Stroke is a common type of vascular event with important implications for both cardiovascular and neurologic nurses. Recent and newly emerging advances in the management and treatment of acute ischemic stroke make the care of stroke patients one of the most exciting fields in health care today. These advances are exciting for two reasons. First, stroke is a life-threatening, devastating disease that, until recently, has not received adequate attention from health care providers. Stroke is the third leading cause of death and the primary cause of adult disability in the United States. As startling as these statistics are, the actual incidence of stroke may have been underestimated by as much as 40%. A recent study by the University of Cincinnati 1 has revealed the incidence of stroke to be over 730,000 annually instead of the previously accepted report of 500,000. In addition to the high mortality and morbidity associated with stroke, its economic costs are staggering. The American Heart Association estimates the cost of stroke at 41.9 billion dollars each year. 2 As research into the prevention and management of stroke intensifies, we hope to be able to reduce the huge personal and societal impact of these statistics.
The second reason for excitement in the area of stroke management is that, until the current decade, there was no proven approach for aggressively treating stroke. The management of stroke was largely palliative, with no method for stopping the progression of stroke once ischemic neurologic symptoms developed. However, with the 1996 Food and Drug Administration approval of intravenous tissue plasminogen activator for acute ischemic stroke symptoms, we now can effectively intervene to halt stroke progression and, in many cases, prevent serious neurologic sequelae. As the first proven, beneficial therapy for interrupting stroke, 3 it has completely changed the way we view and treat this condition.
In this issue of JCN (13:1), you will find several articles highlighting the latest advances in stroke care. Management options are expanding with use of interventional procedures and new pharmaceutical agents. The administration of intra-arterial thrombolysis, use of cerebral angioplasty, Guglielmi Detachable coils, and placement of carotid or vertebrobasilar stents has created a new subspecialty for neuroradiologists, neurologists, and neurosurgeons. Nurses caring for these patients are challenged with understanding a new frontier in nursing management, and the first article in this issue by Bader provides important information for nurses caring for patients with acute cerebrovascular problems who are undergoing neuroradiologic procedures.
A variety of new pharmacologic agents is being investigated to determine safety and efficacy in the treatment of the patient with acute ischemic stroke. As Hock points out, the investigation of neuroprotective agents has markedly expanded our knowledge of stroke pathophysiology. This knowledge dissolves the myth that when stroke occurs, the damage to the brain is immediate, and nothing can be done. Stroke is a process that evolves over time. Just as "time is muscle" for the patient with acute myocardial infarction symptoms, "time is brain" for the patient with acute ischemic stroke symptoms, and the earlier intervention begins, the greater the likelihood of preserving brain tissue and maintaining or restoring function.
Stroke occasionally occurs as a complication of other procedures, particularly in patients with existing cardiovascular disease. Young and co-authors discuss stroke as a complication of coronary artery bypass grafting (CABG). They highlight several areas of interest, including factors predictive of increased risk of stroke in patients undergoing CABG, methods to diagnose intraoperative and postoperative stroke, and assessment measures that lead to earlier identification and intervention.
Application of various medical procedures such as hypothermia has proven to be effective in patients with head injuries and is now being explored in patients with stroke. 4 Bell and colleagues discuss the potential promise of mild hypothermia as a management strategy for reducing adverse neurologic consequences of acute cerebrovascular disease.
New technology is allowing us to better understand the process of stroke and to assist in the immediate identification of brain blood flow problems. Massaro discusses one of the most promising of these technologies, xenon-enhanced computed tomography. This new and innovative technique allows practitioners to quantify cerebral blood flow. This information is invaluable in accurately diagnosing various acute cerebrovascular disease presentations and in guiding decision-making regarding the most appropriate management of patients presenting with acute ischemic brain symptoms.
As stroke technology improves and definitive treatment becomes available, the body of knowledge related to stroke pathophysiology continues to grow. Until stroke was treated urgently, few examined the natural history of stroke or appreciated the impact of the stroke process on other body systems. Kocan thoroughly discusses the brain-heart connection and the impact of stroke on the cardiac system. Nurses can use this growing body of knowledge to enhance their care of patients with neurologic conditions.
The nursing role is expanding with advances in acute stroke care. Nurses are prominently involved in system changes to meet the demands of quality care for acute ischemic stroke patients. These system changes include providing community education regarding stroke prevention and symptom recognition; expanding prehospital nursing roles and responsibility for assessment and management; providing appropriate emergent care of stroke patients in triage and emergency departments; and providing appropriate inhospital stroke assessment and nursing intervention to address complications of stroke. 5 The nurse's role also has expanded to include development of pathways for the evaluation of health care delivery. Summers and co-author describe the implementation and evaluation of a stroke clinical pathway and its impact on patient outcomes and on the cost of stroke care.
In addition to these roles, nurses are actively contributing to the body of stroke knowledge by conducting research. O'Donnell and co-authors describe their efforts to answer an important clinical question about stroke patients' delay in seeking treatment for symptoms that led to development of a large multicenter research project.
As a neuroscience nurse, my hope is that information you gain from this issue will motivate you to incorporate needed changes into your practice. Patient education is critical for all patients with cardiovascular disease. Content for patients and their significant others should include reduction and modification of risk factors, stroke symptom recognition, and the importance of seeking immediate medical care for these symptoms. Use of the National Institutes of Health Stroke Scale should be standard practice in your setting to assess and quantify neurologic deficits. A method of rapid response and treatment for stroke symptoms, the "Stroke Code," should be implemented and taught on a regular basis. These changes must be implemented now so that definitive stroke care can be delivered in a timely manner to all patients with acute ischemic stroke symptoms. All nurses must be prepared to offer patients the highest level of acute stroke care possible so that their patients can benefit from the many recent advances in this field of care.
-Carol A. Barch, MN, CRNP, CNRN
Program Director; UPMC Health System Stroke Institute; Department of Neurology; University of Pittsburgh; Pittsburgh, Pennsylvania
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