay

Similarly, the intensive and enthusiastic collaboration with the Department of Computer Science and Systems Engineering of the University of Pavia (in particular with the late Mario Stefanelli, and with Silvana Quaglini and Silvia Panzarasa, among others) allowed us to develop and test some extremely interesting management models (22). The Pavia group came to international renown through its study and demonstration of the important benefits to be obtained from adherence to guidelines (first those of the AHA and then the Italian SPREAD guidelines), namely reduction of mortality and disability as well as of hospitalisation costs. The collaboration with this group led to the development of computerised medical record systems equipped with software, such as that for assisted clinical decision-making (workflow management), whose applications continue to be used in both the nursing and the medical areas.

At the same time, the capacity, thanks to the computer systems used, to store numerous data has allowed us to publish some extremely interesting studies, including one on the importance of monitoring in the care of the acute cerebrovascular patient (23). The up-to-date models developed and the results obtained have allowed the centre based at the C. Mondino Institute to be among the first and the most advanced stroke units in Italy, and also to participate (as the only Italian centre) in the Stroke Unit Trialist Collaboration, coordinated by Peter Langhorne.Stroke/Cerebrovascular Disease Essay

The experience gained through these projects, as well as through the everyday care of the patients regularly referred to the stroke unit (both at the “new” and the “old” site) – in spite of the absence, already noted, of an accident and emergency department –, contributed, in the early 2000s, to the development of regional health care models. These models were finalised after the important PROSIT project (the first author of this piece was also a member of the scientific committee of that project, coordinated by Livia Candelise, Milan, which demonstrated the superiority of the stroke unit compared with traditional departments: a net reduction [9%] of mortality and disability), and included the stroke unit in the Lombardy Regional Health Plan 2002-2004, in the subsequent regional “Cardiocerebrovascular Plan”, and in the documents of the regional Cardiocerebrovascular Commission. All this led to decisions, at regional level, of great importance from the perspective of the organisation of stoke units and their integration with emergency and rehabilitation services (24-26).Stroke/Cerebrovascular Disease Essay

A stroke registry and emergency neurology

Alongside these developments, there also began to develop, within a joint SIN-SNO (Italian Society of Neurology and Society of Hospital Neurosciences), group founded in Milan in 2008 during the annual meeting of the SNO, the concept of emergency neurology herein discussed; its postulates were collected in a position paper of these two Italian neurological societies which is now being circulated in Italian (27) and in English, in the journal Neurological Sciences.

In 2001, the Pavia group, acting on a mandate from the coordinating SIN-SNO group, began to develop the network that would subsequently be named SUN (Stroke Unit Network) Lombardia; this network was created as means of sharing information tools so as to unify and standardise health care practices at regional level. This project subsequently led to the birth, at the end of 2006, of the Lombardia Stroke Unit Registry, the first (and still the only) registry of this kind in Italy, which has a data base now shared by as many as 37 neurology departments equipped with stroke units spread across the region (28).Stroke/Cerebrovascular Disease Essay

The registry, currently being released as a Lombardy Region Electronic Health Record, contains data on an average of 12,000 stroke patients hospitalised in the region’s stroke units; it employs advanced computer applications (such as those for verifying application of the Italian SPREAD stroke guidelines, or process mining techniques used to define the optimal care pathway, in terms of the timing and sequence of interventions, within hospitals that receive patients with stroke and have, naturally, a stroke unit). Because of its particular features and innovative character, it was recently compared with other registries in Europe and elsewhere in the world at a workshop hosted, on February 4, 2011, by the Regione Lombardia (regional government) in its prestigious headquarters on the 31st floor of the Pirelli building in Milan.Stroke/Cerebrovascular Disease Essay

While the feverish activity on the database for this registry continues, with widespread interest also forthcoming from other Italian regions, another regionally funded project has come to light which, through the collaboration of all the centres in the region that treat stroke, should make it possible to study the genotype of that common but poorly understood cerebral small-vessel disease, of which monogenic variants are known, but that mostly seems to be attributable, as said earlier, to the classic and dynamic interaction between genes (polymorphisms) and the environment. The SVE-LA (Small VEssel and LAcunar) project, like other projects of the Stroke Centre and Emergency Neurology Trust (SCENT) at the C. Mondino Institute, bear witness to the existence of a true vocation which has ancient roots in the research and treatment of cerebrovascular diseases. That said, nothing can be achieved without the contribution of people who, passionate about their work, are, prepared, over the passing days, months and years, to work long hours and, indefatigably, to devote their resources (intelligence, passion, efficiency) to the achievement of excellent results.Stroke/Cerebrovascular Disease Essay

Acknowledgements

In addition to the people mentioned in the text, it is appropriate and proper to point out that much of the work described herein could not have been achieved without the contribution of Dr Anna Cavallini, now head of the Mondino Cerebrovascular Diseases and Stroke Unit. Sincere thanks are also due to our collaborators from at the present Department of Emergency Neurology and Emergency Room: Alessandra Persico, Elisa Candeloro, Maurizia Maurelli, Franca Moschiano, Simona Fanucchi, Alfredo Costa and Isabella Ghione. Dr Anna Bersano has recently begun a close collaboration with the institute in the field of genetics, and it is she who is to be thanked for designing the institute’s projects on the genetics of cerebrovascular diseases. To her go our best wishes for a bright and well deserved future as a researcher in this field. We hope that her collaboration will contribute to the institute’s ongoing success and affirmation in this difficult, but stimulating, field.Stroke/Cerebrovascular Disease Essay

Finally, particularly warm thanks go to all those individuals – nurses (particularly those who, like Federica Negri, Serafino D’Amico, Veronica Tosca, Adriana Negro, Flavia Bocchino, and Monica Bianchi, among others, have generously and enthusiastically worked in the Stroke Unit since 1996), nurse coordinators (Emanuela Sacchi, Fiorenza Montini), physiotherapists, and nurse’s manager Claudia Fiore, – who, over the years, have worked in the care of our stroke unit patients, helping, with patience and courage, to change the approach to and organisation of cerebrovascular patient care

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This essay will explore a ‘needs orientated’ approach to the care of CVA patients and examines the importance of using models and frameworks within nursing practice. National and global statistics of CVA will be discussed. Using a case scenario, the needs of the patient will be explored and nursing interventions discussed with respect to dignity. The social, biological and psychological impact of mobility problems of CVA patients with reference to the scenario patient and other patients seen during nursing placement will be investigated. A holistic plan of care will be critiqued with respect to nursing models and frameworks utilised by NHS, underlining the importance of individualised care plans.
The patient scenario is of a retired gentleman (William) of 70 years, previously diagnosed with hypertension, obesity and a BMI of 5. Recent GP consultation reported tiredness, headaches and dizziness, with persistent high BP despite medication changes. William was found by his wife suffering with facial weakness, asymmetry, slurred speech and an inability to raise arm or leg on the right-hand side. He was diagnosed with left-sided CVA and has right-sided , affecting balance and co-ordination, total incontinence, memory loss, dysphagia and difficulty with mastication. Psychologically, he has emotional lability and appears anxious and depressed. He is dependant for daily activities of living (AL’s) and forgetful of his condition.
CVA occurs when blood flow is absent in the brain for longer than a few seconds, resulting in cell death and permanent damage. The pathological background may be ischemic or hemorrhagic disturbances of the cerebral blood circulation.Stroke/Cerebrovascular Disease Essay
Ischemic stroke is caused by blockages in blood vessels that supply the brain. These may be due to plaques on the arterial walls caused by fat, cholesterol and other plaque-forming substances. This may happen in two ways:
1. Thrombotic stroke occurs when a clot forms in a narrowed artery.
2. Cerebral embolism or embolic stroke occurs when a clot is transported into the cerebral circulation, causing localised cerebral infarct.
Hemorrhagic strokes are caused by blood leaking into the brain due to damage blood vessels in brain rupturing, conditions such as hypertension, ateriovenous malformations or bleeding disorders can the increase risk (McCance, 1997).
Left-hemisphere (LH) stroke is characterised by loss of movement control on the right side of the body. The LH of the brain controls speech and language abilities, which may lead to aphasia, manifesting in a wide range of difficulties including inability to control speech related muscles or the ability to write, read or understanding language. LH stroke victims often develop a cautious behavioural style. Frequent instruction and feedback to complete tasks may be necessary. Development of memory problems is common to all CVA patients and can manifest as shortened retention span, failure to understand and absorb new information or difficulty in generalising and conceptualising (McCance, 1997).
The essay will focus on the motor difficulties that William faces due to right-sided hemiplegia, the resulting complications and concomitant reduction in AL’s. Mobility is a key issue with CVA patients and affects most aspects of life. In William’s case, due to his forgetfulness he attempts to stand unaided, increase risk of further injury. CVA occurs suddenly, affecting all aspects of living, resulting in a loss of independence and bringing unexpected and unwanted changes. The main result is often a loss of freedom within one’s own body resulting in feelings of vulnerability, helplessness, fear and loss, as well as the loss of dignity caused by feelings of inability to manage even the simplest of tasks independently.Stroke/Cerebrovascular Disease Essay

Main
CVA
The World Health Organisation (WHO) defines CVA as clinical signs of focal (or sometimes global) cerebral impairment (WHO, 2006). These may develop rapidly and continue for 24 hours+ or lead to morbidity without distinguishable reason other than vascular source (Aho et al., 1980). The consequences of CVA are often complex and heterogeneous depending on etiology, localisation and severity. In the UK, CVA is the 3rd frequent cause of death with approximately 24% of patients dying within 4 weeks of onset (Wolfe, 2000) and globally it is the 2nd leading cause of death (WHO, 2006). In the UK, incidence of CVA is around 150,000 per annum (National Audit Office, Department of Health. 2005) and it consumes around 5% of health service resources (Langhorne, 2009). CVA incidents are a major cause of complex adult disability and up to 300,000 individuals adjust their life around moderate to severe disability (Adamson et al. 2004). Epidemiological studies have shown that approximately 52% of survivors return home with lasting disability (Wolfe 2000) although 30-40% will remain dependent in AL’s (Dobkin, 1995).Stroke/Cerebrovascular Disease Essay

Cause of CVA
CVA is a multi-factorial disease with many determinants categorised as changeable or non- changeable. Risk factors such as age and sex are non-changeable and in many populations, older males are associated with an increased susceptibility (WHO, 2006). In contrast, reduced exposure to changeable factors can reduce CVA risk. These factors include smoking, physical activity, diet, or environmental aspects such as passive smoking (McCance, 1997). These combined risk factors, which do not all have to be present, will over time influence the subject’s possibility of suffering CVA. In the case scenario of William, his lifestyle contained a number of risk factors both changeable and non-changeable, e.g. gender and poor diet leading to hypercholesterolemia.
According to WHO, diagnosis of CVA includes one or more of these focal signs (WHO, 2006):
• Unilateral or bilateral motor impairment including un-coordination
• Unilateral or bilateral sensory impairment Stroke/Cerebrovascular Disease Essay
• Aphasia/dysphasia
• Hemianopia
• Diplopia
• Forced gaze
• Acute onset apraxia
• Acute onset ataxia
• Acute onset perception deficit

Biopsychosocial care and the impact of CVA
Understanding the impact of a health-state on a person requires measuring that person’s performance of tasks and actions in their normal environment (WHO, 2006). The biopsychosocial approach to health focuses on person-centred care, where patient involvement in clinical decision-making and self-management are key factors (Fayers P, 2007). CVA recovery is not predictable, and while improvement from initial symptoms predominantly occurs, there is tremendous variability in the degree of progress a patient may make. Some will return to normal while others make only moderate improvement, and a few have little or no recovery. Generally, the first 6 months sees the greatest recuperation after the stroke, although recovery can occur for up to 2 years.
The biopsychosocial consequence of CVA can be overwhelming; for both the patient and for their family, resulting in a great strain to family life. CVA can change the family power dynamic: the sufferer becomes more dependent, requiring greater emotional support as well as physical help. These strains can lead to a divorce, the spouses of CVA survivors report a lower fulfilment in quality of life (Ostwald, 2008). CVA’s unpredictable recovery process can result in victims living a fraction of their previous life. A long-term CVA survivors survey found that 87% had ongoing motor problems, 54% suffered walking difficulties, 52% reported hand movement/coordination problems and 58% experienced spasticity (Jones, 2006). These high figures demonstrate how life after CVA can radically change all aspects of living. A biopsychosocial model for sufferers of CVA is appropriate because post-stroke stressors, e.g. degree of handicap, are unique to each patient and this model can allow for these variations within the care regime (Aben et al., 2006). This model can also be used to predict long-term rehabilitation participation in CVA patients (Desrosiers et al., 2006).Stroke/Cerebrovascular Disease Essay

Dignity and the wider impact on nursing
Dignity is defined as ‘a state, quality or manner worthy of esteem or respect; and by extension self-respect’. Within the healthcare setting, dignity has become a major concern in UK health policy, especially in regard to vulnerable or older people (Gallagher, 2008). The National Health Service (NHS) Patient Charter for Scotland (NHS, 1991) states that patient dignity should be respected. A Royal Commission report on long-term care of the elderly stated “the dignity of those who have or who may come to have the need of long-term care should be recognised” , (NHS, 2005). In 2000, the NHS Plan (NHS, 2000) made emphasis to maintenance of patient dignity and the International Code of Conduct of Nursing (ICN, 1973) states that: “Inherent in nursing is respect for life, dignity and the rights of man, which is unhampered by concerns of nationality, race, creed, and colour, age, sex, politics or social status”.Stroke/Cerebrovascular Disease Essay
Dignity is recognition of the intrinsic value of people, regardless of circumstances, by respecting their uniqueness (Aspinall, 1995). Nurses can make patients within their care feel dignified and valued by having an attentive presence during communication which makes it explicit that the patient is unique and esteemed and their opinions are being taken into account; feelings of worth are central to dignity and important to health and quality of life (Thomas and Quinn, 2002). Nurses should encourage patients to attempt AL’s and aid where needed, rather than forcing the patient to be ‘cared for’(Mains, 1994, McCartney, 1974, Silverman). Communication and cognitive problems in CVA survivors can result in patient opinions being misinterpreted or overlooked and decisions can be made on their behalf without adequate consultation. Therefore it is important to ensure patient wishes are adhered to and where necessary, to involve Speech and language (SLT) and Occupational therapy (OT) to provide supportive communication methods, thus respecting patient dignity (Silverman).Stroke/Cerebrovascular Disease Essay

Caring for the CVA Patient
Despite advances in CVA prevention with better acute care and greater emphasis on rehabilitation, prognosis after acute CVA remains poor with 20-30% of patients dying within a month and 13% being discharged to institutional care (Rodgers, 2008). Multi-disciplinary teams are recognised as best practice care in CVA management, and each discipline takes a unique role in the recovery process, e.g. physiotherapy interventions focus primarily on interactions between body function and motion by strengthening weakened muscle and increasing flexibility. SLT is involved in the recovery of communication and swallowing, and can provide supportive communications methods. Dieticians help in nutritional management for over or underweight CVA patients and in conjunction with SLT, the correct food consistencies required for individuals with dysphagia. OT focuses on independence and function, setting individual goals using task adaptation and environmental modification to underpin action and activity of the patient (Rowland T. J., 2008). Nursing interventions are often characterised by caring for basic needs and sustaining personal and social integrity (McCartney, 1974), which is vital in ensuring the correct professionals in a stoke rehabilitation team are informed of the day to day changes in the patient (Hartigan, 2011). Therefore nursing professionals should have a thorough understanding of what each profession can contribute to patient rehabilitation.
In accord with NHS stroke models (NHS, 2010), care and rehabilitation should aim to re-establish and maintain functioning, promote health, and prevent and minimise disability (Stucki G, 2002). Essentially, rehabilitation should optimise participation in life and empower the CVA sufferer. The manifold and chronic consequences of CVA necessitate the combined efforts of different disciplines to fulfil rehabilitation objectives (NHS, 2010). For this reason, specialised multidisciplinary teams are characteristic of stroke units, providing the most beneficial outcome globally (Seenan P, 2007).Stroke/Cerebrovascular Disease Essay

Nursing plan of care
Clinical stroke guideline CG68 as set out by the National Institute for Health and Clinical Excellence (NICE), recommends that ‘all people with suspected CVA should be admitted directly to a specialist acute stroke unit following initial assessment’. Studies have shown that inter-professional, patient-centred care and rehabilitation optimises participation in life (Stucki G, 2002). A care plan for William has been made detailing the nursing APIE, the main details have been summarised in table 1.

The care strategy for William considers not just the CVA but also his pre-existing conditions. William suffered with hypertension which would require monitoring to warn of risk of further CVA incidence (Ahmed, 2010). This would be performed by taking BP readings regularly and notifying appropriately if the BP readings were sufficiently elevated to denote risk.
William is obese with a high BMI, and at present he is suffering from feeding difficulties as the CVA has caused dysphagia, a difficulty in swallowing and mastication caused by the right-side hemiplegia. Discussion with dieticians would ensure he has the best diet for his condition presently. Dysphagia can introduce a number of risk factors, e.g. choking or food lodging in the airways, which could cause chest infection. SLT should assess William’s swallow reflex and discuss whether he requires a nasogastric tube for nutrition. NICE 2010 Quality Standard 4 for Stroke states. “Patients with acute stroke have their swallowing screened by a specially trained healthcare professional within 4 hours of admission to hospital, before being given any oral food, fluid or medication, and they have an ongoing management plan for the provision of adequate nutrition” (NICE, 2010). If he be capable of swallowing without risk, a soft food diet could be given initially, with solid food being introduced gradually with encouragement to self-feed as much as possible. This would help increase dexterity and upper limb function, although private meals will reduce loss of dignity in the early period (Bernhardt et al., 2004, Mains, 1994).Stroke/Cerebrovascular Disease Essay
William has double incontinence due to the CVA. CVA suffers frequently become urinary incontinent which can cause considerable distress (Brittain, 1998), faecal incontinence more so. Nurses need to manage this problem respectfully, furthermore, they should appreciate embarrassment over incontinence can adversely affect the rehabilitation progress (Chipps, 2011). Therefore it is important to retain patient dignity during occurrence of incontinence and reassure that muscle controlled can be regained with training. There are a number of behavioural strategies that can help the sufferer, for example, helping William to sit on the toilet just after a meal (Silverman). NICE 2010 Quality Standard 8 for Stroke states: “Patients with stroke who have continued loss of bladder control two weeks after diagnosis are reassessed to identify the cause of incontinence, and have an ongoing treatment plan involving both patients and carers” (NICE, 2010). Initially, William will be wearing incontinence pads and so peritoneal skin examinations are needed to ensure tissue viability. Incontinence is a by-product of stroke and is often viewed poorly by family of the CVA survivor. It is vital to emphasise to the family that this condition is extremely common following stroke and that this problem is not controllable by William (Brittain, 1998).Stroke/Cerebrovascular Disease Essay
William will require physiotherapy for the hemiplegia to increase strength and muscle tone, which is necessary full limb mobility recovery. The most common physical effect of stroke is muscle weakness and reduced control of the affected arm and/or leg. Research has show that on average patients daily spend 28% of the time sitting out of bed and only 13% engaged in activities based on movement (Bernhardt et al., 2004), sitting without activity will not aid towards increasing mobility, therefore it is imperative to schedule and encourage activity. Activities can be devised in conjunction with OT supplying walking aids and other environmental adaptations to aid with early mobility and independence of AL’s. NICE 2010 Quality, Standards Standard 7 states: “Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it”(NICE, 2010).
William is confused and suffering from memory loss, he is depressed and anxious about the future, while this is common to stroke sufferers, these emotions should be treated with understanding and sympathy, and nursing staff should be watchful for signs of acute depression (Pelissier, 2008). NICE 2010 Quality, Standards Standard 9 states: “All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment” (NICE, 2010). Most stroke victims experience a grieving process at the loss of their old life, until they reach an acceptance of who they are after the stroke.Stroke/Cerebrovascular Disease Essay
Even when William is discharged from hospital there are standards that will ensure high quality community care for him and his family (Siegler et al., 2006, Wolfe et al., 2000). NICE Quality Standard 10 states: “All patients discharged from hospital who have residual stroke-related problems are followed-up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management.” (NICE, 2010) and Quality Standard 11 states: “Carers of patients with stroke have: a named contact for stroke information; written information about patient’s diagnosis and management plan; and sufficient practical training to enable them to provide care” (NICE, 2010)

Mobility and the biopsychosocial impact
Mobility has been identified as a vital functional ability which determines the degree of independence and thus health care needs especially among older people, and the greatest impact of impaired mobility is the effect on self-concept and self-esteem (Hogue, 1984). CVA patients often state that they feel ‘fearful and helpless’ and want to ‘regain control of their lives’ (McKevitt et al., 2000). Benchmarks associated with physical functioning evaluate progress and CVA survivors often relate their improvement using activities that have a wider social meaning (Hartigan, 2011). Often the limb is blamed for the difficulties (Hartigan, 2011), during placement one older gentleman would thump his leg and call it useless, transferring all his mobility problems onto the affected limb. Patient perception of their health influences rehabilitation, reinforcing the need for biopsychosocial models of health, as this demonstrates the interrelated nature of physical and social activities, also emotional well-being facilitates recovery from CVA (Dowswell, 2000). On placement, a gentleman spoke about his plans to play golf again when he could stand unaided. Often patients do not express personal goals to medical personnel but nurses can convey this information to the stroke team ensuring patient focussed recovery goals (Hartigan, 2011). Nurses can help with the bereavement process that most stroke victims will suffer at the loss of their pre-stroke life, monitoring patient perception of recovery and aiding in education of stroke to ensure they have a positive and realistic view of their post-stroke life to allow patients to retain dignity throughout rehabilitation (Christensen et al., 1997, Mangset et al., 2008, McKevitt et al., 2000).Stroke/Cerebrovascular Disease Essay

Conclusion
The global burden of CVA is increasing with frequent lasting disability, but holistic care plans and biopsychosocial models may reduce rehabilitation time and retain dignity of the patient by being involved in their recovery. CVA is a sudden crisis; patients are often fearful of the future and left feeling trapped within a non-responsive body. Nursing staff are in a unique position to aid with mobility and continence by encouragement; to discuss with patients about their personal goals for recovery and pass this information to the stroke team allowing patient-orientated goals to be devised; and to aiding in the bereavement process CVA victims suffer. For a few, mobility will never fully return but with changes to the environment around them, they can retain some independence and return to a meaningful life.Stroke/Cerebrovascular Disease Essay

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