• Stroke is a clinical syndrome characterized byrapidly developing clinical symptoms and/orsigns of focal, and at times global, loss ofcerebral function, with symptoms lasting morethan 24 hours or leading to death, with noapparent cause other than that of vascularorigin – WHO• TIA (Transient Ischaemic Attack) recovery iscomplete within 24 hours.
• 3rd most common cause of death inMalaysia NASAM 2013• Incidence of Stroke in Malaysia increasingtrend but inhospital mortality rate is indeclining trend. Information and Documentation Unit, Ministry Of health 1998• The incidence of stroke has been reportedto be more in men compared to women (Huet al, 1992; al-Rajeh et al, 1993; Lopez et al, 1995; Korv et al, 1996; Rozenthul-Sorokin et al, 1996)
• Every two seconds, someone in theworld suffers a stroke.• Every six seconds, someone dies of astroke.• Every six seconds, someone’s qualityof life will forever be changed – he willbe physically disabled permanently dueto a stroke.REF :http://thestar.com.my/health/story.asp?file=/2011/10/30/health/9788575&sec=health
• 3 Simple Questions☺Ask the person tosmile☺Ask the person toraise both arms☺Ask the person tosay a simplesentence “The sky isblue in Johor”The sky isblue in Johor
Sudden numbness orweakness of face, arm or leg,especially on one side of thebodySudden confusion,trouble speaking orunderstandingSudden troubleseeing in one orboth eyesSudden troublewalking, dizziness, loss of balance orcoordinationSudden severeheadache with noknown cause
Non-modifiable ModifiableAge (uncommon below 40) High blood pressure (systolic &diastolic)Sex M>F Cigarettes smokingEthnic/race Diabetes melitusFamily history of stroke Atrial fibrillationCoronary heart diseaseHyperlipidemiaObesity & physical inactivityHigh dietary salt intakeHeavy alcohol consumptionPrevious strokeHigh homocystein level
Atherosclerosis,thrombosis,embolism,arterial spasm,hypotension,Vasculitis cerebral venous infarctioninfarctionDestruction of brain substanceMark oedema ofsurrounding brainOedema of surrouding brain tissueHPT, aneurysm, bleeding diathesis,arteriovenous malformationneoplasmSpace occupying lessionsExpending mass fromarterial haemorrhageDestruction of brain substance
Increase intracranial pressureLocalizing sign(due to destruction of brain tissue/Substance and oedema)Loss of sensationSlurred speechNumbness and weakness ofLeft upper limbUpper motor lessionLeft upper limb-hypertonia-hyperreflexia
Occlusion in brain blood flow♣ Thrombotic stroke: clot forms in an area ofatherosclerosis. Plaques that completely clog ormarkedly narrow an artery also can causeischemic stroke.♣ Embolic stroke: clot, or piece of plaque formed inone of the arteries leading to the brain or in theheart, is brought by bloodstream to lodge innarrower brain arteries.
Three main causes of ischemic stroke are:1. Atherothromboembolism (50%)i. Large vessel occlusion or stenosis (e.g.: carotidartery)ii. Branch vessel occlusion or stenosis (e.g.: MCA)iii. Perforating vessel occlusion (lacunar infarction)2. Intracranial small vessel disease (penetrating arterydisease) (25%)i. Collagen disease e.g.: RA, SLEii. Vasculitis e.g.: PAN, temporal arteritisiii. Granulomatous vasculitis e.g.: Wegener’sgranulomatosisiv. Miscellaneous: syphilitic vasculitis, fibromusculardysplasia, sarcoidosis, trauma3. Cardiogenic embolism (20%) – Valvular heart disease,
Disease of Blood• E.g.: Coagulopathies, HaemoglobinopathiesVenous Thrombosis• Venous Thrombosis may occur with infection anddehydration or in a/w arterial occlusion when relatedto estrogen excess (pregnancy, oral contraceptives)Decrease cerebral perfusion• Infarction between arterial territories may result fromimpaired perfusion e.g.: cardiac dysrhythmia, GIblood loss
Artery occluded Areas Infarcted Clinical EffectAnterior CerebralArteryFrontal lobe Confusion, disorientatedMotor and sensory cortex(leg area)C/lateral weakness, max in leg,cortical type sensory loss, max inlegMiddle cerebralarteryLateral surface C/lateral hemiparesis, face>leg;c/lateral cortical type sensory lossSpeech area (dominant) Expressive aphasiaOptic Radiation HemianopiaPosterior cerebralarteryOccipital lobe Cortical type-visual lossVertebrobasilararteriesCerebellum Intention tremor, incoordination,hypotoniaBrain stem C/lateral hemiparesis and sensoryloss; ipsilateral CN palsies
• Hemorrhagic stroke occurs when a vesselin the brain suddenly ruptures and bloodbegins to leak directly into brain tissueand/or into the clear cerebrospinal fluidthat surrounds the brain and fills itsventricles.
• Hemorrhagic strokes are less commonthan ischemic strokes but cause asignificant number of deaths worldwide.• Approx. 70-80% of all strokes areischemic,20-30% are hemorrhagic(10-20%-intracerebral hemorrhage5-10% -subarachnoid hemorrhage)Kase et al., 2004
• The fatality rate for hemorrhagic strokes ishigher than for ischemic strokes and theoverall prognosis is poorer• It is the location of the hemorrhage, rather thanthe amount of bleeding, that tends to be thebigger factor in influencing the severity of thestroke.• For example, bleeds in the brainstem, thoughrelatively tiny, can be quite lethal, whereas thesame-sized bleed in the frontal lobe may noteven be noticeable
A = Penetratingcortical branchesACA, MCA or PCAB = Basal gangliaC = ThalamusD = PonsE = Cerebellum
1. Consciousness pointi. Alert 0ii. Drowsy and stupor 1iii. Semicoma and coma 22. Vomiting/ headache within 2 hrsi. No 0ii. Yes 13. Atheroma(diabetic history, angina,claudication)i. None 0ii. ≥1 1Formula:(2.5 x consciousness) + ( 2 x vomiting) + ( 2 x headache) + ( 0.1 x DBP) – ( 3 x atheroma) – 12Diagnosis>1 cerebralhaemorrage90. 0%