Approach to a patient with stroke
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An overview of the approach to a patient presenting with symptoms suggestive of a CVA

An overview of the approach to a patient presenting with symptoms suggestive of a CVA

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  • The best presentation on CVA's I have ever come across.
    Admirable work.

    Vidaisha,
    South Africa.
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  • thank you very much
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  • ขอบคุณมากค่ะ
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  • thanks very useful ^^
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  • very useful but how do i print the info out?
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    Approach to a patient with stroke Approach to a patient with stroke Presentation Transcript

    • Ashwin Haridas Asem Ali Ashraf Adam Ebrahim
    • Definitions
      • Stroke
        • Clinical syndrome of rapid onset of focal deficits of brain function lasting more than 24 hours or leading to death
      • Transient Ischemic attack (TIA)
        • Clinical syndrome of rapid onset of focal deficits of brain function which resolves within 24 hours
        • Amaurosis fugax
    • Definitions
      • Progressive Stroke
        • A stroke in which the focal neurological deficits worsen with time
        • Also called stroke in evolution
      • Completed Stroke
        • A stroke in which the focal neurological deficits persist and do not worsen with time
    • Epidemiology
      • Third most common cause of death after cancer and ischeamic heart disease
      • Most common cause of severe physical disability
      • Prevalence of stroke in India is about 1.54 per 1000
      • Death rate is about 0.6 per 1000
      • Incidence and prevalence of stroke is on the rise due to increasing adoption of unhealthy lifestyle & an increasing life expectancy
    • Stroke Risk Factors
      • Fixed
        • Age
        • Gender (Male>Female)
        • Race (Afro-Caribbean>Asian>European)
        • Heredity
        • Previous vascular event eg. MI, peripheral embolism
        • High fibinogen
      • Modifiable
        • Hypertension
        • Heart disease (Atrial fibrillation, endocarditis)
        • Diabetes mellitus
        • Hyperlipidaemia
        • Smoking
        • Excess alcohol consumption
        • Oral contraceptives
    • Anterior Circulation Posterior Circulation
    • Middle Cerebral Artery
    • Anterior Cerebral Artery
    • Posterior Cerebral Artery
    • Types of Stroke
      • Ischemic
      • Hemorrhagic
    • Ischemic Stroke
      • 80% of strokes
      • Arterial occlusion of an intracranial vessel leads to hypoperfusion of the brain region it supplies
      • Two etiological types
        • Thrombotic
        • Embolic
    • Etiology of ischemic stroke
      • Thrombotic
        • Lacunar stroke
        • Large vessel thrombosis
        • Hypercoagulable disorders
      • Embolic
        • Artery to artery
          • Carotid bifurcation
          • Aortic arch
        • Cardioembolic
          • Atrial fibrillation
          • Myocardial infarction
          • Mural thrombus
          • Bacterial endocarditis
          • Mitral stenosis
          • Paradoxical embolus
    • Thrombotic Stroke
      • Atherosclerosis is the most common pathology leading to thrombotic occlusion of blood vessels
      • Hypercoagulable disorders – uncommon cause
        • Antiphospholipid syndrome
        • Sickle cell anemia
        • Polycythemia vera
        • Homocysteinemia
      • Vasculitis: PAN, Wegener’s granulomatosis, giant cell arteritis
      • Lacunar stroke
      • Accounts for 20% of all strokes
      • Results from occlusion of small deep penetrating arteries of the brain
      • Pathology: lipohyalinosis & microatheroma
      • Thrombosis leads to small infarcts known as lacunes
      • Clinically manifested as lacunar syndromes
      Thrombotic Stroke
    • Embolic Stroke
      • Cardioembolic stroke
        • Embolus from the heart gets lodged in intracranial vessels
        • MCA most commonly affected
        • Atrial fibrillation is the most common cause
        • Others: MI, prosthetic valves, rheumatic heart disease
      • Artery to artery embolism
        • Thrombus formed on atherosclerotic plaques gets embolized to intracranial vessels
        • Carotid bifurcation atherosclerosis is the most common source
        • Others: aortic arch, vertebral arteries etc.
    • Etiology of ischemic stroke
      • Blood supply to the brain is autoregulated
      • Blood flow
        • If zero leads to death of brain tissue within 4-10min
        • <16-18ml/100g tissue/min infarction within an hour
      • Ischemia leads to development of an ischemic core and an ischemic penumbra
      Pathophysiology of Ischemic Stroke
    •  
    • Ischemic Penumbra
      • Tissue surrounding the core region of infarction which is ischemic but reversibly dysfunctional
      • Maintained by collaterals
      • Can be salvaged if reperfused in time
      • Primary goal of revascuralization therapies
    • ATP depletion Hypoperfusion Failure of Na + /K + ATPase membrane ionic pump Calcium entry Glutamate release Activation of lipid peroxidases, proteases & NO synthase Destruction of intracellular organelles, cell membrane & release of free radicals Free fatty acid release Activation of pro-coagulant pathways Liquefactive necrosis Thrombus/embolus Membrane depolarization & cytotoxic cellular edema
    • Hemorrhagic Stroke
      • Two types
        • Intracerebral hemorrhage(ICH)
        • Subarachnoid hemorrhage(SAH)
      • Higher mortality rates when compared to ischemic stroke
    • Intracerebral Hemorrhage
      • Result of chronic hypertension
      • Small arteries are damaged due to hypertension
      • In advanced stages vessel wall is disrupted and leads to leakage
      • Other causes: amyloid angiopathy, anticoagulant therapy, cavernous hemangioma, cocaine, amphetamines
    • Subarachnoid Hemorrhage
      • Most common cause is rupture of saccular or Berry aneurysms
      • Other causes include arteriovenous malformations, angiomas, mycotic aneurysmal rupture etc.
      • Associated with extremely severe headache
    • Pathophysiology Of Hemorrhagic Stroke
      • Explosive entry of blood into the brain parenchyma structurally disrupts neurons
      • White matter fibre tracts are split
      • Immediate cessation of neuronal function
      • Expanding hemorrhage can act as a mass lesion and cause further progression of neurological deficits
      • Large hemorrhages can cause transtentorial coning and rapid death
    • CLINICAL FEATURES
    • History
      • Ask for onset and progression of neurological symptoms – completed stroke or stroke in evolution
      • History of previous TIAs & amaurosis fugax
      • History of hypertension & diabetes mellitus
      • History of heart conditions like arrhythmias, RHD & prosthetic valves
      • History of seizures & migraine
      • History of anticoagulant therapy
      • History of oral contraceptive use
      • History of any hypercoagulable disorders like sickle cell anemia & polycythemia vera
      • Substance abuse: cocaine, amphetamines
      History
    • Examination of a stroke patient
      • The neurological examination is highly variable and depends on the location of the vascular lesion.
      • Skin: look for xanthelasma,rashes (arteritis,splinter haemorrhages,livedo reticularis),limb ischemia(DVT)
      • Eyes:look for diabetic changes,retinal emboli,hypertensive changes,arcus senilis(refer to ophthalmologist)
    • Examination of a stroke patient
      • CVS: hyper/hypotension, abnormal rhythm(atrial fibrillation),murmurs(valvular anomaly),raised JVP(heart failure),peripheral pulses and bruits(generalised arteriopathy)
      • Respiratory system: pulmonary edema, infection
      • Abdomen: urinary retention
      • Locomotor system: injuries sustained during collapse with stroke, comorbities which influence functional abilities.
    • General feature
      • Most cerebrovascular diseases are manifest by the abrupt onset of a focal neurologic deficit, as if the patient was &quot;struck by the hand of God.”
      • The clinical manifestations of stroke are highly variable because of the complex anatomy of the brain and its vasculature.
    • ‘ HAND OF GOD’
    • CLINICAL CLASSIFICATION
    •  
    • Stroke Syndromes
      • Stroke syndromes are divided into: (1) large-vessel stroke within the anterior circulation
      • (2) large-vessel stroke within the posterior circulation,and
      • (3) small-vessel disease of either vascular bed.
    • Stroke Within the Anterior Circulation
      • The internal carotid artery and its branches comprise the anterior circulation of the brain i.e the anterior and middle cerebral arteries
    • Middle cerebral artery
      • Signs and symptoms: Structures involved
      • Paralysis of the contralateral face, arm, and leg; sensory impairment over the same area: Somatic motor area
      • Motor aphasia: Motor speech area of the dominant hemisphere
      • Central aphasia: Central, suprasylvian speech area and parietooccipital cortex of the dominant hemisphere
      • Conduction aphasia: Central speech area (parietal operculum)
    • Cont….
      • Homonymous hemianopia (often homonymous inferior quadrantanopia): Optic radiation deep to second temporal convolution
      • Paralysis of conjugate gaze to the opposite side: Frontal contraversive eye field or projecting fibers
      • Central aphasia: Central, suprasylvian speech area and parietooccipital cortex of the dominant hemisphere
      • Conduction aphasia: Central speech area (parietal operculum)
      • Homonymous hemianopia (often homonymous inferior quadrantanopia): Optic radiation deep to second temporal convolution
    • Cont..
      • Apractognosia(agnosia +apraxia) of the nondominant hemisphere: Nondominant parietal lobe (area corresponding to speech area in dominant hemisphere); loss of topographic memory is usually due to a nondominant lesion, occasionally to a dominant one.
      • Apraxia is a neurological disorder characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements. It is a disorder of motor planning.
      • Agnosia ( a-gnosis , &quot;non-knowledge&quot;, or loss of knowledge) is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss
    • Deficits Due To ACA Occlussion
      • Occlusion of the anterior cerebral artery may result in the following defects:
        • If stroke occurs prior to the anterior communicating artery it is usually well tolerated secondary to collateral circulation
        • Paralysis of the contralateral foot and leg
        • Sensory loss in the contralateral foot and leg
        • Left sided strokes may develop transcortical motor aphasia
        • Gait apraxia
        • Urinary incontinence which usually occurs with bilateral damage in the acute phase
    • Internal Carotid Artery
      • The clinical picture of internal carotid occlusion varies depending on whether the cause of ischemia is propagated thrombus, embolism, or low flow. The cortex supplied by the MCA territory is affected most often. With a competent circle of Willis, occlusion may go unnoticed.
    • Internal Carotid Artery
      • If the thrombus propagates up the internal carotid artery into the MCA or embolizes it, symptoms are identical to proximal MCA occlusion.
      • Sometimes there is massive infarction of the entire deep white matter and cortical surface.
    • Internal Carotid Artery
      • When the origins of both the ACA and MCA are occluded at the top of the carotid artery, abulia or stupor occurs with hemiplegia, hemianesthesia, and aphasia or anosognosia. When the PCA arises from the internal carotid artery (a configuration called a fetal posterior cerebral artery ), it may also become occluded and give rise to symptoms referable to its peripheral territory
    • Internal Carotid Artery
      • In addition to supplying the ipsilateral brain, the internal carotid artery perfuses the optic nerve and retina via the ophthalmic artery. In ~25% of symptomatic internal carotid disease, recurrent transient monocular blindness (amaurosis fugax) warns of the lesion. Patients typically describe a horizontal shade that sweeps down or up across the field of vision
    • Internal Carotid Artery
      • A high-pitched prolonged carotid bruit fading into diastole is often associated with tightly stenotic lesions. As the stenosis grows tighter and flow distal to the stenosis becomes reduced, the bruit becomes fainter and may disappear when occlusion is imminent.
    • Posterior Circulation
      • DYSARTHRIA & FACIAL NUMBNESS
      • ATAXIA & HORNER’S SYNDROME
      • FACIAL WEAKNESS(LMN)
      • HEMIPARESIS
      • HEMISENSORY LOSS
      • HEMIANOPIA
      • LOSS OF CONSCIOSNESS
      • DIPLOPIA, VERTIGO, VOMITING
    • CLASSICAL PRESENTATIONS
      • THROMBOTIC
      • H/O TIA
      • STROKE IN EVOLUTION
      • USUALLY HAPPENS EARLY MORNING
      • EMBOLIC
      • PATIENTS WITH KNOWN HEART DISEASE LIKE IHD, VALVULAR HEART DISEASE
      • RAPID RECOVERY
      • HAEMORRHAGIC
      • STROKE IN HYPERTENSIVE PATIENTS
      • ASSOCIATED WITH EMOTIONAL EXCITEMENT
      • HEADACHE & VOMITING
    • DIFFERENTIAL DIAGNOSIS
      • SPACE OCCUPYING LESION(TUMOR)
      • SEIZURE
      • MIGRAINE
      • SUBDURAL HAEMATOMA
      • METABOLIC DISTURBANCE LIKE HYPOGLYCAEMIA
    • Hypoglycemia
      • That transient hypoglycemia may produce a stroke like picture with hemiplegia and aphasia has been known for years.
      • The wide use of bedside rapid laboratory testing for glucose now makes this easily detectable and treatable. The hemiplegia may resolve immediately with the administration of intravenous glucose but resolution over a hours is also reported
    • Space Occupying Lesions
      • Subacute or chronic duration of symptoms, however some patients may present with acutely probably due to bleeding into a tumour
      • Associated with deep seated bursting headache, projectile vomiting due raised ICT
    • SEIZURES AND POST ICTAL STATES
      • Traditional thought is that these postictal symptoms are manifestations of seizure-induced alterations in neuronal function that are reversible; structural neuronal alterations are not present. The postictal weakness or Todd’s paralysis usually follows partial motor seizures but may follow generalized seizures as well. Duration is usually brief but may last 48 hours
    • MIGRAINE
      • Migraine may actually precipitate a stroke, but there is also a variant of migraine, hemiplegic migraine, where unilateral hemiparesis outlasts the headache. This is difficult if not impossible to diagnose correctly at first presentation when it must be regarded as a diagnosis of exclusion; only with recurrent, stereotypic attacks can this be suspected. Cases with alternating hemiplegia have been reported. At times this disorder has been shown to be familial.
      •  
    • SUMMARY
      • Rapid onset focal deficit of brain function confirms stroke
      • Onset and progression will decide the aetiology
      • Precise history of deficit will decide the site of lesion
    •  
    • INVESTIGATION OBJECTIVES
      • To confirm the vascular nature of the lesion
      • The pathological type of the vascular lesion
      • The underlying vascular disease
      • Risk factors present
    • INVESTIGATION MODALITIES: BRAIN
      • NON-INVASIVE
      • CT Scan
      • MRI Scan
      • MR Angiography
      • Doppler Ultrasound
      • EEG
      • PET
      • SPECT
      • INVASIVE
      • Lumbar Puncture
      • Contrast Angiography
      • (Cerebral Arteriography)
      • CT Angiography
    • PATHOLOGICAL TYPES STROKE HAEMORRHAGIC ISCHAEMIC
    • CT SCAN
      • Mandatory initial investigation
      • Haemorrhage appears instantly as a hyperdense area
      • Infarct appears as a hypodense area
      • Infarct may not appear before 48 hrs
      • MRI may be done instead but ct scan is more sensitive for detecting haemorrhage
      • Diffusion weighted MRI is good for identifying ischaemic lesion
    •  
    • ISCHAEMIC LESION
    • CT SCAN/MRI VASCULAR NATURE CONFIRMED HAEMORRHAGE ISCHAEMIA Cont’d… STROKE PATIENT
    • SEARCH FOR SOURCE Cont’d… SEARCH FOR SOURCE CEREBRAL ARTERIOGRAPHY MRA/CTA DOPPLER PET/SPECT
    •  
    • Carotid Artery Ultrasound Showing a Completely Calcified Atherosclerotic Plaque
    •  
    • 3-D reconstruction of CT angiogram showing stenosis at the carotid bifurcation
    • Intra-arterial angiography showing arteriovenous malformation
    • MR angiogram showing giant aneurysm at the middle cerebral artery bifurcation
    • HAEMORRHAGE CONFIRMED NORMAL CT SCAN HAEMORRHAGE SUSPECTED LUMBAR PUNCTURE CSF WITH BLOOD/ XANTHOCHROMIA
    • UNDERLYING DISEASE
      • Cerebral vasculature
      • Abnormalities like aneurysms or
      • AV malformations
      • Cerebral angiography
      • Vascular imaging – MRA/CTA or doppler (non invasive)
      • CARDIOVASCULAR
      • Like MI, atrial fibrillation, valvular diseases etc.
      • Electrocardiogram
      • Chest X-Ray
      • Echocardiography
      • Transesophageal ultrasound
      • Holter monitoring(paroxysmal nocturnal arrhythmia)
      • Blood cultures
      UNDERLYING DISEASE
    • UNDERLYING DISEASE
      • Serum lipids for hyperlipidemia
      • ANA for SLE
      • MR Angiography for arterial dissection
      • Lupus anticoagulant for antiphospholipid antibody syndrome
      • ESR, CRP, ANCA for vasculitis
      • PT, aPTT, Platelet count for bleeding disorders
      • Proteins C & S for hypercoagulability
    • TREATMENT OBJECTIVES
      • 1. MINIMIZE VOLUME OF BRAIN IRREVERSIBLY DAMAGED
      • 2. PREVENT COMPLICATIONS
      • 3. REHABILITATION
      • 4. REDUCE RISK OF RECCURENCE
    • MANAGEMENT OF A TRANSIENT ISCHAEMIC ATTACK (TIA)
      • MEDICAL MANAGEMENT
      • (if diffuse atherosclerotic disease or poor operative candidates)
      • Stop smoking
      • Concurrent medical problems to be addressed:
        • Emboli from heart and other parts of cardiovascular system
      • (a) anti coagulants: Heparin(IV), Warfarin(oral)
      • (b) anti platelet drugs: Aspirin(oral), Ticlopidine
        • Diabetes, Hypertension, Hyperlipidemia
    • MANAGEMENT OF A TRANSIENT ISCHAEMIC ATTACK(TIA) – Cont’d
      • SURGICAL MANAGEMENT
      • CAROTID AND CEREBRAL ARTERIOGRAPHY
      • STENOSIS
      • Mild to Moderate Severe
      • Regular Follow Up
      • Carotid Endarterectomy
      • All above can be done only if there is relatively little atherosclerosis elsewhere in cerebrovascular system.
    • MANAGEMENT OF AN ACUTE EPISODE OF STROKE
      • AIRWAY - Maintain airway, prevent aspiration, keep nil per oral
      • BREATHING - Maintain oxygen saturation > 97%
      • - Supplementary oxygen
      • CIRCULATION - Adequacy of pulse and BP
      • - Fluid, Anti Arrhythmics, Ionotropes
      • HYDRATION - Prevent dehydration ; give adequate fluids
      • - Parenteral or via nasogastric tube
      • NUTRITION - Nutritional supplements and Nasogatric feeding
      • MEDICATION - Administer medication also by routes other than oral
    • MANAGEMENT OF AN ACUTE EPISODE OF STROKE Cont’d
      • BLOOD PRESSURE - unless indicated (heart or renal failure,hypertensive encephalopathy or aortic dissection) it should not be lowered for the fear of expansion of infarct.
      • Ischaemic stroke - maintain 180/110 mm Hg
      • Haemorrhagic stroke – keep MAP <115 mm Hg
      • BLOOD GLUCOSE - INSULIN to treat hyperglycaemia(can increase infarct size)
      • - maintain < 200mg%
      • TEMPERATURE - early use of antipyretics
      • PRESSURE AREAS – To prevent occurrence of decubitus ulcers
      • INCONTINENCE
    • EARLY MANAGEMENT
    •  
    • ISCHAEMIC STROKE
      • THROMBOLYTICS and REVASCULARISATION -
      • - tPA (alteplase)-0.9mg/kg(max 90mg)
      • 10% of dose – initial IV bolus
      • remainder infused over one hour
      • - to be used < 3 hrs of onset of symptoms
      • (for maximum efficacy)
      • - haemorrhage to be ruled out
      • NEUROPROTECTIVE AGENTS
    • ANTI PLATELET THERAPY
      • Asprin, Clopidogrel
      • - act by inhibiting platelet aggregation and adhesion.
      • - aspirin 300mg single dose to be given immediately following diagnosis.
      • - if alteplase given it can be with held for 24 hrs.
      • - later aspirin at a dose of 75 mg in combination with clopidogrel 75 mg daily for about one year duration.
    • ANTI COAGULANTS
      • HEPARINS , WARFARIN
      • - heparins act by accelerating the inhibition of factor II and factor X of coagulation cascade
      • - warfarin antagonises vitamin K to prevent activation of clotting factors
      • -decrease risk of recurrence and venous thromboembolism
      • -intra cranial haemorrhage to be excluded before therapy
      • -more useful if stroke is evolving
    • ANTI COAGULANTS - Cont’d
      • HYPEROSMOLAR AGENTS
      • - reduce cerebral oedema
      • - 20% mannitol IV – 100ml TID
      • - oral glycerol if swallow is normal
      • Concurrent medical problems such as atrial fibrillations to be tackled
      • OTHERS:
      • - PENTOXYPHYLLINE (hemorrheology modifier)
      • to be used within 12 hrs
      • -NEUROPROTECTIVE AGENTS
    • HAEMORRHAGIC STROKE
      • Control of hypertension
      • Control coagulation abnormalities (esp due to oral anticoagulants)
      • Surgical decompression
      • Surgery for aneurysms and arterio-venous malformations
      • Anti platelet and anti coagulants are contraindicated
    • REHABILITATION
      • PHYSIOTHERAPY - as early as possible
      • - initially passive moments
      • - later active movements
      • - in every case early mobilization
      • - prevents contractures, spasticity and atrophy
      • OCCUPATIONAL THERAPY
    • REHABILITATION - Cont’d
      • SPEECH THERAPY
      • IMPROVE QUALITY OF LIFE WITH MOTOR AIDS -leg brace, toe spring , cane , walking stick
    • STROKE UNITS – A MULTIDISCIPLINARY APPROACH
      • Immediate resuscitation , prevent complications and recurrence
      • Emergency 24 hr evaluation and comprehensive care
      • Improves neurological outcome
      • Reduces mortality
      • 1000 patients admitted to stroke units saves the lives of atleast 5o patients at end of 6 months
    • SECONDARY PREVENTION
      • Blood pressure control
      • Diabetes Management
      • Lipid Management
      • Smoking Cessation
      • Alcohol Moderation
      • Weight Reduction/Physical Activity
      • Carotid Artery Interventions
      • Anti platelet agents / Anti coagulants
      • Statins
      • Diuretics +/- ACE inhibitors
    • COMPLICATIONS
      • Due to cortical brain injury(immediate)
      • - Epilepsy/seizures
      • - Cerebral oedema
      • Residual deficits from stroke
      • - Paralysis
      • - Aphasia
    • COMPLICATIONS – Cont’d
      • Due to immobility
      • - Chest infections
      • - Pressure sores
      • - Deep vein thrombosis /
      • pulmonary embolism
      • - Painful shoulder
      • - Urinary infection/constipation
      • - Depression and anxiety
    • PROGNOSIS
      • ISCHAEMIC STROKE
      • Mortality rate in first 30 days is 8-12%
      • Can vary depending upon size, location, symptoms of stroke
      • Time that elapses from the event to medical intervention
      • First 3 hrs after stroke - GOLDEN PERIOD
    • PROGNOSIS – Cont’d
      • INTRACEREBRAL HAEMORRHAGE
      • Mortality rate in first 30 days is almost 50%
      • Site and extent of hematoma also plays a role in determining the prognosis
      • Hamorrhagic strokes have a poor prognosis compared to ischaemic type .
    •