stroke 2

* Cerebrovascular diseases 2

Stroke
Dr. Mohammed AzizF.I.B.M.S Neuro.

Hemiplegia & hemiparesis

-Cerebral hemisphere cortical subcortical capsular -Brain stem -Spinal cord
*

*

*

*

*

* Stroke

Clinical features


*

* Symptoms of stroke

MCA occlusion
Cortical Frontal Parietal Temporal Capsular Subcortical Main artery

*

ACA occlusion

Cortical Frontal Paracentral collosal Capsular Main artery

*

* INTERNAL CAROTID ARTERY (I.C.A)

* causes of stroke in I.C.A 
I.C.A. blocking:- Immunological: collagen diseases & vasculitis Inflammatory process: infection in the neck may lead to fibrosis or L.N. enlargement lead to occlusion. Trauma Surgical ligation Massive emboli As part of atherosclerosis

* Clinical features of stroke I.C.A

Preceding amaurosis fugax. Bruit over carotid A. Ipsilateral horner syndrome In addition to sign of M.C.A.&ACA occlusion

* Ophthalmic Artery

Amaurosis fugax (TIA of ophth. A) Momentary attack of unilateral impairment of vision(20-30sec.) as if you are closing curtain this occurs due to thromboembolisim

Vertebro-basalar occlusion

Partial occlusion Syncope Diplopia Ophthalmoplgia Vertigo & tinnitus Bulbar symptoms Hemiplegia , hemihypesthsia ataxia
*

Complete occlusion Deep coma Quadriplegia Bulbar paralysis Respiratory failure

*

SCA OCCLUSION

IL cerebellar ataxia IL Horner syndrome IL deafness CL hemihypesthesia

*

AICA OCCLUSION

IL cerebellar ataxia IL Horner syndrome IL deafness IL cranial nerves 6th,7th 8th lesion CL hemihypesthesia

*


PICA OCCLUSION
VERTIGO Nausea , vomiting Bulbar symptoms IL cerebellar ataxia IL Horner syndrome IL deafness CL hemihypesthesia of body IL hemihypesthesia of face

*

PCA OCCLUSION

Cortical branches occlusion Homonymous hemianopia Visual agnosia Perforating branches Thalamic -Thalamic pain -CL hemihypesthsia

*

Brain stem syndromes

Weber syndrome Benedikt syndrome Millard-gubler syndrome Foville syndrome Lateral medullary syndrome Medial medullary syndrome
*

*

*

*

* Lacunar infarction

Small, deep infarcts caused by occlusion of penetrating brain arteries .


* Lacunar infarction
The small arteries that penetrate deeper brain structures : Basal ganglia. Internal capsule Thalamus, Pons are especially susceptible to degenerative changes caused by hypertension

* Lacunar stroke

Types:- Pure motor ( Hemiparesis) Pure sensory ( Hemisensory loss) Mixed sensory & motor Ataxic Hemiparesis Dysarthria-clumsy hand syndrome Hemiballusmus /hemichoria

* Stroke under age of 40

Accelerated atherosclerosis(HPT,DM) Cardiac emboli Vasculitis I.V. coagulation defect

* Investigations

Brain imaging: CT Brain: should be done first in all cases ( R/O bleed) MRI Brain: with Diffusion-weighted imaging (DWI), detects ischemia early


*

*

*


*

*

*

*

* Investigations

Doppler study of carotid arteris :Carotid ultrasound TCD- transcranial Doppler ultrasound Echocardiogram: Transthoracic, Transesophageal To look for cardiac source of embolism

Stroke mimic

Functional Hypoglycemia Todd's paresis Conversional disorders Encephalitis Demyelination Migraine with aura
Structural Primary brain tumor Metastatic brain tumor SDH Cerebral abscess
*

Management

Time is Brain-save the penumbra Concept of acute brain attack: Treat acute stroke as emergency CVA :not an accident !! Preventable Determine the cause Avoid hyperglycemia, hyperthermia & sedatives all harmful to the penumbra
*

*


*

Acute Management: Vitals

A B C
Airway - secure? Breathing - O2 Sat, CHF? Circulation - BP too high or too low? A-Fib?
*

Supportive Measures

Control of blood pressure remember the figure 220/110 Control of blood sugar Adequate hydration Control infections Control brain oedema
*

BP management in acute stroke

Natural for BP to increase during first few hours after stroke& spontaneously decline within first 24 hrs
*

Management T.I.A.

*

Age
>60 years
1 point
Blood pressure
≥140/90 mmHg 1 point
Clinical features
Other than below
0 points
Speech disturbance without weakness
1 point
Unilateral weakness
2 points
Duration
<10 minutes
0 points
10–59 minutes 1 point
≥60 minutes 2 points
Diabetes
Present
1 point
*


Management
Less than three hr. rTPA. (recombinant tissue plasminogen activator )
*

THROMBOLYSIS

rt-PA decreases chance of unfavorable outcome if it is given within 3 hours of stroke onset and the benefit is greater if is given within 1 hour Narrow time window !
*

Time dependent treatment

IV t-PA must be given within 3 hours from onset of symptoms or from “time last seen normal”Intra-arterial (IA) therapy must be given within 6 hours
4.5 hours
*

Stroke: The Challenge

Only 1-3% of all stroke victims receive treatment with tPA in the US 25% of Acute MI patients receive treatment (lytics) in the US Mean time to presentation AMI: 3hrs Acute Stroke: 4-10hrs
*

Thrombolytic Therapy for Acute Ischemic Stroke

< 4.5 hours
IV t-PA
IA t-PA
4.5-6 hours
Onset of Symptoms
Therapy
*


Characteristics of Patients With Ischemic Stroke Who Could Be Treated With rtPA
*

Diagnosis of ischemic stroke causing measurable neurological deficit The neurological signs should not be clearing spontaneously. The neurological signs should not be minor and isolated.
*

Caution should be exercised in treating a patient with major deficits. The symptoms of stroke should not be suggestive of subarachnoid hemorrhage. Onset of symptoms _3 hours before beginning treatment
*

No head trauma or prior stroke in previous 3 months No myocardial infarction in the previous 3 months No gastrointestinal or urinary tract hemorrhage in previous 21 days
*

No major surgery in the previous 14 days No arterial puncture at a noncompressible site in the previous 7 days No history of previous intracranial hemorrhage
*

Blood pressure not elevated (systolic >185 mm Hg and diastolic >110 mm Hg) No evidence of active bleeding or acute trauma (fracture) on examination Not taking an oral anticoagulant or, if anticoagulant being taken, INR <1.7
*

If receiving heparin in previous 48 hours, aPTT must be in normal range. Platelet count >100 000 mm3 Blood glucose concentration >50 mg/dL (2.7 mmol/L) & less than 400 mg /dl
*


No seizure with postictal residual neurological impairments CT does not show a multilobar infarction (hypodensity >1/3 cerebral hemisphere). The patient or family members understand the potential risks and benefits from treatment.
*

Weight (kg) : __Ч 0.9 mg = __ mg Give 10% bolus over 1 minute __ mg (ml)Give remaining 90 % constant infusion over 60 minutes __ mg (ml) Total maximum dose 90 mg. M.D. Physician Signature ………………… Dosage calculation and How to infuse
*

*

Stroke Therapy Pre t-PA

*

Stroke Therapy: Thrombolytic Era

*

Mechanical embolus removal in cerebral ischemia (MERCI)

*

*

*


*

Antiplatelet Agents

ASA (Aspirin) 50 – 325mg po dailyTiclopidine (Ticlid) 250mg po twice daily with foodClopidogrel (Plavix) 75mg po dailyDipyridamole 200mg + ASA 25mg (Aggrenox) po twice daily *

Antiplatelet

Aspirin is mainstay treatment in noncardioembolic ischemic stroke
*

Heparin IS NOT an acute treatment for stroke

*

Antiplatelet

Clopidogrel (Plavix tab. 75mg once daily) is indicated when there is C/I or intolerance to aspirin and it is slightly more effective than aspirin in those who are (poor responders)to aspirin e.g. Females, Diabetics Vertebrobasilar disease, and patients with peripheral vascular disease
*

Indication of antiplatelet

Completed stroke & no indication for anticoagulant.Single TIAHigh risk group (DM ’ Hypertension) *

Anticoagulants

WARFARIN is mainstay treatment for cardioembolic stroke esp. AF


*

Indication of anticoagulants

Cardiac causes Failure of antiplatlets Fluctuating stroke Stroke in evolution Thrombophilia Arterial dissection
*

Statins

They decrease recurrence risk even in patients with normal serum lipids They exert their beneficial action through decreasing serum lipids mostly , but other actions like plaque stabilization and improvement of endothelial function
*

Carotid Artery Disease

Carotid endarterectomy is indicated for symptomatic stenosis (70-99%) esp. in those with recent symptoms, ulcerative plaques hemispheric TIA or stroke Recent analysis recommends early operation and ideally within few days
*

*

Causes of deterioration of stroke

Extension of ischemia Edema Hemorrhagic transformation
*

Complication of stroke

Chest infection Seizure DVT & Pulmonary embolism Shoulder pain Bed sore UTI Constipation Depression & anexiety
*


* THANK YOU