Stroke

Stroke

== Stroke is the third most common cause of death == accounts for 10% of all deaths == Accounts for 50% of the medical ward admission == Most common cause of disability

1--the anterior [carotid ] circulation a- anterior cerebral A b- middle cerebral artery 11--The posterior[vertibro basiler circulation] a- vertibral A b- Basiler A c- Posterior cerebral A

Blood supply of brain

Blood supply of brain

Blood supply of brain

CBF remains relatively constant when mean arterial blood pressure is 50–150 mmHg

Cerebral blood flow (CBF) Normal 50 cc/100 g/min Change in electrophysiological activity 20 cc/100 g/min

Irreversible ischemia 10 cc/100 g/min [blood interruption for 5 minutes]

1 minute blood interruption ,neuronal function ceases;
Pathophysiology
The penumbra is the area of brain with the potential to survive

50-55 mL/100 g brain per minute

20 mL/100 g brain per minute
Less 10 mL/100 g brain per minute
10-20 mL/100 g brain per minute
Normal cerebral blood
electrical failure
ischemic penumbra
Cell death

Save the Penumbra!!

CEREBRAL BLOOD FLOW (ml/100g/min)

CBF < 8
CBF 8-18
TIME (hours)
1
2
3
20
15
10
5

PENUMBRA
CORE
Neuronal dysfunction
Neuronal death
Normal function
www.acponline.org/about_acp/chapters/ok/gordon.ppt‎


Cerebral blood flow (CBF) Normal 50 cc/100 g/min Change in electrophysiological activity 20 cc/100 g/min dysfunctional secondary to electrical failure although not dead Irreversible ischemia 10 cc/100 g/min
Pathophysiology

Risk Factors A. Nonmodifiable risk factors Age: strongest determinant of stroke; incidence rises exponentially with age >65 years Sex: men 3. Race: in the United States, blacks (intracranial > extracranial disease) followed by Hispanic = whites (extracranial > intracranial disease); in Japan, hemorrhage is more common than atherothrombosis
B-Modifiable risk factors Hypertension Smoking Diabetes mellitus Atrial fibrillation Heart disease Dyslipidaemia Alcohol Obesity Symptomatic and asymptomatic carotid stenosis Drug misuse

CAUSES OF STROKE IN YOUNGE below 40 years 1- cardiac causes AF valvular heart disease prosthetic valve endocarditis atrial myxoma patent foramen ovale IHD SBE 2- vasculitis eg SLE , rheumatoid arthritis ,giant cell arterits 3- inherited diseases:Homocystinuria Marfan's,hyperlipidemia 4-hypercoagable state like antiphospholipid antiody disease, Behcets disease 5-blood disease : sickle cell disease, polycythemia vera

Stroke

Hemorrhagic 15%
Ischemic 85%
Inracerebral hemorrhage 10%
Subarachnoid hemorrhage 5%

mechanisms of ischaemic stroke

Thrombosis embolism hypoperfusion


Stroke: acute focal neurological deficit resulting from vascular disease.[those events last more than 24 hours] Transient ischemic attack (TIA):focal neurological symptoms attributed to cerebral ischemia lasting less than 24 hours, with complete recovery. Intracranial hemorrhage = primary intrcerebral hemorrhage subarachnoid hemorrhage
Definitions


volume of the tissue (<1.5 cm— secondary to occlusion of a penetrating artery found in subcortical white matter or the basal ganglia pathology
Lacunars infarct
asymptomatic changes on imaging of the deep white matter known as leuco-araiosis


Larger infarcts volume of the tissue more than 1.5 cm. involve a wedge of both cortical and sub cortical white matter. result from occlusion of the trunk or branches of the major cerebral arteries.
Territorial infarction


infarction occupies the border-zones between arterial supplies, particularly if the infarction follows an episode of generalized reduction in cerebral blood flow (e.g. after cardiac arrest) or results from internal carotid artery occlusion
3- border-zone or watershed infarction.


Lateral surface ---------------- MCA Medial -------------------------- ACA Occipital ---------------------- PCA Brain stem and cerebellum--- PCA

Carotid territory Monocular visual loss[amarausis fugax] Unilateral weakness Dysphasia Headache Dysarthria Hemianopia Unsteadiness Sensory loss
Vertebrobasilar Diplopia Vertigo/dysequilibrim Bilateral visual loss Bilateral weakness Headache Dysarthria Hemianopia Unsteadiness Sensory loss
Symptoms of transient ischemia
Clinical features



Common lacunar syndromes. : lack cortical signs. Cortical signs include dysphasia, neglect syndrome, apraxia, hemianopia and conjugate eye deviation Pure motor Sensorimotor Pure sensory Ataxic hemiparesis Dysarthria/clumsy hand
Clinical features

ACA lower limb Urinary center Psychomotor function

MCA Upper limb Speech area apraxia

Stroke : either completed stroke when the deficit reaches its peak immediately ,or progressive [evolving] when the deficit worsened over more than 6 hours ,
Anterior circulation stroke [Carotid] clinical features : contra lateral hemiplegia, conjugate eye deviation toward the side of the infarct , hemi anesthesia, homonymous hemianopia. Aphasia occurs if the dominant hemisphere is involved hemi neglect with nondominant hemispheric lesions Incontinence mostly accompany ACA
MCA ---weakness more sever involvement of upper limb ACA ---weakness more sever involvement of lower limb
Clinical features

Clinical features

Vertibro basiler stroke Vertigo ataxia dysphagia diplopia dysarthria nystagmus gaze palsies, contra lateral hemiplegia with ipsilateral facial hypoalgesia and thermo anesthesia or Ipsilateral facial paralysis and other cranial nerve palsies [crossed hemiplagia] miosis Horner's syndrome corneal hypoasthesia

CT is the most practical and widely available method of imaging the brain. It will usually exclude non-stroke lesions, including subdural haematomas and brain tumours. It will demonstrate intracerebral haemorrhage within minutes of stroke onset . However, especially within the first few hours after symptom onset, CT changes in cerebral infarction may be completely absent or very subtle, though changes usually evolve over time

More than 6 hours

Less than 6 hours
MRI benefits over CT scanning times are longer some individuals with contraindications MRI diffusion weighted imaging (DWI) can detect ischaemia earlier than CT, . MRI is more sensitive than CT in detecting strokes affecting the brain stem and cerebellum



time is brainHOURS EVERY PATIENT WITH STROKE ELIGIBLEFOR rTPA == admission to stroke unit3—4.5 patient with sever and above 80 years should be excluded Management

Management

Acute phase fibrinolytic treatment BP Control blood sugar control rhythm control rehabilitation; speech urine mobility nutrition and hydration state Secondary prevention

Acute management

Admission to stroke unit Blood pressure should not be treated unless hypertensive encephalopathy aortic dissection acute MI coexistent left ventricular hypertrophy BP 22O/120 Oxygen : given when oxygen saturation below 92% Glucose should be reduced below 180 by insuline Reduce fever by cold sponging and paracetamol Treat infection [UTI chest infection ] Hydration ;treat dehydration with isotonic slain Dysphagia treatment by NG tube DVT prophylaxis : [sq heparin ; pressure stoking ] Treat any depression seizure Physiotherapy

Acute phase treatment fibrinolytic treatment

Below 4.5 hours Intra venous[IV] Tissue plasminogen activator Window time 4.5 hours from onset BP should be maintained below 185/110 Blood sugar below 180 and above 60 mg/dl INR 1.7 platelet above 100, 000/mm2 Above 4.5 hours Intra arterial [IA] Tissue plasminogen activator Mechanical thrombectomy interventional mechanical clot removal

INELIGIBLE FOR tPA TREATMENT) Contraindications: Evidence of intracranial hemorrhage on noncontrast CT History of intracranial hemorrhage/stroke Uncontrolled HTN: At time treatment begins SBP remains >185mm Hg or DBP remains >110mm Hg Glucose level < 50 0r > 400 Platelet count <100,000/mm3 INR > 1.7 Within prior 3 months: intracranial or spinal surgery, head trauma, or previous stroke Arterial puncture at noncompressible site within last 7 days Surgery with in 14 days GIT or urinary bleeding with in 21 days

Thrombolysis

Alteplase rTPA 0.9mg /Kg 10% of total dose –Bolus 2-3 mins90% of total dose –Infuse over 60 mins

Secondary prevention

Anti platelet aspirin clopedogril combined aspirin – dypiridamol Statin to reduce s. LDL cholesterol below 100mg/dl Hypertension and diabetes strict control Anticoagulent for AF prosthetic heart valve Carotid stenosis more than 70% == carotid endarterctomy or carotid stenting


Complications of Stroke
Aspiration Pneumonia Urinary infection DVT Pulmonary Embolus Shoulder subluxation Depression Malnourishment Pressure sores Falls Seizures

Swallow Complications(Dysphagia)

Chest Infection Aspiration Pneumonias 50% are silent Swallow screen Nil by mouth first 24hours Guided eating & drinking regime Encourage to cough Sitting out of bed Mobilisation

Bladder &Bowels

Urinary incontinence Urinary infection Avoid catheters Early plan of care Adequate hydration Bowels Privacy & dignity

Pressure Sores

Air mattress Two hourly turns Nutrition Hydration Personal hygiene

Deep Vein Thrombosis

Early mobilisation Low molecular weight heparin Compression devices TED stockings not beneficial in stroke patients Clots Trial 2009

Positioning

Loss of sensation Loss of power Subluxation Supportive IV lines and BP cuffs avoided on affected limb Assess moving and handling Good technique


Nutrition
Malnourishment associated with poor outcome Weight MUST assessment Naso gastric tube History of patients eating habits Controversial When to commence invasive feeding regime


65 ys old male hypertensive diabetic smoker past history of MI Right sided weakness and aphasia of sudden onset
65 ys old male hypertesive dibetic smoker past history of MI Right sided weakness no aphasia of sudden onset

65 ys old male hypertensive diabetic smoker past history of MI Right sided weakness and aphasia of sudden onset associated with headache and nausea vomiting with brief loss of consciousness BP ==230/120 mmhg
65 ys old male hypertensive diabetic smoker past history of MI Right sided weakness NO aphasia of sudden onset associated with headache and nausea vomiting with brief loss of consciousness BP ==230/120 mmhg

Questions?