Ischaemic Stroke Overview

1. ISCHAEMIC STROKE

2. INTRODUCTION
• The blood supply is
blocked by a blood clot or
clump of fat. This
damages your brain cells
and they begin to die.
• Ischaemic stroke affects
about 9 out of every 10
people who have a stroke.
It’s most common in
people over the age of 65,
although can happen at
any age.

3. TWO TYPES
ARTERIAL THROMBOSIS
• Also called thrombotic
stroke or cerebral
thrombosis.
• This is when a blood clot
forms in an artery that
supplies your brain and
blocks the blood supply.

4. TWO TYPES (cont’d)
CEREBRAL EMBOLISM
• Also known as embolic
stroke.
• This is when a blood clot
forms somewhere else in
your body and travels to
your brain and blocks the
blood supply. The clot
usually forms in your heart
or one of the large arteries
that supplies your brain.

5. RISK FACTORS
NON-MODIFIABLE RISK FACTORS
• Age
• Gender
• Race, Ethnicity
• Heredity

6. RISK FACTORS (cont’d)
MODIFIABLE RISK FACTORS
• Hypertension
• Cardiac Disease
• Diabetes Mellitus
• Smoking
• Alcohol
• Cholesterol
• Illicit Drug Use
• Migraines

7. RISK FACTORS (cont’d)
MODIFIABLE RISK FACTORS
• Oral Contraceptives
• Haemostatic and
Inflammatory Factors.
• Hyperhomocysteinemia
• Asymptomatic Carotid
Stenosis
• Transient Ischemic Attacks
• Lifestyle Factors (Obesity,
Physical Activity, Diet, and
Acute Triggers).

8. SIGNS & SYMPTOMS
• Symptoms usually come
on suddenly, within
seconds or minutes.
• You may also have a
Transient Ischaemic
Attack (TIA) before a
full blown stroke.

9. SIGNS & SYMPTOMS (cont’d)
• A good way to
recognise if you or
someone you’re with
has had a stroke is to
use the ‘FAST’ test.

10. SIGNS & SYMPTOMS (cont’d)
• The exact symptoms
depend on where in
your brain the blood
supply has been
blocked.
• This is because different
areas of your brain
control different
functions and they all
receive blood through
different arteries.

11. SIGNS & SYMPTOMS (cont’d)
TRANSIENT ISCHAEMIC ATTACK
(TIA)
• A transient neurologic
attack that lasts <24 hours
(most last <1 hour) and is
determined to be of
ischaemic etiology.

12. SIGNS & SYMPTOMS (cont’d)
ANTERIOR CEREBRAL ARTERY
• Contralateral paresis and
sensory loss in the leg.
• Cognitive or personality
changes.

13. SIGNS & SYMPTOMS (cont’d)
MIDDLE CEREBRAL ARTERY
• Pneumonic: “CHANGes”
– Contralateral paresis and
sensory loss in the face and
the arm.
– Homonymous Hemianopsia.
– Aphasia.
– Neglect.
– Gaze preference toward the
side of the lesion.

14. SIGNS & SYMPTOMS (cont’d)
POSTERIOR CEREBRAL ARTERY
• Pneumonic: The 4 D’s
– Diplopia
– Dizziness
– Dysphagia
– Dysarthria

15. SIGNS & SYMPTOMS (cont’d)
BASAL GANGLIA LACUNAR
• Pure motor or sensory
stroke.
• Dysarthria-clumsy hand
syndrome, ataxic
hemiparesis.

16. SIGNS & SYMPTOMS (cont’d)
BASILAR ARTERY
• Coma
• “Locked-In” Syndrome
• Cranial Nerve Palsies
• Apnea
• Visual Symptoms
• Drop Attacks
• Dysphagia
• Dysarthria
• Vertigo
• “Crossed” weakness and sensory
loss affecting the ipsilateral face
and contralateral body.

17. DIAGNOSIS
• You will have your blood
pressure measured and an
electrocardiogram (ECG) to
record the rhythm and
electrical activity of your
heart.
• Echocardiogram (ECHO) of
your heart if embolic stroke
is suspected.
• You may then have tests to
measure the levels of
cholesterol and sugar in
your blood.

18. DIAGNOSIS (cont’d)
• As soon as possible you’ll
also have a brain scan, such
as a CT or MRI. This will
determine whether you
have had an ischaemic
stroke or a haemorrhagic
stroke. A haemorrhagic
stroke is when an artery or
vein bursts and bleeds into
your brain.
• Strokes <6 hours old are
usually NOT visible on CT
scan.

19. DIAGNOSIS (cont’d)
• White signals on left side
are suggestive of
blockage of blood flow in
Left side blood vessel
(MCA) suggestive of acute
brain attack (infarction).
• Diffusion-weighted MRI is
sensitive for acute stroke
with changes as early as
20 minutes after an
ischaemic event.

20. DIAGNOSIS (cont’d)
• MRI of acute middle carotid
artery (MCA) stroke on MRI at 12
hours post-ictus. T2-weighted
image shows mild hyper-intensity
of the middle carotid artery
territory (arrows). Non-contrast
T1-weighted image demonstrates
early stroke changes with
effacement of cortical sulci in the
MCA territory associated with
swelling and mild hypo-intensity
of the cortical ribbon (arrows).
After contrast (gadolinium)
administration, intravascular
enhancement is present,
indicating sluggish flow in the
ischemic zone (arrows).

21. DIAGNOSIS (cont’d)
• MRI axial FLAIR images
of Brain show an infarct
involving left frontal
lobe anterior to sylvian
fissure. Area of
involvement
corresponds to left MCA
Superior Division
territory.

22. DIAGNOSIS (cont’d)
• Left: CT scan slice of the
brain showing a right-
hemispheric ischemic
stroke.
• Right: MRI showing
damaged brain cells due
to a left-hemispheric
ischaemic stroke.

23. DIAGNOSIS (cont’d)
VASCULAR STUDIES
• Carotid Ultrasound
• Transcranial Doppler
• MRA (Magnetic Resonance
Angiography)
• CT Angiography
• Conventional Angiography

24. DIAGNOSIS (cont’d)
LABORATORY STUDIES
• Complete blood count (CBC)
• Basic chemistry panel
• Coagulation studies
• Toxicology screening: May assist
in identifying intoxicated patients
with symptoms/behaviour
mimicking stroke syndromes.
• Arterial blood gas analysis: In
selected patients with suspected
hypoxemia. It defines the severity
of hypoxemia and may be used to
detect acid-base disturbances.

25. TREATMENT

26. TREATMENT (cont’d)
• If you can't swallow, you’ll be
given fluid through a drip in
your arm to stop you
becoming dehydrated.
• You will have a nasogastric
tube inserted to give you all
the nutrients and medicines
that you need.
• You may also be given oxygen
through a face mask or by
means of endotracheal
intubation to help maintain
optimum blood oxygen
saturation levels.

27. TREATMENT (cont’d)
• You’ll be helped to sit up and
encouraged to move around as
soon as you’re able.
• If you can’t move, your
healthcare team will regularly
help you to turn in your bed. This
will reduce your risk of getting
bed sores and deep vein
thrombosis (DVT).
• You may also be given a
mechanical pump to use on your
feet and legs. This is called an
intermittent compression device.
The pump automatically squeezes
your feet and lower legs to help
your blood circulate.

28. TREATMENT (cont’d)
MEDICINES
• Alteplase is a medicine (IV
tPA-Tissue Plasminogen
Activator) used to break up
blood clots, and will help
restore the blood flow to
your brain. You need to
have it within four and a
half hours of your
symptoms starting for it to
be effective.
• Intra-arterial thrombolysis
can be used within 6 hours
of a major stroke from
Middle Cerebral Artery
occlusion if such patients
are not suitable candidates
for Alteplase.

29. CONTRAINDICATIONS TO ALTEPLASE
THERAPY
Pneumonic: SAMPLE STAGES
– Stroke or head trauma within
the last 3 months.
– Anticoagulation with INR>1.7
or prolonged PTT.
– MI (recent).
– Prior Intracranial
Haemorrhage.
– Low Platelet Count
(<100,000/mm3 )
– Elevated BP: Systolic>185 or
Diastolic >110mmHg
– Surgery in the past 14 days.
– TIA (mild symptoms or rapid
improvement of symptoms).
– Age<18
– GI or urinary bleeding in the
past 21 days
– Elevated (>400mg/dl) or
Decreased (<50mg/dl) Blood
glucose.
– Seizures present at the onset
of stroke.

30. TREATMENT (cont’d)
MEDICINES
• Aspirin and Clopidogrel are
used to reduce your risk of
blood clots forming after a
stroke.
• Aspirin is associated with
reduced morbidity and
mortality in acute ischaemic
stroke presenting <48 hours
from onset.
• Warfarin, non-vitamin K
antagonist oral anticoagulant
medicines (NOACs) or Heparin
can also prevent blood clots
forming. You may have these
medicines if your doctor thinks
the clot came from your heart.
Again, these aren’t suitable for
everybody.
• You may also be given some
other medicines to control
your blood pressure, blood
sugar and lower your
cholesterol.

31. TREATMENT (cont’d)
SURGERY
• This may involve an
operation called Carotid
Endarterectomy to remove
blood clots and fatty
deposits from one of the
carotid arteries in your
neck. The surgery may help
to reduce your risk of
having another stroke but
isn’t suitable for everyone.

32. TREATMENT (cont’d)
CAROTID ENDARTERECTOMY
• If stenosis is >70% in
symptomatic patients or
>60% in asymptomatic
patients (Contraindicated
on 100% occlusion).

33. TREATMENT (cont’d)
• Monitor for signs and
symptoms of brain
swelling, ↑ICP and
herniation.
• Serial CTs are helpful in
the evaluation of
deteriorating patients.
• As a temporizing
measure, treat with
Mannitol and
hyperventilation.

34. TREATMENT (cont’d)
SEVERE HYPERTENSION (SYSTOLIC
BP>220 OR DIASTOLIC BP>120mmHg)
• Treat with IV Labetalol or
Nicardipine infusion.
• For the administration of
Alteplase, the patient’s
systolic BP must be <185
and diastolic BP<110mmHg.

35. TREATMENT (cont’d)
• Treat: Fever and
Hyperglycaemia, as
both are associated
with worse prognoses
in the setting of acute
stroke.
• Prevent and treat post-
stroke complications:
Aspiration Pneumonia,
UTI and DVT.

36. COMPLICATIONS

37. REHABILITATION
• A multidisciplinary team of
health professionals will work
out a rehabilitation
programme for you that’s
designed around your
particular needs.
• Rehabilitation aims to help you
stay as independent as
possible and get back to your
usual activities, or adapt to
new ways of doing things.
• You may make most of your
recovery in the early weeks
and months afterwards but
you may continue to improve
for years.

38. REHABILITATION (cont’d)

39. PROGNOSIS
• In the acute phase of stroke, the strongest
predictors of outcome are : Stroke Severity
and Patient Age.
• Stroke severity can be judged clinically, based
upon the degree of neurologic impairment
and the size and location of the infarction on
neuroimaging with MRI or CT.
• Other important influences on stroke
outcome include infarct location, ischemic
stroke mechanism, comorbid conditions,
epidemiologic factors, and complications of
stroke.
• In the period from 12 hours to 7 days after
ischemic stroke onset, many patients who
are without complications experience
moderate but steady improvement in
neurologic impairments. The greatest
proportion of recovery occurs in the first 3 to
6 months after stroke, with lesser
improvements thereafter.

40. PROGNOSIS (cont’d)
• The return of arm and hand
function after stroke is
particularly important to a
good functional recovery.
Early active finger
extension, grasp release,
shoulder shrug, shoulder
abduction, and active range
of motion are associated
with a favourable prognosis
for arm and hand recovery
at 6 months.