This document provides an overview of strokes, including:
- Globally, about 17 million strokes occur annually, making it a leading cause of death and disability.
- Strokes are caused by blockages or ruptures in blood vessels in the brain. The brain then does not receive enough blood and oxygen.
- Risk factors include high blood pressure, smoking, diabetes, high cholesterol, obesity, lack of exercise, poor diet, family history, older age, and prior heart attack or stroke.
- Early detection and treatment are important to reduce long-term effects such as paralysis or speech problems. Managing risk factors can also help prevent future strokes.
The document provides information about intracranial hemorrhage including types, causes, symptoms, diagnosis and management. It discusses two main types of intracranial hemorrhage: intra-axial bleed which occurs within the brain tissue and includes intraparenchymal and intraventricular hemorrhage, and extra-axial bleed which is outside the brain tissue and includes subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage. Focal neurological signs that may result from hemorrhages in different areas of the brain are also outlined.
The document provides guidance on reading head CT scans for physicians. It outlines the basic principles of CT scanning, including its history and components. It then reviews normal neuroanatomy as seen on head CT scans, illustrating various anatomical structures and landmarks visible in different axial sections. The document aims to help physicians accurately interpret CT findings to diagnose and treat time-sensitive conditions without specialist assistance.
The document discusses coma, including its definition, causes, clinical assessment, investigations, differential diagnosis and management. Coma is characterized by a total lack of arousal and awareness lasting at least 1 hour. It can be caused by structural brain injuries or metabolic derangements and represents a severe impairment of cerebral function. A systematic clinical approach is needed to identify treatable causes of coma such as head injuries, infections, drugs or toxic exposures.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Eisenmenger syndrome is a condition where a congenital heart defect causes a long-standing left-to-right shunt, resulting in pulmonary hypertension and eventual reversal of blood flow into a right-to-left shunt. Over time, the increased blood pressure in the lungs causes damage that leads to pulmonary vascular disease and cyanosis. Patients experience clinical manifestations such as cyanosis, clubbed fingers, fainting, heart failure, abnormal heart rhythms, and bleeding disorders.
This document discusses intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, or bleeding disorders. Common symptoms include sudden headache, weakness on one side of the body, and altered mental status. Treatment focuses on controlling blood pressure, reducing pressure in the brain, and potentially surgically evacuating large bleeds. SAH most often results from aneurysms and presents with a sudden, severe headache. Angiography is used to locate the source of bleeding, and aneurysms are often clipped surgically to prevent rebleeding.
Atrial septal defect (ASD) is an abnormal opening in the wall separating the left and right atria of the heart. There are several types of ASDs including secundum, ostium primum, sinus venosus, and coronary sinus defects. ASDs are usually diagnosed through echocardiography which can determine the size and location of the defect. Small, asymptomatic ASDs may not require treatment, but larger defects with evidence of right heart strain often warrant closure either through open heart surgery or a nonsurgical approach using an implantable device delivered through catheters. Both methods effectively close the defect to prevent long-term complications like heart failure and pulmonary hypertension.
This document discusses coma and disorders of consciousness. It defines coma as a state of unresponsiveness and unconsciousness, and notes that coma can be a medical emergency requiring intervention. The document outlines different levels of arousal from alert to coma and describes conditions like encephalopathy, locked-in syndrome, and persistent vegetative state. Causes of impaired consciousness discussed include alcohol, epilepsy, intoxication, trauma, infection, stroke, and hypoxia-ischemia. The Glasgow Coma Scale for assessing coma is also summarized.
The document provides information about intracranial hemorrhage including types, causes, symptoms, diagnosis and management. It discusses two main types of intracranial hemorrhage: intra-axial bleed which occurs within the brain tissue and includes intraparenchymal and intraventricular hemorrhage, and extra-axial bleed which is outside the brain tissue and includes subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage. Focal neurological signs that may result from hemorrhages in different areas of the brain are also outlined.
The document provides guidance on reading head CT scans for physicians. It outlines the basic principles of CT scanning, including its history and components. It then reviews normal neuroanatomy as seen on head CT scans, illustrating various anatomical structures and landmarks visible in different axial sections. The document aims to help physicians accurately interpret CT findings to diagnose and treat time-sensitive conditions without specialist assistance.
The document discusses coma, including its definition, causes, clinical assessment, investigations, differential diagnosis and management. Coma is characterized by a total lack of arousal and awareness lasting at least 1 hour. It can be caused by structural brain injuries or metabolic derangements and represents a severe impairment of cerebral function. A systematic clinical approach is needed to identify treatable causes of coma such as head injuries, infections, drugs or toxic exposures.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Eisenmenger syndrome is a condition where a congenital heart defect causes a long-standing left-to-right shunt, resulting in pulmonary hypertension and eventual reversal of blood flow into a right-to-left shunt. Over time, the increased blood pressure in the lungs causes damage that leads to pulmonary vascular disease and cyanosis. Patients experience clinical manifestations such as cyanosis, clubbed fingers, fainting, heart failure, abnormal heart rhythms, and bleeding disorders.
This document discusses intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, or bleeding disorders. Common symptoms include sudden headache, weakness on one side of the body, and altered mental status. Treatment focuses on controlling blood pressure, reducing pressure in the brain, and potentially surgically evacuating large bleeds. SAH most often results from aneurysms and presents with a sudden, severe headache. Angiography is used to locate the source of bleeding, and aneurysms are often clipped surgically to prevent rebleeding.
Atrial septal defect (ASD) is an abnormal opening in the wall separating the left and right atria of the heart. There are several types of ASDs including secundum, ostium primum, sinus venosus, and coronary sinus defects. ASDs are usually diagnosed through echocardiography which can determine the size and location of the defect. Small, asymptomatic ASDs may not require treatment, but larger defects with evidence of right heart strain often warrant closure either through open heart surgery or a nonsurgical approach using an implantable device delivered through catheters. Both methods effectively close the defect to prevent long-term complications like heart failure and pulmonary hypertension.
This document discusses coma and disorders of consciousness. It defines coma as a state of unresponsiveness and unconsciousness, and notes that coma can be a medical emergency requiring intervention. The document outlines different levels of arousal from alert to coma and describes conditions like encephalopathy, locked-in syndrome, and persistent vegetative state. Causes of impaired consciousness discussed include alcohol, epilepsy, intoxication, trauma, infection, stroke, and hypoxia-ischemia. The Glasgow Coma Scale for assessing coma is also summarized.
A transient ischemic attack (TIA) is a brief episode of neurological dysfunction caused by restricted blood flow. TIAs last less than 24 hours and have an annual incidence of 3 per 10,000 people. Approximately 10% of patients experience a TIA before having a stroke. Management involves identifying risk factors like hypertension and treating the underlying cause, often through antiplatelet agents, anticoagulation, or carotid endarterectomy to prevent future strokes.
This document discusses the causes of hemiplegia, which include stroke, central nervous system infections, demyelination disorders, trauma, hemiplegic migraines, and vasculitis. Stroke is described in more detail, with the main causes being cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage. Risk factors for stroke include conditions like hypertension, heart disease, diabetes, and lifestyle factors such as smoking. The pathophysiology of cerebral infarction and primary intracerebral hemorrhage are also summarized.
The document discusses the radiological anatomy of a normal CT brain scan. It begins by describing the lobes of the brain and surfaces visible on CT. It then discusses the history and technique of CT scanning, describing how different tissues appear in varying shades of gray. Common artifacts are also reviewed. Key features of a normal CT brain include symmetric ventricles and sulci, with intact skull and no masses or fluid collections seen.
Three main sensory syndromes can result from parietal stroke:
1) Pseudothalamic sensory syndrome involving elementary sensation loss in the face, arm, and leg, caused by anterior-inferior parietal lesions including the parietal operculum and posterior insula.
2) Cortical sensory syndrome of isolated discriminative sensation loss in one or two body parts, from superior-posterior parietal lesions.
3) Atypical sensory syndrome with sensory loss across all modalities in a partial body distribution, from variably located parietal lesions, representing a minor variant of the first two syndromes. Neuropsychological dysfunction was present in most patients.
A simplified description of basal ganglia stroke to help understand the clinical scenarios where patients present with neurological symptoms not clearly pointing towards possibility of stroke.
Diffuse axonal injury is a widespread axonal damage that occurs after traumatic brain injury. It involves stretching and shearing of axons that disrupts neuronal transport and homeostasis. This leads to primary axotomy at the time of injury and secondary axotomy over time through injury cascades. Neuroinflammation mediated by microglia also contributes to secondary injury. Biomarkers and advanced neuroimaging techniques can help detect and monitor diffuse axonal injury. While there are no definitive treatments, potential therapies involving calcineurin modulation, stem cells, and other agents are being explored.
The document defines various types of strokes and transient ischemic attacks. It discusses the epidemiology, risk factors, clinical features, investigations, and management of strokes. The main types are ischemic and hemorrhagic strokes. Investigations include brain imaging like CT scan and MRI to identify the type of stroke and underlying causes. Treatment focuses on minimizing brain damage, preventing complications, rehabilitation, and reducing the risk of recurrence.
Exercise testing is a noninvasive tool to evaluate the cardiovascular system's response to stress from exercise. During exercise, the body's metabolic rate and cardiac output increase substantially, placing high demands on the cardiopulmonary system. This makes exercise an effective way to assess cardiac function and perfusion. Various protocols exist for exercise testing using treadmills, bicycles, or other devices, with different protocols suited for evaluating patients with different cardiovascular conditions or exercise capacities. Careful analysis of electrocardiogram changes during and after exercise can provide information about myocardial ischemia.
- Seizures are caused by abnormal excessive neuronal activity in the brain and can be classified as either partial or generalized seizures. Partial seizures originate in a localized region of the brain while generalized seizures involve both hemispheres.
- Common types of generalized seizures include absence seizures, characterized by brief lapses of consciousness, and tonic-clonic seizures which involve tonic muscle contraction followed by clonic movements.
- Complex partial seizures originate in the temporal lobe and involve psychic experiences such as hallucinations followed by automatisms like lip smacking and confusion after the seizure.
Stroke occurs when blood flow to the brain is interrupted, depriving brain tissue of oxygen and nutrients. It is a leading cause of death and disability. There are two main types of stroke - ischemic (80%), caused by blockage of a blood vessel, and hemorrhagic (20%), caused by bleeding. Risk factors include high blood pressure, smoking, diabetes, high cholesterol, obesity, lack of exercise, and family history. Treatment involves lifestyle modifications, medications, and rehabilitation to prevent complications and help recovery.
Approach to patient with Dilated CardiomyopathyNizam Uddin
This document provides an overview of dilated cardiomyopathy (DCM), including its definition, classification, etiologies, pathophysiology, clinical presentation, diagnosis and management. Key points include:
1) DCM is characterized by dilation and impaired contraction of the ventricles. Causes include genetic factors, viral myocarditis, toxins and idiopathic cases.
2) Diagnosis involves assessing history, symptoms of heart failure, echocardiogram showing reduced systolic function, and ruling out other potential causes.
3) Presentation varies from asymptomatic to heart failure symptoms. Management focuses on treating heart failure and its causes. Prognosis depends on the severity and reversibility of the underlying
1. The document discusses various neurological emergencies including coma, seizures, syncope, and stroke. It provides guidance on assessing and managing the airway, breathing, and circulation for patients with an altered mental status.
2. For seizures, it describes different seizure types and emphasizes protecting the patient during a seizure and assessing them afterwards.
3. Syncope or fainting is discussed as a temporary loss of consciousness often due to low blood pressure or cardiac issues. Stroke signs like paralysis and speech problems are also outlined.
4. stroke- investigations and managementmariam hamzah
The document summarizes the investigations and management of stroke. Key points include:
1. Imaging such as CT or MRI is used to distinguish between hemorrhagic and ischemic stroke and identify underlying causes. CT is more widely available while MRI is more sensitive.
2. Risk factors, cardiac investigations, and vascular imaging are also conducted to determine the cause of ischemic stroke.
3. Management of ischemic stroke involves supportive care, thrombolysis within 3 hours, aspirin to prevent recurrence, and carotid surgery for severe stenosis to reduce risk of further stroke.
4. For hemorrhagic stroke, reversal of coagulopathy and surgical evacuation may be considered to control bleeding and intracranial pressure
This document discusses the management of cyanotic patients. It covers several topics:
1. Causes of cyanosis including cardiac and non-cardiac causes such as lung diseases and neurological issues.
2. Evaluation of cyanotic newborns including detecting cyanosis and checking oxygen saturation levels.
3. Complications of cyanosis such as cyanotic spells, neurological complications, erythrocytosis, and anemia. Management of these complications is also discussed.
Traumatic brain injury (TBI) is caused by an external force to the head that can lead to temporary or permanent impairment. It is a leading cause of death and disability, especially in young people. A TBI can be closed, without skull fracture, or open, with skull penetration. Initial management involves assessing severity with CT or MRI scans and monitoring for complications like increased intracranial pressure. Rehabilitation therapies like physiotherapy and occupational therapy aim to restore functions and prevent issues like spasticity or contractures. Outcomes depend on the severity of injury but long-term disabilities can impact cognition, movement, speech, and behavior.
Thoracic aortic aneurysms can occur in the ascending aorta, aortic arch, or descending aorta. They are generally asymptomatic but can potentially rupture or dissect, leading to death. Surgical repair is recommended for thoracic aortic aneurysms over 5.5 cm in the ascending aorta or over 6.5 cm in the descending aorta, or if the aneurysm is growing rapidly. Both open surgical graft replacement and endovascular stent grafting are options for repair, with endovascular approaches having shorter recovery but risk of complications like endoleaks. Untreated thoracic aortic aneurysms have high mortality from rupture.
ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
Globally, about 17 million strokes occur every year. Stroke is the second leading cause of death and the third most common cause of disability worldwide. The presentation of stroke includes sudden onset of focal neurological deficits such as numbness, weakness, confusion, trouble speaking or understanding, or trouble with vision, walking, balance or coordination. Timely treatment is critical, as more time elapsed means greater brain damage. Prehospital evaluation involves using stroke scales to identify high-risk patients who require rapid transport to certified stroke centers for emergency evaluation and treatment within strict time windows in order to minimize disability or death from stroke.
A transient ischemic attack (TIA) is a brief episode of neurological dysfunction caused by restricted blood flow. TIAs last less than 24 hours and have an annual incidence of 3 per 10,000 people. Approximately 10% of patients experience a TIA before having a stroke. Management involves identifying risk factors like hypertension and treating the underlying cause, often through antiplatelet agents, anticoagulation, or carotid endarterectomy to prevent future strokes.
This document discusses the causes of hemiplegia, which include stroke, central nervous system infections, demyelination disorders, trauma, hemiplegic migraines, and vasculitis. Stroke is described in more detail, with the main causes being cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage. Risk factors for stroke include conditions like hypertension, heart disease, diabetes, and lifestyle factors such as smoking. The pathophysiology of cerebral infarction and primary intracerebral hemorrhage are also summarized.
The document discusses the radiological anatomy of a normal CT brain scan. It begins by describing the lobes of the brain and surfaces visible on CT. It then discusses the history and technique of CT scanning, describing how different tissues appear in varying shades of gray. Common artifacts are also reviewed. Key features of a normal CT brain include symmetric ventricles and sulci, with intact skull and no masses or fluid collections seen.
Three main sensory syndromes can result from parietal stroke:
1) Pseudothalamic sensory syndrome involving elementary sensation loss in the face, arm, and leg, caused by anterior-inferior parietal lesions including the parietal operculum and posterior insula.
2) Cortical sensory syndrome of isolated discriminative sensation loss in one or two body parts, from superior-posterior parietal lesions.
3) Atypical sensory syndrome with sensory loss across all modalities in a partial body distribution, from variably located parietal lesions, representing a minor variant of the first two syndromes. Neuropsychological dysfunction was present in most patients.
A simplified description of basal ganglia stroke to help understand the clinical scenarios where patients present with neurological symptoms not clearly pointing towards possibility of stroke.
Diffuse axonal injury is a widespread axonal damage that occurs after traumatic brain injury. It involves stretching and shearing of axons that disrupts neuronal transport and homeostasis. This leads to primary axotomy at the time of injury and secondary axotomy over time through injury cascades. Neuroinflammation mediated by microglia also contributes to secondary injury. Biomarkers and advanced neuroimaging techniques can help detect and monitor diffuse axonal injury. While there are no definitive treatments, potential therapies involving calcineurin modulation, stem cells, and other agents are being explored.
The document defines various types of strokes and transient ischemic attacks. It discusses the epidemiology, risk factors, clinical features, investigations, and management of strokes. The main types are ischemic and hemorrhagic strokes. Investigations include brain imaging like CT scan and MRI to identify the type of stroke and underlying causes. Treatment focuses on minimizing brain damage, preventing complications, rehabilitation, and reducing the risk of recurrence.
Exercise testing is a noninvasive tool to evaluate the cardiovascular system's response to stress from exercise. During exercise, the body's metabolic rate and cardiac output increase substantially, placing high demands on the cardiopulmonary system. This makes exercise an effective way to assess cardiac function and perfusion. Various protocols exist for exercise testing using treadmills, bicycles, or other devices, with different protocols suited for evaluating patients with different cardiovascular conditions or exercise capacities. Careful analysis of electrocardiogram changes during and after exercise can provide information about myocardial ischemia.
- Seizures are caused by abnormal excessive neuronal activity in the brain and can be classified as either partial or generalized seizures. Partial seizures originate in a localized region of the brain while generalized seizures involve both hemispheres.
- Common types of generalized seizures include absence seizures, characterized by brief lapses of consciousness, and tonic-clonic seizures which involve tonic muscle contraction followed by clonic movements.
- Complex partial seizures originate in the temporal lobe and involve psychic experiences such as hallucinations followed by automatisms like lip smacking and confusion after the seizure.
Stroke occurs when blood flow to the brain is interrupted, depriving brain tissue of oxygen and nutrients. It is a leading cause of death and disability. There are two main types of stroke - ischemic (80%), caused by blockage of a blood vessel, and hemorrhagic (20%), caused by bleeding. Risk factors include high blood pressure, smoking, diabetes, high cholesterol, obesity, lack of exercise, and family history. Treatment involves lifestyle modifications, medications, and rehabilitation to prevent complications and help recovery.
Approach to patient with Dilated CardiomyopathyNizam Uddin
This document provides an overview of dilated cardiomyopathy (DCM), including its definition, classification, etiologies, pathophysiology, clinical presentation, diagnosis and management. Key points include:
1) DCM is characterized by dilation and impaired contraction of the ventricles. Causes include genetic factors, viral myocarditis, toxins and idiopathic cases.
2) Diagnosis involves assessing history, symptoms of heart failure, echocardiogram showing reduced systolic function, and ruling out other potential causes.
3) Presentation varies from asymptomatic to heart failure symptoms. Management focuses on treating heart failure and its causes. Prognosis depends on the severity and reversibility of the underlying
1. The document discusses various neurological emergencies including coma, seizures, syncope, and stroke. It provides guidance on assessing and managing the airway, breathing, and circulation for patients with an altered mental status.
2. For seizures, it describes different seizure types and emphasizes protecting the patient during a seizure and assessing them afterwards.
3. Syncope or fainting is discussed as a temporary loss of consciousness often due to low blood pressure or cardiac issues. Stroke signs like paralysis and speech problems are also outlined.
4. stroke- investigations and managementmariam hamzah
The document summarizes the investigations and management of stroke. Key points include:
1. Imaging such as CT or MRI is used to distinguish between hemorrhagic and ischemic stroke and identify underlying causes. CT is more widely available while MRI is more sensitive.
2. Risk factors, cardiac investigations, and vascular imaging are also conducted to determine the cause of ischemic stroke.
3. Management of ischemic stroke involves supportive care, thrombolysis within 3 hours, aspirin to prevent recurrence, and carotid surgery for severe stenosis to reduce risk of further stroke.
4. For hemorrhagic stroke, reversal of coagulopathy and surgical evacuation may be considered to control bleeding and intracranial pressure
This document discusses the management of cyanotic patients. It covers several topics:
1. Causes of cyanosis including cardiac and non-cardiac causes such as lung diseases and neurological issues.
2. Evaluation of cyanotic newborns including detecting cyanosis and checking oxygen saturation levels.
3. Complications of cyanosis such as cyanotic spells, neurological complications, erythrocytosis, and anemia. Management of these complications is also discussed.
Traumatic brain injury (TBI) is caused by an external force to the head that can lead to temporary or permanent impairment. It is a leading cause of death and disability, especially in young people. A TBI can be closed, without skull fracture, or open, with skull penetration. Initial management involves assessing severity with CT or MRI scans and monitoring for complications like increased intracranial pressure. Rehabilitation therapies like physiotherapy and occupational therapy aim to restore functions and prevent issues like spasticity or contractures. Outcomes depend on the severity of injury but long-term disabilities can impact cognition, movement, speech, and behavior.
Thoracic aortic aneurysms can occur in the ascending aorta, aortic arch, or descending aorta. They are generally asymptomatic but can potentially rupture or dissect, leading to death. Surgical repair is recommended for thoracic aortic aneurysms over 5.5 cm in the ascending aorta or over 6.5 cm in the descending aorta, or if the aneurysm is growing rapidly. Both open surgical graft replacement and endovascular stent grafting are options for repair, with endovascular approaches having shorter recovery but risk of complications like endoleaks. Untreated thoracic aortic aneurysms have high mortality from rupture.
ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
Globally, about 17 million strokes occur every year. Stroke is the second leading cause of death and the third most common cause of disability worldwide. The presentation of stroke includes sudden onset of focal neurological deficits such as numbness, weakness, confusion, trouble speaking or understanding, or trouble with vision, walking, balance or coordination. Timely treatment is critical, as more time elapsed means greater brain damage. Prehospital evaluation involves using stroke scales to identify high-risk patients who require rapid transport to certified stroke centers for emergency evaluation and treatment within strict time windows in order to minimize disability or death from stroke.
This case presentation describes a 35-year-old male with sickle cell disease (SCD) presenting with shortness of breath. He has a history of end stage renal disease requiring dialysis and obstructive jaundice from gallbladder stones. On examination, he has jaundice and lower extremity edema. Investigations show abnormal renal and liver function tests. Dyspnea in SCD can be caused by acute chest syndrome, pulmonary hypertension, asthma, pulmonary fibrosis, or venous thromboembolism. SCD is also associated with renal complications like acute kidney injury, proteinuria, and focal segmental glomerulosclerosis.
This case presentation describes a 30-year-old male who presented with gradual weakness in both lower limbs over 3 days. Initial treatment with analgesics and IV fluids provided no improvement. Nerve conduction studies revealed sensorimotor nerve affection in the lower limbs suggestive of Guillain-Barré syndrome. However, after admission the patient was found to be hypokalemic, which when corrected with IV potassium infusion resulted in rapid improvement of his weakness. Differential diagnoses discussed include various causes of secondary periodic paralysis and other entities that could cause acute generalized weakness.
* Case presentation: hyperosmolar hyperglycemic state (HHS)
Mortality attributed to hyperosmolar hyperglycemic state (HHS) is considerably higher than that attributed to DKA, with recent mortality rates of 5–20%.
* Agenda:
Historical perspectives and diagnosis.
Pathophysiology.
Treatment issues.
Rhabdomyolysis: an overlooked complication.
Final bottom line and take home message.
1) The document discusses atrial fibrillation (AF), its increasing prevalence, and its association with increased risk of stroke.
2) It reviews stroke risk assessment tools like CHADS2 and CHA2DS2-VASc scores and guidelines for stroke prevention in AF patients using anticoagulation or the newer oral anticoagulants (NOACs).
3) It also discusses left atrial appendage closure with the Watchman device as an alternative for stroke prevention in patients who cannot tolerate long-term anticoagulation. The Watchman trials demonstrated the device's safety and efficacy in reducing stroke risk comparable to warfarin.
1) Static preload parameters like CVP and PAOP do not correlate well with fluid responsiveness, while dynamic parameters like SVV and PPV have a stronger correlation.
2) Mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2) reflect global tissue oxygen delivery and consumption, with a target of >70% during resuscitation.
3) Venous to arterial carbon dioxide difference (P(v-a)CO2) and central venous to arterial carbon dioxide difference (P(cv-a)CO2) can indicate tissue perfusion and respond to changes in cardiac output.
This patient is a 23-year-old female who presented with generalized swelling and abdominal pain for 8 months. Her symptoms started 2 years ago with abdominal pain and obstruction, for which she was diagnosed with FMF and treated with colchicine. Over time she developed edema, ascites, hepatomegaly and thrombocytopenia. She was diagnosed with lupus based on positive ANA and anti-DNA antibodies, but subsequent tests for these were negative. Workup revealed hepatic vein and IVC thrombosis consistent with Budd-Chiari syndrome. Testing found protein C deficiency and lupus anticoagulant consistent with antiphospholipid antibody syndrome. She was started on anticoagulation, diure
The document discusses cerebrovascular accidents (strokes), including types of strokes, risk factors, signs and symptoms, nursing management in the acute and hyperacute phases, and collaborative care approaches for prevention, diagnosis, and treatment. It provides an overview of strokes, their causes, impact, and the critical role of nurses in monitoring patients, administering treatments, and coordinating multidisciplinary care.
1) Hepatitis C virus genotype 4 is predominant in Egypt, with a prevalence of around 9%.
2) New direct-acting antiviral agents have improved treatment outcomes, but the virus's ability to mutate rapidly can lead to resistance.
3) The document provides treatment recommendations and regimens using direct-acting antivirals like sofosbuvir and daclatasvir to treat hepatitis C genotype 4, including for different patient populations and treatment experiences. It establishes guidelines for Egyptian treatment protocols.
Intracerebral Hemorrhage Case presentationUsama Ragab
1. This document presents the case of a 65-year-old male who presented comatose with right side weakness after suddenly feeling weakness on his right side while eating dinner.
2. His medical history includes hypertension, diabetes, chronic kidney disease, and smoking. On examination he was comatose with a Glasgow Coma Scale of 6.
3. Imaging showed a left basal ganglia hemorrhage. His management involved treatment of hypertension and coagulopathy. Guidelines recommend lowering blood pressure to 140 mmHg for hemorrhagic stroke patients to reduce hematoma expansion and improve outcomes.
This document provides an overview of prosthetics and orthotics. It defines prosthetics as devices that replace missing body parts, while orthotics are devices that support or correct limb or torso function. Various materials are used for prosthetics and orthotics including metals, plastics, wood, leather, rubber and fabric. The document outlines the specifications and types of prosthetics and orthotics used for different parts of the body, such as the upper and lower limbs as well as the spine. It provides details on the components, suspension systems and various models of prosthetic knees, feet and orthotic devices.
Guidelines for management of acute strokesankalpgmc8
This document provides an overview of stroke types, pathophysiology, investigations, and management guidelines. It discusses the three main types of stroke: ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage. For ischemic stroke, it describes the ischemic core and penumbra. It outlines the emergency evaluation of acute ischemic stroke including vital signs, blood tests, imaging, and scales like the NIH Stroke Scale. Management strategies discussed include thrombolysis, antiplatelet/anticoagulation drugs, neuroprotective agents, and surgical interventions. Complications like cerebral edema and their management are also summarized.
The document discusses stroke rehabilitation, including the mechanisms of impairment and recovery from stroke. It describes how rehabilitation aims to reduce disability through relearning skills and regaining independence using a multi-disciplinary approach. The goal of rehabilitation is to assess the impact of stroke and set realistic goals to restore function and independence by treating impairments and reducing barriers at all levels.
1) The document discusses strokes (cerebrovascular accidents or CVAs), their causes, types, symptoms, diagnosis and treatment.
2) Strokes are caused by disturbances in the vascular system and can be ischemic (caused by clot or blockage) or hemorrhagic (caused by bleeding).
3) Common symptoms of strokes include weakness or numbness on one side of the body, speech problems, and visual issues. The specific symptoms depend on the area of the brain affected.
Orthotics are devices used to support or correct deformities and impairments of the foot, ankle, knee, and hip joints. A foot orthotic is customized to fit inside the shoe to correct foot alignment. An ankle-foot orthosis (AFO) consists of a shoe attachment, ankle control, and leg band to support the ankle. A knee-ankle-foot orthosis (KAFO) adds a knee control to an AFO. The most specialized orthosis is a total hip-knee-ankle-foot orthosis (THKAFO) which incorporates a hip joint and trunk band. Orthoses are customized to meet individual functional needs and goals.
The document defines orthotics and prosthetics and describes common devices used for each. Orthotics are devices that support or immobilize parts of the body, like splints or braces, while prosthetics replace missing body parts like limbs. It provides details on various static and dynamic orthoses, including examples like knee braces or back supports. For prosthetics, it outlines the components of lower and upper limb prostheses and different suspension, joint, and terminal device options. The ideal orthosis or prosthesis is described as functional, fitting well, light weight, easy to use, acceptable cosmetically, and easily maintained or repaired.
This document provides an overview of strokes, including:
- Strokes are caused by a blockage or rupture of an artery to the brain, cutting off oxygen flow.
- Symptoms include weakness, paralysis, difficulty speaking or swallowing.
- Diagnosis involves medical imaging, blood tests, and physical exams to determine the type and location of blockage or rupture.
- Treatment depends on the type of stroke but may include clot-busting drugs, surgery, medication, and lifestyle changes to prevent future strokes.
The document discusses stroke, including risk factors, signs and symptoms, and the importance of rapid treatment. It outlines the "Stroke Chain of Survival and Recovery" which includes early detection, emergency dispatch, pre-hospital transport and management, emergency department triage, evaluation and specific therapies, and fibrinolytic drug therapy. Rapid recognition of stroke, emergency medical response, and treatment are critical to limiting neurological damage and improving patient outcomes.
Stroke results from a disruption in blood flow to the brain. It is a leading cause of death and disability. Risk factors include hypertension, smoking, heart disease, diabetes, and older age. There are two main types - ischemic caused by blockage and hemorrhagic caused by bleeding. Treatment depends on the type but may include blood thinners, clot busters, or surgery. Physical therapy focuses on regaining mobility and function through exercises, gait training, and positioning. Prevention emphasizes controlling risk factors like blood pressure, cholesterol, diabetes, and lifestyle changes like quitting smoking.
The document discusses ischemic stroke, including its epidemiology, classification, risk factors, and etiopathogenesis. Some key points:
- Stroke occurs every 5 seconds worldwide and is a leading cause of death and disability globally. Incidence and prevalence varies significantly between countries and regions.
- Strokes are classified based on their underlying cause (ischemic vs hemorrhagic) and further subtyped based on etiology (large vessel atherosclerosis, cardioembolism, small vessel disease, etc).
- Major risk factors for ischemic stroke include hypertension, atrial fibrillation, diabetes, smoking, obesity, high cholesterol, lack of physical activity, and a family history of stroke.
Stroke : Introduction, types and treatment.Obed Adams
Stroke is defined as the rapid loss of brain function due to disturbance in blood flow and supply to the brain.
OR
An acute episode of focal dysfunction of the brain, retina, or spinal cord.
It is clinically defined as the rapid onset of cerebral deficit lasting more than 24hours and is caused by acute vascular injury to parts of the brain. Presented by Obed Adams.
Stroke is defined as a neurological deficit persisting beyond 24 hours caused by occlusion or hemorrhage of brain arteries. The main types are ischemic (85%) caused by clot or embolism, and hemorrhagic (15%) caused by ruptured blood vessels. Risk factors include age, gender, race, family history, diabetes, atrial fibrillation, smoking, hypertension, and hyperlipidemia. Diagnosis involves tests like CT, MRI, Doppler, and echocardiogram. Treatment goals are to reduce injury, prevent complications, and recurrence with approaches like thrombolytics, antiplatelets, anticoagulants, statins, and blood pressure control.
There are two main types of stroke: ischemic and hemorrhagic. Ischemic strokes are caused by blockage of an artery while hemorrhagic strokes result from bleeding. The goal of acute stroke treatment is to revive brain tissue at risk of infarction by rapidly restoring blood flow. Alteplase is a thrombolytic drug approved for treatment of acute ischemic stroke within 4.5 hours of symptom onset to dissolve clots. It works by activating plasminogen into plasmin, which breaks down fibrin clots.
Stroke is caused by interrupted blood flow to the brain and can be ischemic (blockage of blood flow) or hemorrhagic (bleeding in the brain). The main symptoms include sudden weakness or numbness, trouble speaking or understanding, vision changes, and severe headache. Risk factors include high blood pressure, smoking, diabetes, obesity, high cholesterol, and atrial fibrillation. Diagnosis involves CT or MRI imaging of the brain along with medical history and exam. Treatment depends on the type of stroke but may include managing blood pressure, anticoagulants, surgery to repair burst blood vessels, and rehabilitation therapy.
1. Myocardial infarction, also known as a heart attack, occurs when blood flow to part of the heart is blocked, damaging heart muscle.
2. It is usually caused by a buildup of fatty plaques in the coronary arteries that supply blood to the heart. When a plaque ruptures, a blood clot forms that blocks one of the arteries.
3. Symptoms of a heart attack include chest pain or discomfort that may travel to the arm, shoulder, or jaw. Early treatment is critical to reduce damage to the heart.
Stroke is the 5th leading cause of death in the US. There are three main types of stroke: ischemic, hemorrhagic, and transient ischemic attacks (TIAs). Ischemic strokes, which account for 85% of cases, occur when a blood clot blocks an artery supplying blood to the brain. Hemorrhagic strokes occur when a brain artery ruptures due to conditions like hypertension. TIAs are temporary and cause no permanent damage but indicate risk for future strokes. Symptoms of stroke appear suddenly and include face drooping, arm weakness, speech difficulties, and severe headache. Diagnostic tests help determine the type and location of stroke. Lifestyle changes and medical treatment can help prevent strokes.
This document provides an overview of cerebrovascular accidents (CVA) and transient ischemic attacks (TIA). It defines TIA as a temporary neurological deficit lasting less than 24 hours. Signs and symptoms of TIA include weakness, numbness, slurred speech, and visual problems. Management of TIA involves antithrombotic therapy and controlling risk factors like hypertension and diabetes. Stroke is defined as neurological signs lasting over 24 hours due to a vascular cause. Ischemic and hemorrhagic strokes are described along with their causes, signs, and diagnostic tests. Treatment includes thrombolysis, anticoagulants, surgery, and rehabilitation involving a multidisciplinary team.
Is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.
It can occur
in the carotid
artery of the
neck as well as
other arteries.
When an artery is acutely occluded by thrombus or embolus, the area of the CNS supplied by it will undergo infarction if there is no adequate collateral blood supply.
Surrounding a central necrotic zone, an ‘ischemic penumbra’ remains viable for a time, i.e. it may recover function if blood flow is restored.
CNS ischemia may be accompanied by swelling for two reasons:
● cytotoxic oedema – accumulation of water in damaged glial cells and neurones,
● vasogenic oedema – extracellular fluid accumulation as a result of breakdown of the blood–brain barrier.
In the brain, this swelling may be sufficient to produce clinical deterioration in the days following a major stroke, as a result of a rise in intracranial pressure and compression of adjacent structures.
Enoxaparin is used to treat strokes. Strokes are caused by interrupted blood flow to the brain and can be ischemic (caused by clots) or hemorrhagic (caused by bleeding). Timely treatment is important to reduce brain damage. Patients may experience symptoms like weakness or speech problems. Diagnosis involves imaging tests and ruling out other causes. Treatment focuses on rapidly restoring blood flow through thrombolysis or thrombectomy and preventing further issues.
The document compares three definitions of stroke from the AHA/ASA consensus, AHA/ASA website, and UpToDate. All three definitions agree that stroke involves acute neurological dysfunction in the brain, spinal cord, or retina, and can be either ischemic, due to reduced blood flow, or hemorrhagic, due to bleeding. The consensus definition and UpToDate provide additional detail on ischemic stroke being thrombotic, embolic, or due to hypotension and hemorrhagic stroke involving intracerebral or subarachnoid bleeding. The consensus definition is proposed for use in the clinical model.
This document provides an overview of cerebrovascular disease and stroke. It defines stroke as an abrupt neurological deficit caused by a focal vascular issue. Strokes are classified as either ischemic, due to reduced blood flow, or hemorrhagic, caused by bleeding in the brain. The major risk factors for stroke include age, high blood pressure, heart disease, diabetes, and smoking. Diagnosis involves assessing clinical neurological signs and symptoms, and imaging tests like CT/MRI to determine if the stroke is ischemic or hemorrhagic and identify any underlying vascular abnormalities.
This document provides an overview of the management of acute stroke. It defines stroke and transient ischemic attack, and discusses the epidemiology, classification, risk factors, pathophysiology, clinical presentation, diagnosis, management, complications and prognosis of stroke. The management involves resuscitation, reperfusion therapies like thrombolysis and thrombectomy, treating complications, secondary prevention including blood pressure and diabetes control, and rehabilitation. The document emphasizes the importance of specialized stroke units and timely management to improve outcomes for patients with acute stroke.
Stroke is a medical emergency caused by interrupted or reduced blood flow to the brain. The main types are ischemic (caused by blockage) and hemorrhagic (caused by bleeding). Risk factors include high blood pressure, atrial fibrillation, diabetes, and smoking. Symptoms depend on the affected brain region and may include paralysis, confusion, and speech problems. Diagnosis involves brain imaging and blood tests. Treatment focuses on restoring blood flow and preventing complications and recurrence through medication and lifestyle changes. Outcomes vary depending on the severity and location of brain damage.
neurological disoder and sign symptoms causeswajidullah9551
The document discusses neurological disorders and provides details about cerebrovascular accidents (strokes). It describes the blood supply to the brain from arteries like the internal carotid and vertebral arteries. There are two main types of strokes - ischemic caused by blockage and hemorrhagic caused by bleeding. Symptoms can include weakness, difficulty speaking, and vision issues. Diagnosis involves scans and tests of the blood. Treatment depends on the type but may include clot-busting drugs or surgery. Lifestyle changes can help prevent strokes by maintaining healthy blood pressure and cholesterol levels.
Diabetic Peripheral Neuropathy and Vitamin B12 IssueUsama Ragab
Diabetic Peripheral Neuropathy and Vitamin B12 Issue
By Dr. Usama Ragab Youssif
Diabetic neuropathies are the most prevalent chronic complications of diabetes
Central and Peripheral Precocious PubertyUsama Ragab
Precocious Puberty
By Dr. Usama Ragab Youssif
Precocious puberty (PP) is defined as the development of pubertal changes (2ry sexual characters), at an age younger than the accepted lower limits for age of onset of puberty.
Algorithms for Diabetes Management for StudentsUsama Ragab
This document discusses type 2 diabetes and cardiovascular disease. It provides the following key points:
1. Type 2 diabetes significantly increases the risk of cardiovascular disease, which is the leading cause of death in people with type 2 diabetes. Even modest reductions in blood sugar levels through treatment can substantially reduce cardiovascular risks.
2. Multiple modifiable risk factors like hypertension, dyslipidemia, and smoking are common in people with type 2 diabetes and contribute to increased cardiovascular risk. A multifactorial treatment approach targeting these risk factors alongside blood sugar control is recommended to reduce complications.
3. Incretin-based therapies that target the glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide pathways
Gestational Diabetes mellitus (GDM) for StudentsUsama Ragab
Gestational diabetes is diabetes that develops during pregnancy. It is diagnosed either pre-existing type 1 or type 2 diabetes, or gestational diabetes diagnosed during pregnancy. Gestational diabetes screening involves a glucose challenge test between 24-28 weeks of pregnancy, or earlier for those at high risk. Treatment involves lifestyle changes like diet and exercise, and may require insulin if needed to control blood glucose levels. After delivery, women with gestational diabetes have increased risk of developing type 2 diabetes and should undergo testing to check for prediabetes or diabetes.
This document provides information about an upcoming event celebrating World Diabetes Day hosted by the Egyptian Society of Metabolic Syndrome. It includes contact information for Dr. Usama Ragab, who is a speaker at the event. The event will take place on November 16, 2023 at the Sharkia Medical Syndicate. The document also contains slides on topics related to diabetes classification, diagnosis, and epidemiology.
Renal System - History Taking
By Dr. Usama Ragab Youssif
Lecturer of Medicine, Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Clinical Endocrinology Round
By Dr. Usama Ragab Youssif
Lecturer of Medicine
Zagazig University
Acromegaly
Cushing
Diabetes
Thyroid
Addison
Techniques and clinical insights
This document provides an overview of peripheral neuropathy (PN), including:
- PN most commonly presents as a length-dependent, symmetric sensorimotor polyneuropathy affecting the distal portions of limbs more than proximal.
- The clinical exam evaluates superficial sensation, deep sensation, motor function, and autonomic involvement. Sensory testing assesses patterns, distributions, and cortical sensation when possible.
- Common causes of PN include diabetes, paraproteinemias, alcoholism, renal failure, vitamin deficiencies, and some infectious diseases. A thorough history helps determine the temporal pattern and potential etiologies.
This document provides information on functional bowel disorders and gastroparesis. It begins with an overview of functional bowel disorders, noting they refer to disorders of gut function without obvious structural abnormalities. It then discusses the Rome IV diagnostic criteria for functional gastrointestinal disorders, which categorizes them into several classes including esophageal, gastroduodenal, bowel, and anorectal disorders. Specific disorders like irritable bowel syndrome, functional dyspepsia, and rumination syndrome are defined. The document then focuses on gastroparesis, defining it as delayed gastric emptying without mechanical obstruction. It discusses the difference between functional dyspepsia and gastroparesis, classifications, epidemiology, etiology, predictive factors, typical presentation,
Heat, Cold and High Altitude Related illnessUsama Ragab
Heat, Cold and High Altitude Related illness
By Dr Usama Ragab
Lecturer of Medicine
Topics are heat and cold related illness and high altitude medical disorders
Sensory, coordination & gait Examination for UndergradUsama Ragab
The document provides information on examining the sensory system. It discusses the different types of sensation including somatic, visceral, and special senses. It then describes in detail how to examine superficial sensation, deep sensation including vibration, joint position, nerve, and muscle sensation. The document outlines examining dermatomal distribution and patterns of sensory loss. It also discusses examining cortical sensation including tactile localization, two-point discrimination, stereognosis, and other tests. Finally, it provides guidance on examining coordination and gait abnormalities.
Imeglimin is a novel, first-in-class antidiabetic drug that targets mitochondrial function. It was shown to improve both insulin resistance and insulin secretion based on animal and human studies. Imeglimin received its first approval in Japan in 2021 based on positive results from the Phase III TIMES clinical trials program demonstrating its efficacy in lowering blood glucose levels and its safety both as monotherapy and in combination with other oral antidiabetic drugs or insulin. Imeglimin may also provide cardiovascular benefits given its effects on improving mitochondrial function in multiple tissues beyond just glycemic control.
Diabetes and Gut interplay
By Dr. Usama Ragab Youssif
In Gastro Canal Association Annual Conference
Agenda
Diabetes as the main player
Gut as the main player
Diabetes and gut in a separate game
Gut as game changer
Tips and tricks: diabetes drugs
Guidelines in Obesity management
By Dr. Usama Ragab Youssif
Obesity-related counseling should be offered to those with BMI ≥25 kg/m2
A 3% to 5% weight loss can result in meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes
Set an initial weight loss goal of 5% to 10% of current body weight over 6 mo
After 6 mo, focus on weight maintenance before attempting further weight loss
Participating in a weight loss program long-term can help improve weight maintenance
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
Insulin Lispro Revisited
By Dr. Usama Ragab Youssif
The discovery of insulin was one of the most dramatic and important milestones in medicine - a Nobel Prize-winning moment in science.
No, the combination of an ACE inhibitor and an ARB is not generally recommended for patients with diabetes and CKD. Some key points:
- There is no evidence that combining an ACEi with an ARB provides additional renal protection compared to monotherapy in patients with diabetes and CKD.
- Combining the two classes of drugs increases the risk of hyperkalemia and acute kidney injury without proven additional benefit over monotherapy.
- Current guidelines recommend using either an ACEi or an ARB as first-line therapy for albuminuria, but do not recommend combining the two classes of drugs.
So in summary, while ACEis and ARBs are both reasonable first-line options, combining
This document summarizes key findings from the IDF Diabetes Atlas 2021:
1) An estimated 537 million adults aged 20-79 have diabetes globally in 2021, representing 1 in 10 adults. 6.7 million deaths are attributed to diabetes each year.
2) The top 10 countries for number of adults with diabetes are China, India, USA, Brazil, Pakistan, Indonesia, Mexico, Egypt, Italy, and Bangladesh. The top countries for diabetes healthcare expenditure are USA, China, Japan, Germany, and India.
3) Diabetes prevalence is increasing worldwide, with the majority (75%) of people with diabetes living in low and middle income countries. Cardiovascular disease is the leading cause of death for people
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
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2. Learning Objectives
• To be able to differentiate
between stroke and other
conditions
• To discuss the latest stroke
treatment strategies (either
interventional or non
interventional)
• To be able to define stroke, its pathophysiology and risk
factors
• To emphasize the role of early evaluation and
management of stroke patients
3. Disease makes men more physical, it leaves
them nothing but body.
Thomas Mann
4. Epidemiology
• Globally, about 17
million strokes occur
every year and stroke is
the second leading
cause of death after
coronary heart disease,
and the third most
common cause of
disability.
1- Krishnamurthi RV: Lancet Glob Health. 2013;1(5):e259.
Figure: http://www.who.int/mediacentre/factsheets/fs310/en/
5. Epidemiology
• Globally, the incidence of stroke due to ischemia is 68
%, while the incidence of hemorrhagic stroke
(intracerebral hemorrhage and subarachnoid
hemorrhage combined) is 32 %.
• Men have a higher incidence of stroke than women at
younger but not older ages, with the incidence reversed
and higher for women by age 75 years and older.
Mikulik R: J Intern Med 2015; 278: 145–165.
Lozano R, et al: Lancet. 2012 Dec;380(9859):2095-128.
6. Brief History of Definitions of Stroke and TIA
• The word “stroke” was likely
first introduced into medicine in
1689 by William Cole.
Before Cole, the common term
used to describe very acute
nontraumatic brain injuries was
“apoplexy.” Apoplexy was used
by Hippocrates circa 400 BC.
7. Brief History of Definitions of Stroke and TIA
• The World Health Organization definition of stroke
(in 1970) is “rapidly developing clinical signs of
focal (or global) disturbance of cerebral function,
lasting more than 24 hours or leading to death,
with no apparent cause other than that of vascular
origin (time frame of 24 hours being chosen arbitrarily).
• The term brain attack was introduced for use
according to the American Stroke Association,
who since 1990 have used the term.
2- Segen's Medical Dictionary. Farlex, Inc. 2010.
1- World Health Organisation (1978). Cerebrovascular Disorders (Offset Publications). Geneva
8. Brief History of Definitions of Stroke and TIA
• In 2002 then in 2009, an expert
committee of the AHA/ASA published
proposed definition that was: a
transient episode of neurological
dysfunction caused by focal brain,
spinal cord, or retinal ischemia
without acute infarction (arbitrary
time point of < 24 hours was
suspended).
During the 1950s, physicians felt the need to also introduce a term
for temporary vascular-related episodes of brain dysfunction that
would not qualify as strokes, and “transient ischemic attack” came
into use.
Stroke. 2009 Jun;40(6):2276-93.
9. Brief History of Definitions of Stroke and TIA
• The International Classification of Diseases (ICD) system
aims to standardize diagnostic classification for most
diseases. Recent iterations, including the 10th revision
along with its clinical modification (ICD-11-CM) published in
2010,11 classified cerebrovascular disorders chiefly as TIA,
cerebral ischemic stroke, ICH, or SAH.
10. Brief History of Definitions of Stroke and TIA
The World Health Organization’s definition of stroke is
obsolete. Based on advances including modern brain imaging,
the 24-hour inclusion criterion for cerebral infarction is
inaccurate and misleading, because permanent injury can
occur much sooner.
Sacco R L: Stroke 44 (2013): 2064-2089.
11. Brief History of Definitions of Stroke and TIA
The word “transient” indicates a lack of permanence. Modern
brain imaging has shown that many patients in whom
symptoms and signs of brain ischemia are clinically transient
have evidence of brain infarction. If the ischemia caused death
of the tissue, it is misleading to designate the ischemia as
transient. Sacco R L: Stroke 44 (2013): 2064-2089.
12. The updated definition of stroke incorporates clinical and
tissue criteria and can be incorporated into practice,
research, and assessments of the public health.
Sacco R L: Stroke 44 (2013): 2064-2089.
13. Central nervous system infarction is defined as brain,
spinal cord, or retinal cell death attributable to ischemia,
based on neuropathological, neuroimaging, and/or
clinical evidence of permanent injury.
Central nervous system infarction occurs over a clinical
spectrum: either overt or silent
Stroke also broadly includes intracerebral hemorrhage
and subarachnoid hemorrhage.
Sacco R L: Stroke 44 (2013): 2064-2089.
15. Lacunar Infarction
• Lacunar stroke or lacunar infarct (LACI) is a type
of stroke that results from occlusion of one of the
penetrating arteries that provides blood to the brain's deep
structures.
• The term was penned by Charles Miller Fisher, a
Canadian neurologist who described "lacunes" (Latin for
"empty space") within the brains of stroke victims post
mortem, he also connected them with 5 classic
syndromes.
• Lacunar infarcts are small (<20 mm) infarcts.
Neurology. 1997 May. 48(5):1204-11.
16. Lacunar Infarction (cont.)
It is marked by hemiparesis or hemiplegia that
typically affects the face, arm, or leg of the
contralateral side.
Pure motor
stroke/hemiparesis (most
common lacunar syndrome:
33-50%)
It displays a combination of cerebellar and motor
symptoms, including contralateral weakness and
clumsiness.
Ataxic hemiparesis (second
most frequent lacunar
syndrome)
The main symptoms are dysarthria and
clumsiness (i.e., weakness) of the hand, which
often are most prominent when the patient is
writing.
Dysarthria/clumsy
hand (sometimes considered
a variant of ataxic
hemiparesis)
Marked by persistent or transient numbness,
tingling, pain, burning, or another unpleasant
sensation on one side of the body.
Pure sensory stroke
This lacunar syndrome involves hemiparesis or
hemiplegia with contralateral sensory impairment
Mixed sensorimotor stroke
Bamford, J et al. (1987): Stroke 18 (3): 545–51.
17. Review of Anatomy
• Blood reaches the brain through 2 systems:
1. The carotid system (Anterior Circulation)
2. The vertebral system (Posterior Circulation)
18. Review of Anatomy
The circle of Willis is a part of
the cerebral circulation and is
composed of the following arteries:
•Anterior cerebral artery (left and right)
•Anterior communicating artery
•Internal carotid artery (left and right)
•Posterior cerebral artery (left and right)
•Posterior communicating artery (left and
right)
•Basilar artery
The middle cerebral arteries, supplying the
brain, are not considered part of the circle.
19. Hearing/association
& Smell & taste
Short term Memory
Voluntary
Motor
Sensations
Pain & Touch
Taste
Balance,
Coordination of each
muscle group
Arms
Head
Legs
Mom: Bowel/bladder
Reasoning/judgment
Long term memory
Vision &
visual
memory
CN 5,6,7,8
P,R, B/P CN 9,10,11,12
Tracks cross over
Coordinate
movement,
HR,B/P
20. Pathophysiology of Ischemic stroke
Normal cerebral blood flow (CBF): > 50
mL/100gm/min of brain tissues.1
18-50 mL/100gm/min of brain = oligemia.
Less than 18 mL/100gm/min of brain =
neurological deficit due to electrical failure
(transiant; TIA or permanent; infarction)
< 8 mL = core infarction.
8-18 mL/100gm/min of brain = Penumbra
1- Cipolla MJ. The Cerebral Circulation. San Rafael (CA):
Morgan & Claypool Life Sciences; 2009.
Figure: P, Langhorne. "Stroke Disease." Davidson’s Principles and Practice of Medicine. 22nd ed. N.p.: Elsevier, 2014. 1231-248.
Print.
21. Penumbra is zone of reversible
ischemia around core of irreversible
infarction—salvageable in first few
hours after
ischemic stroke onset
Penumbra damaged by:
• Hypoperfusion
• Hyperglycemia
• Fever
• Seizure
http://www.strokecenter.org/professionals/brain-
anatomy/cellular-injury-during-ischemia/the-ischemic-
penumbra/ (HON code certified)
22.
23. Sir Winston Churchill
Prime Minister of the United Kingdom from
1940 to 1945 and again from 1951 to 1955
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
24. ATHEROSCLEROSIS AND THROMBOSIS
Atherosclerosis: decades-long process; progression
favored by hypercholesterolemia, HTN, cigarette smoking
•Fatty streak: yellowish discoloration on intimal surface of
blood
•Focal plaques: eccentric thickening at bifurcations; addition
of massive extracellular lipids that displaced normal cells and
matrix
•Complicated fibrous plaques: central acellular area of lipid
covered by a cap of smooth muscle cells and collagen
26. Risk factors for stroke
• Ecology and risk factors:
Age and gender: Most thrombotic and embolic strokes related to atherosclerosis
occur in older patients. In contrast, hemorrhages (both ICH and SAH) are
common in adolescents and young adults. Cardiac-origin embolism is also
common in young people who are known to have heart disease.
Smoking — Smoking increases the likelihood of extracranial occlusive vascular
disease, more than doubling the risk of stroke. The risk of ischemic stroke
decreases over time after smoking cessation.
Diabetes increases the likelihood of large and small artery occlusive disease and
ischemic stroke but has not been shown to predispose to hemorrhagic stroke.
However, data from the Nurses’ Health Study suggest that type 1 diabetes might
also be a risk factor for hemorrhagic stroke.
Diabetes Care. 2007 Jul;30(7):1730-5.
27. Risk factors for stroke (cont.)
Heart disease — Heart
disease, including atrial
fibrillation, valvular disease,
recent myocardial infarction,
and endocarditis, increases
the probability of a stroke
due to embolism. Of these,
atrial fibrillation is the most
prominent, causing nearly
half of all cardioembolic
strokes.
Wolf et al. 1991. Stroke. 1991; 22: 983-988
28. Risk factors for stroke (cont.)
Hypertension — Hypertension is an
important stroke risk factor, including
isolated systolic hypertension.
Epidemiologic studies show that
there is a gradually increasing
incidence of both coronary disease
and stroke as the blood pressure
rises above 110/75 mmHg. Both
prior blood pressure and current
blood pressure are important risk
factors (for both ischemic and
hemorrhagic stroke).
Data from Prospective Studies Collaboration, Lancet 2002; 360:1903.
29. Risk factors for stroke (cont.)
Bishop T, Figueredo VM. Hypertensive therapy: attacking the renin-angiotensin system. Western Journal of Medicine. 2001;175(2):119-124.
30. Risk factors for stroke (cont.)
Howard G. Bruenn, "Clinical Notes On The Illness and Death of President Franklin D. Roosevelt," Ann. of Int. Med. 72 (1970): 579–59.
Franklin Delano Roosevelt:
represents a unique and superb
example of the natural history of
untreated hypertension and the
complications that can arise if left
untreated.
Dr Bruenn reported the President's
last words: "I have a terrific
headache.“
Of notable FDR had suffered also
from severe anemia (Hb: 4.5 gm%),
proteinuria 4+ and cholelithiasis!!!
31. Risk factors for stroke (cont.)
Other risk factors — Other risk factors for stroke include the following:
(Dyslipidemia): Elevated total cholesterol and decreased high density
lipoprotein (HDL) cholesterol have been associated with increased risk of
ischemic stroke and large artery stroke in some, but not all, studies.
Elevated serum lipoprotein(a) has been associated with intracranial,
extracranial, and aortic large artery occlusive disease.
Stroke during the puerperium has an increased likelihood of being related to
venous or arterial thrombosis.
The presence of a known bleeding disorder or prescription of warfarin or
other anticoagulants predisposes to hemorrhage, into either the brain or the CSF.
Vascular anomaly: Arteriovenous malformation, Cavernous haemangioma.
32. Risk factors for stroke (cont.)
TIA is a risk factor for future stroke
SC Johnston et al: Validation and refinement of score to predict very early stroke risk after transient ischaemic attack.
Lancet 369:283, 2007.
33. Risk factors for stroke (cont.)
Potential Genetic Risk Factors for Stroke
• Apolipoprotein E4
• Elevated homocysteine levels
• Factor V mutation
34. Joseph Stalin
The leader of the Soviet Union from the
mid-1920s until his death in 1953
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
41. Presentation
• Sudden onset
• Focal neurological deficit
• Progresses over minutes to hours
• Depends on location
• Symptoms include:
SUDDEN numbness or weakness of face, arm or leg
SUDDEN confusion, trouble speaking or understanding.
SUDDEN trouble with vison.
SUDDEN trouble walking, dizziness, loss of balance or coordination.
SUDDEN severe headache.
43. Presentation (cont.)
P, Langhorne. "Stroke Disease." Davidson’s Principles and Practice of Medicine. 22nd ed. N.p.: Elsevier, 2014. 1231-248. Print.
44. Clinical Clue to diagnosis
Stroke type Clinical course Risk factors Other clues
Intracerebral
hemorrhage
Gradual progression during
minutes or hours
Hypertension, trauma, bleeding
diatheses, illicit drugs (eg,
amphetamines, cocaine),
vascular malformations. More
common in blacks and Asians
than in whites.
May be precipitated by sex or
other physical activity. Patient
may have reduced alertness.
Subarachnoid
hemorrhage
Abrupt onset of sudden, severe
headache. Focal brain
dysfunction less common than
with other types.
Smoking,
hypertension, moderate to
heavy alcohol use, genetic
susceptibility (eg, polycystic
kidney disease, family history of
subarachnoid hemorrhage) and
sympathomimetic drugs (eg,
cocaine)
May be precipitated by sex or
other physical activity. Patient
may have reduced alertness.
Ischemic
(thrombotic)
Stuttering progression with
periods of improvement.
Lacunes develop over hours or
at most a few days; large artery
ischemia may evolve over
longer periods.
Atherosclerotic risk factors (age,
smoking, diabetes mellitus,
etc.). Men affected more
commonly than women. May
have history of TIA.
May have neck bruit.
Ischemic (embolic)
Sudden onset with deficit
maximal at onset. Clinical
findings may improve quickly.
Atherosclerotic risk factors as
listed above. Men affected more
commonly than women. History
of heart disease (valvular, atrial
fibrillation, endocarditis).
Can be precipitated by getting
up at night to urinate, or sudden
coughing or sneezing.
Caplan, L. Overview of the evaluation of stroke. In: UpToDate, Kanser S (Ed), UpToDate, Waltham, MA. (Accessed on December 2015.)
45. Charles Dickens
English writer and social critic
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
46. Time is BRAIN
• The longer the time period that the person remains
unresponsive, the less likely it is that the person will
recover.
• It has calculated that in a typical large-vessel acute
ischaemic stroke, about 1.9 million neurons die every
minute during which stroke is untreated, 14 billion
synapses, and 12 km (7.5 miles) of myelinated fibers are
destroyed.1
• The first few days after onset is critical.
1- Saver, J. L. (2006). Time is brain—quantified. Stroke, 37(1), 263-266.
47. Assessment
Stroke Signs – Cincinnati Stroke Scale (Smile, Wave, Talk)
Interpretation: if any of these 3 signs is abnormal, the probability of a stroke is 72%
48. Assessment (cont.)
Teasdale G, Jennett B. (1974). "Assessment of coma
and impaired consciousness. A practical
scale.". Lancet 13 (2): 81–4.
Glasgow Coma Scale:
The Glasgow Coma Scale or GCS is
a neurological scale that aims to give a
reliable, objective way of recording the
conscious state of a person for initial as well as
subsequent assessment. A patient is assessed
against the criteria of the scale, and the
resulting points give a patient score between 3
(indicating deep unconsciousness) and either
14 (original scale) or 15 (the more widely used
modified or revised scale).
49. Assessment (cont.)
Score Description
0 No symptoms at all
1
No significant disability despite symptoms; able to carry out all usual
duties and activities
2
Slight disability; unable to carry out all previous activities, but able to
look after own affairs without assistance
3
Moderate disability; requiring some help, but able to walk without
assistance
4
Moderately severe disability; unable to walk without assistance and
unable to attend to own bodily needs without assistance
5
Severe disability; bedridden, incontinent, and requiring constant
nursing care and attention
6 Dead
Modified Rankin scale: a commonly used scale for measuring the degree of disability or dependence
in the daily activities of people who have suffered a stroke or other causes of neurological disability.
Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients.
Stroke 1988; 19:604.
50. • Maximum score described is 5 in which
% of mortality at 30 days is nearly 100%.
• Although an ICH Score of 6 is possible
with the scale, this is rarely observed and
is considered highly likely to be fatal.
ICH Score
JC Hemphill et al: Stroke 32:891, 2001; JC Hemphill et
al: Neurology 73:1088,2009.
51. Modified Hunt and Hess classification
For Subarachnoid Hemorrhage
Based upon initial neurologic examination; adapted from: Hunt W, Hess R, J Neurosurg 1968; 28:14.
52. World Federation of Neurosurgeon (WFNS)
For Subarachnoid Hemorrhage
Based upon data from: Report of World Federation of Neurological Surgeons Committee on a Universal
Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988; 68:985.
53. Differential Diagnosis
‘Functional’ stroke mimics‘Structural’ stroke mimics
Todd’s paresis (after epileptic
seizure)
Hypoglycaemia
Migrainous aura (with or without
headache)
Focal seizures
Ménière’s disease or other vestibular
disorder
Conversion disorder
Encephalitis
CO2 narcosis
Primary cerebral tumours
Metastatic cerebral tumours
Subdural haematoma
Cerebral abscess
Peripheral nerve lesions (vascular or
compressive)
Demyelination
P, Langhorne. "Stroke Disease." Davidson’s Principles and Practice of Medicine. 22nd ed. N.p.: Elsevier, 2014.
1231-248. Print.
54. By the year 2000 the commonest killers such
as coronary heart disease, stroke, respiratory,
diseases and many cancers will be wiped out.
Anonymous
Irish Times (24 Apr 1987)
56. Investigations
Investigation of acute stroke aims to confirm the vascular
nature of the lesion, distinguish cerebral infarction from
haemorrhage and identify the underlying vascular disease
and risk factors
57. Investigations (cont.)
Diagnostic question
CT/MRIIs it a vascular lesion?
CT/MRIIs it ischaemic or haemorrhagic?
CT/lumbar punctureIs it a subarachnoid haemorrhage?
Electrocardiogram (ECG)
24-hour ECG
Echocardiogram
Is there any cardiac source of embolism?
Duplex ultrasound of carotids
Magnetic resonance
angiography (MRA)
CT angiography (CTA)
Contrast angiography
What is the underlying vascular disease?
Full blood count
Cholesterol
Blood glucose
What are the risk factors?
Erythrocyte sedimentation rate
Serum protein electrophoresis
Clotting/thrombophilia screen
Is there an unusual cause?
P, Langhorne. "Stroke Disease." Davidson’s Principles and Practice of Medicine. 22nd ed. N.p.: Elsevier, 2014. 1231-248. Print.
58. Investigations (cont.)
Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from
ICH (Class I; Level of Evidence A)
For diagnosing ischemic stroke in the emergency setting:
CT scans (without contrast enhancements):
sensitivity= 16%specificity= 96%
MRI scan:
sensitivity= 83%specificity= 98%
For diagnosing hemorrhagic stroke in the emergency setting:
CT scans (without contrast enhancements):
sensitivity= 89%specificity= 100%
MRI scan:
sensitivity= 83%specificity= 98%
Contrast-enhanced CT scans add specificity by showing contrast enhancement of subacute
infarcts and allow visualization of venous structures. Coupled with multidetector scanners, CT
angiography (CTA) can be performed with administration of IV iodinated contrast allowing
visualization of the cervical and intracranial arteries, intracranial veins, aortic arch, and even
the coronary arteries in one imaging session.
Hemphill et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015;46:000-
000. DOI: 10.1161/STR.0000000000000069.
59. Investigations (cont.)
CT imaging is also sensitive for detecting SAH (although by itself does not rule
it out), and CTA can readily identify intracranial aneurysms.
Because of its speed and wide availability, noncontrast head CT is the imaging
modality of choice in patients with acute stroke, and CTA and CT perfusion
imaging may also be useful and convenient adjuncts.
MRI reliably documents the extent and location of infarction in all areas of the
brain, including the posterior fossa and cortical surface.
MRI scanners with magnets of higher field strength produce more reliable and
precise images. Diffusion-weighted imaging is more sensitive for early brain
infarction than standard MR sequences or CT, as is fluid-ttenuated
inversion recovery (FLAIR) imaging. Using IV administration of gadolinium
contrast, MR perfusion studies can be performed. Brain regions showing poor
perfusion but no abnormality on diffusion provide, compared to CT, an
equivalent measure of the ischemic penumbra.
60. Investigations (cont.)
Cerebral Angiography
Conventional x-ray cerebral angiography is the gold standard for identifying
and quantifying atherosclerotic stenoses of the cerebral arteries and for
identifying and characterizing other pathologies, including aneurysms,
vasospasm, intraluminal thrombi, fibromuscular dysplasia, arteriovenous
fistulae, vasculitis, and collateral channels of blood flow.
Conventional angiography carries risks of arterial damage, groin hemorrhage,
embolic stroke, and renal failure from contrast nephropathy, so it should be
reserved for situations where less invasive means are inadequate.
62. Investigations (cont.)
A. Computed tomography (CT)
perfusion mean-transit time
map showing delayed
perfusion of the left MCA
distribution (blue).
B. Predicted region of infarct
(red) and penumbra (green)
based on CT perfusion data.
C. Conventional angiogram
showing occlusion of the left
internal carotid–MCA
bifurcation (b4 & after
successful thrombectomy).
D. The clot rmoved by
thrombectomy device.
E. CT scan of the brain 2 days
later; note infarction in the
region predicted in B but
preservation of the
penumbral region by
successful revascularization.
63. Investigations (cont.)
A. MRI diffusion-weighted image
(DWI) of an 82-year-old woman 2.5 h
after onset of right-sided weakness and
aphasia reveals restricted diffusion
within the left basal ganglia and internal
capsule (colored regions).
B. Perfusion defect within the left hemisphere
(colored signal) imaged (gadolinium contrast). The discrepancy between
the region of poor perfusion shown in B and the diffusion deficit shown in
A is called diffusion-perfusion mismatch and provides an estimate of the
ischemic penumbra.
C. Fluid-attenuated inversion recovery image obtained 3 days later
showing a region of infarction (coded as white) that corresponds to the
initial DWI image in A, but not the entire area at risk shown in B,
suggesting that successful embolectomy
64. Investigations (cont.)
Ultrasound Techniques
Stenosis at the origin of the internal carotid artery can be identified and
quantified reliably by ultrasonography that combines a B-mode ultrasound
image with a Doppler ultrasound assessment of flow velocity (“duplex”
ultrasound). Transcranial Doppler (TCD) assessment of MCA, ACA, and
PCA flow and of vertebrobasilar flow is also useful.
However, its sensitivity & specificity is expert
dependent…
73. Investigations (cont.)
Modified Fisher scale on CT brain (predict risk of vasospasm):
Risk of vasospasmIVHSAH
24%-No or minimalGrade I
33%+MinimalGrade II
33%-Diffuse focal or thickGrade III
40%+Diffuse focal or thickGrade IV
Frontera, Jennifer A., et al. "Prediction of Symptomatic Vasospasmafter Subarachnoid Hemorrhage: the Modified
Fisher Scale." Neurosurgery 59.1 (2006): 21-27.
74. Fisher, CM, Kistler, JP, Davis, JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by CT
scanning. Neurosurgery 1980; 6:1.
Frontera, Jennifer A., et al. "Prediction of Symptomatic Vasospasmafter Subarachnoid Hemorrhage: the Modified
Fisher Scale." Neurosurgery 59.1 (2006): 21-27.
75. Louis Pasteur
French chemist and microbiologist
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
77. Treatment
The era of interventional therapy (Not Egypt)
NINDS* and ACLS** Recommended Stroke Evaluation Time Benchmarks for
Potential Thrombolysis Candidate
*National Institute of Neurological Disorders and Stroke
**Advanced Cardiac Life Support guidelines
Time Interval Time Target
Door to doctor 10 min
Access to neurologic
expertise
15 min
Door to CT scan completion 25 min
Door to CT scan interpretation 45 min
Door to treatment 60 min
Admission to stroke unit or
ICU
3 h
78. 1- Primary Prevention
FACTORS RECOMMENDATION
Physical activity Physical activity is recommended because it is associated
with a reduction in the risk of stroke (Class I; Level of
Evidence B).
Diet Reduced intake of sodium and increased intake of potassium
as indicated in the US Dietary Guidelines for Americans are
recommended to lower BP (Class I; Level of Evidence A).
A DASH-style diet, which emphasizes fruits, vegetables, and
low-fat dairy products and reduced saturated fat, is
recommended to lower BP127,218 (Class I; Level of Evidence
A).
Hypertension Annual screening for high BP and health-promoting lifestyle
modification are recommended for patients with prehypertension
(SBP of 120 to 139 mmHg or DBP of 80 to 89 mmHg) (Class I;
Level of Evidence A).
Patients who have hypertension should be treated with
antihypertensive drugs to a target BP of <140/90 mm Hg (Class
I; Level of Evidence A).
Stroke. 2014;45:3754–3832.
79. 1- Primary Prevention (cont.)
FACTORS RECOMMENDATION
Dyslipidemia In addition to therapeutic lifestyle changes, treatment with an
HMG coenzyme-A reductase inhibitor (statin) medication is
recommended for the primary prevention of ischemic stroke in
patients estimated to have a high 10-year risk for cardiovascular
events as recommended (Class I; Level of Evidence A).
Obesity Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30
kg/m2) individuals, weight reduction is recommended for
lowering BP and reducing the risk of stroke (Class I; Level of
Evidence A).
Diabetes mellitus Control of BP in accordance with guidelines to a target of
<140/90 mm Hg is recommended in patients with type 1 or type
2 diabetes mellitus (Class I; Level of Evidence A).
Treatment of adults with diabetes mellitus with a statin,
especially those with additional risk factors, is recommended to
lower the risk of first stroke (Class I; Level of Evidence A).
Smoking Cessation of smoking.
Stroke. 2014;45:3754–3832.
80. 1- Primary Prevention (cont.)
FACTORS RECOMMENDATION
AF For patients with valvular AF at high risk for stroke, defined as a
CHA 2DS2-VASc score of ≥2 and acceptably low risk for
hemorrhagic complications, long-term oral anticoagulant therapy
with warfarin at a target INR of 2.0 to 3.0 is recommended (Class I;
Level of Evidence A).
For patients with nonvalvular AF, a CHA2DS2-VASc score of ≥2,
and acceptably low risk for hemorrhagic complications, oral
anticoagulants are recommended (Class I). Options include warfarin
(INR, 2.0 to 3.0) (Level of Evidence A), dabigatran (Level of
Evidence B), apixaban (Level of Evidence B), and rivaroxaban
(Level of Evidence B).
Alcohol Reduction or elimination of alcohol consumption in
heavy drinkers (Class I; Level of Evidence A).
Prophylactic
aspirin !
Aspirin is not useful for preventing a first stroke in lowrisk
individuals (Class III; Level of Evidence A).
Aspirin is not useful for preventing a first stroke in people with
diabetes mellitus in the absence of other highrisk conditions (Class
III; Level of Evidence A).
Stroke. 2014;45:3754–3832.
82. SPRINT trial
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
9361 persons was randomly assigned were at least 50 years old with a
systolic blood pressure of 130 mm Hg or higher (180 mmHg) and an
increased cardiovascular risk, but without diabetes, to a systolic blood-
pressure target of less than 120 mm Hg (intensive treatment) or a target of
less than 140 mm Hg (standard treatment).
83. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
All participants had at least 1 other significant cardiovascular
risk factor, including chronic kidney disease; age 75 years or
older; a previous cardiovascular event (except stroke); or an
elevated cardiovascular risk based on their Framingham risk
score.
84. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
The primary composite outcome was myocardial infarction,
other acute coronary syndromes, stroke, heart failure, or death
from cardiovascular causes. (Funded by the National Institutes
of Health; ClinicalTrials.gov
85. The mean baseline blood pressure among all
participants was 139.7/78.1 mm Hg.
Mean blood pressure values at 1 year into the
study were 121.4/68.7 mm Hg in the intensive
treatment group and 136.2/76.3 mm Hg in the
standard treatment group.
1- ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT).
https://clinicaltrials.gov/ct2/show/NCT01206062?term=Systolic+Blood+Pressure+Intervention+Trial&rank=1. Accessed November 9,
2015.
86. The intervention was stopped early after a median
follow-up of 3.26 years in stead of December
2018 which was the Estimated Study Completion
Date1
1- ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT).
https://clinicaltrials.gov/ct2/show/NCT01206062?term=Systolic+Blood+Pressure+Intervention+Trial&rank=1. Accessed November 9,
2015.
88. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
The lower target group of less than 120 mm Hg systolic
blood pressure had a 25% lower relative risk for the primary
composite end point of myocardial infarction, acute coronary
syndrome, stroke, acute decompensated heart failure, and
cardiovascular death vs the group with a target of less than
140 mm Hg.
89. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
In addition, the lower-target group had 27% lower risk for
all-cause mortality and 43% lower risk for cardiovascular
death. However, this group also had higher adverse events
such as hypotension, syncope, and acute kidney injury or
kidney failure.
90. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
Rates of serious adverse events of hypotension,
syncope, electrolyte abnormalities, and acute
kidney injury or failure, but not of injurious falls,
were higher in the intensive-treatment group than in
the standard-treatment group.
91. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
CONCLUSIONS
Among patients at high risk for cardiovascular events but
without diabetes, targeting a systolic blood pressure of less
than 120 mm Hg, as compared with less than 140 mm Hg,
resulted in lower rates of fatal and nonfatal major
cardiovascular events and death from any cause, although
significantly higher rates of some adverse events were
observed in the intensive-treatment group.
92. SPRINT trial (cont.)
Dr Marc Pfeffer (Harvard Medical School, Boston, MA)
CAUTIONS AS REGARD STUDY
A lot of effort is required to hit this target, including initial combination therapy
and frequent office visits “marathon effort”.
Excluding diabetics is "a black hole" in the study and limits its applicability.
Only approximately half of adults achieve a blood pressure of 140 mm Hg or
less, as consistent with current recommendations.
“Physicians "shouldn't expect a 'thank you' from patients
when you add another pill to reduce their blood pressure.“1
93. Alfred Nobel
Swedish chemist, engineer, innovator, and
armaments manufacturer. He was the
inventor of dynamite.
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
94. 2- Acute Treatment
1. supportive management-
airway, temperature, blood
pressure, blood glucose,
cardiac assessement
2. Specific treatment
according to type of stroke
95. Treatment (cont.)
I- General Management of Acute ischemic Stroke
Factors Recommendation
Airway &Breathing Supplemental oxygen should be provided to maintain
oxygen saturation >94% (Class I; Level of Evidence C).
Supplemental oxygen is not recommended in nonhypoxic
patients with acute ischemic stroke (Class III; Level of Evidence
B).
Mobilization Early mobilization of less severely affected patients and
measures to prevent subacute complications of stroke are
recommended (Class I; Level of Evidence C).
Blood Glucose Glucose should be monitored. Both hyperglycemia and
hypoglycemia should be avoided (Class I; Level of Evidence C).
Nutrition A formal screening procedure for dysphagia should be
performed in all patients before the initiation of oral intake to
reduce the risk of pneumonia (Class I; Level of Evidence B).
Insert a nasogastric tube if the patient fails the swallow test.
Consider PEG only if prolonged enteral feeding is required
(Class I; Level of Evidence B).Stroke. 2013;44:870-947.
96. Infection and
fever
Sources of hyperthermia (temperature >38°C) should be identified and
treated, and antipyretic medications should be administered to lower
temperature (Class I; Level of Evidence C).
Routine use of prophylactic antibiotics has not been shown to be
beneficial (Class III; Level of Evidence B).
Patients with suspected pneumonia or urinary tract infections should be
treated with appropriate antibiotics (Class I; Level of Evidence A).
Hypovolemia Hypovolemia should be corrected with intravenous normal saline, and
cardiac arrhythmias that might be reducing cardiac output should be
corrected (Class I; Level of Evidence C).
Seizures Clinical seizures should be treated with antiseizure drugs (Class I;
Level of Evidence A).
Prophylactic antiseizure medication is not recommended (Class III;
Level of Evidence B).
Prolonged
recumbency
Subcutaneous administration of anticoagulants is recommended for
treatment of immobilized patients with ischemic infarction to prevent deep
vein thrombosis (Class I; Level of Evidence A).
The use of aspirin is reasonable for treatment of patients who cannot
receive anticoagulants for prophylaxis of deep vein thrombosis (Class IIa;
Level of Evidence A).
Treatment (cont.)
97. Hypertension in acute stroke a
management dilemma
Ischemic stroke
The treatment of arterial hypertension immediately after stroke is problematic.
Observational studies have found that a rapid and steep reduction in BP during
the first 24 h after stroke onset might be harmful.1-2
Two important pathophysiologic processes should be considered during
management of acute stroke. These are:
1. Impaired cerebral autoregulation.
2. Increased intracranial pressure (ICP).
In patients with ischemic stroke, perfusion pressure distal to the obstructed vessel
is low, and the distal vessels are dilated. Thus, elevated BP is necessary to maintain
brain perfusion in borderline ischemic areas3
. Lowering of BP in patients with acute
ischemic stroke has been associated with clinical deterioration.
1- Stroke 2004; 35:520–527. 2- Neurology 2003; 61:1047–1051. 3- Stroke 2009; 40:2251–2256.
98. Hypertension in acute stroke a
management dilemma (cont.)
Kaplan, NM. Management of hypertensive emergencies. Lancet 1994; 344:1335.
99. Hypertension in acute stroke a
management dilemma (cont.)
The guidelines:
In patients with markedly elevated blood pressure who do not receive fibrinolysis,
a reasonable goal is to lower blood pressure by 15% during the first 24 hours after
onset of stroke. The level of blood pressure that would mandate such treatment is
not known, but consensus exists that medications should be withheld unless the
systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120
mmHg. (Class I; Level of Evidence C)
If BP is not maintained at or below 185/110 mmHg, do not consider administering
recombinant tissue plasminogen activator (rtPA). During and after thrombolytic
therapy, BP should be maintained below 180/105 mmHg for at least 24 h (Class I;
Level of Evidence B)
Circulation 2010; 122 (Suppl 3): S818–S828.
Stroke. 2013;44:870-947.
100. Hypertension in acute stroke a
management dilemma (cont.)
The guidelines:
Evidence from one clinical trial indicates that initiation of antihypertensive therapy
within 24 hours of stroke is relatively safe. Restarting antihypertensive medications
is reasonable after the first 24 hours for patients who have preexisting hypertension
and are neurologically stable unless a specific contraindication to restarting
treatment is known (Class IIa; Level of Evidence B).
Stroke. 2013;44:870-947.
101. Treatment Recommendations
rTPA In selected patients presenting within 3 hours: IV rt-Pa (0.9mg/kg,
maximum 90mg ) with 10% given as a bolus followed by an infusion over
one hour.
Patients eligible for intravenous r-tPA should receive intravenous r-tPA
even if endovascular treatments are being considered (Class I; Level of
Evidence A).
In patients eligible for intravenous rtPA, benefit of therapy is time
dependent, and treatment should be initiated as quickly as possible. The
door-to-needle time (time of bolus administration) should be within 60
minutes from hospital arrival (Class I; Level of Evidence A).
Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for
administration to eligible patients who can be treated in the time period of
3 to 4.5 hours after stroke onset (Class I; Level of Evidence B).
Intravenous rtPA is reasonable in patients whose blood pressure can be
lowered safely (to below 185/110 mm Hg) with antihypertensive agents,
with the physician assessing the stability of the blood pressure before
starting intravenous rtPA (Class I; Level of Evidence B).
Treatment (cont.)
102. American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.
Inclusion criteria:
Diagnosis of ischemic stroke causing measurable neurological deficit
Onset of symptoms <3 hours before beginning treatment
Aged ≥18 years
Exclusion criteria:
χSignificant head trauma or prior stroke in previous 3 months
χSymptoms suggest subarachnoid hemorrhage
χArterial puncture at noncompressible site in previous 7 days
χHistory of previous intracranial hemorrhage
χIntracranial neoplasm, arteriovenous malformation, or aneurysm
χRecent intracranial or intraspinal surgery
χElevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
χActive internal bleeding
The American Heart Association/American Stroke Association (AHA/ASA)
inclusion guidelines for the administration of rt-PA in under 3 hours are as
follows:
103. American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.
Exclusion criteria (cont.):
χAcute bleeding diathesis
χPlatelet count <100 000/mm³
χHeparin received within 48 hours, resulting in abnormally elevated aPTT
greater than the upper limit of normal
χCurrent use of anticoagulant with INR >1.7 or PT >15 seconds
χCurrent use of direct thrombin inhibitors or direct factor Xa inhibitors with
elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT;
TT; or appropriate factor Xa activity assays)
χBlood glucose concentration <50 mg/dL (2.7 mmol/L)
χCT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
104. Treatment Recommendations
Neuroprotective
Agents
The utility of induced hypothermia for the treatment of patients with
ischemic stroke is not well established, and further trials are recommended
(Class IIb; Level of Evidence B).
At present, no pharmacological agents with putative neuroprotective
actions have demonstrated efficacy in improving outcomes after ischemic
stroke, and therefore, other neuroprotective agents are not recommended
(Class III; Level of Evidence A).
Routine use of nutritional supplements has not been shown to be
beneficial (Class III; Level of Evidence B).
Anticoagulant
s
Guidelines: Guidelines issued in 2013 by the American
Heart Association/American Stroke Association state that urgent
anticoagulation is not recommended for the treatment of patients with acute
ischemic stroke. Similarly, 2012 guidelines from the American College of
Chest Physicians (ACCP) recommend early aspirin therapy over
therapeutic parenteral anticoagulation for patients with acute ischemic
stroke or transient ischemic attack (TIA).
Treatment (cont.)
Stroke. 2013;44:870-947. Chest 2012; 141:e601S.
105. Anti Coagulation following Acute non
hemorrhagic Stroke
While parenteral anticoagulation is not recommended during the first 48 hours
after acute ischemic stroke, oral anticoagulation is recommended for secondary
stroke prevention in patients with atrial fibrillation and other high-risk sources of
cardiogenic embolism (see later).
The timing of its initiation for such patients is mainly dependent on the size of the
infarct, which is presumed to correlate with the risk of hemorrhagic
transformation. Thus, for medically stable patients with a small or moderate-
sized infarct, warfarin can be initiated soon (after 24 hours) after admission with
minimal risk of transformation to hemorrhagic stroke, while withholding
anticoagulation for two weeks is generally recommended for those with 1large
infarctions, 2symptomatic hemorrhagic transformation, or 3poorly controlled
hypertension.
106. A systematic review updated in 2015 examined the effect of anticoagulant therapy
vs. control in the early treatment of patients with acute ischemic stroke. This review
included 24 trials involving 23,748 subjects.
The anticoagulants tested were standard unfractionated heparin, low molecular
weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. The
following were the major findings:
●Based upon 11 trials (22,776 patients), anticoagulant therapy did not reduce the
odds of death from all causes (odds ratio 1.05, 95% CI 0.98-1.12).
●Based upon eight trials (22,125 patients), anticoagulants did not reduce the odds
of being dead or dependent at the end of follow-up (odds ratio 0.99, 95% CI 0.93-
1.04).
●Although full anticoagulant therapy was associated with about 9 fewer recurrent
ischemic strokes per 1000 patients treated, it was also associated with a 9 per 1000
increase in symptomatic intracranial hemorrhages.
Sandercock PA, Counsell C, Kane EJ. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev 2015; 3:CD000024.
Anti Coagulation following Acute non
hemorrhagic Stroke (con.)
107. Atrial fibrillation and cardioembolic
stroke
A subject of intense debate is the role of immediate anticoagulation with heparin in
stroke patients with atrial fibrillation (AF).
A 2007 meta-analysis examined seven trials involving 4624 patients and compared
heparin or low molecular weight heparins started within 48 hours for acute
cardioembolic stroke with other treatments (aspirin or placebo). The following
observations were reported:
●Anticoagulants were associated with a statistically non significant reduction in
recurrent ischemic stroke within 7 to 14 days (3.0 vs. 4.9 %, odds ratio [OR] 0.68,
95% CI 0.44-1.06)
●Anticoagulants were associated with a statistically significant increase in
symptomatic intracranial hemorrhage (2.5 vs. 0.7 %, OR 2.89, 95% CI 1.19-7.01)
●Anticoagulants and other treatments had a similar rate of death or disability at final
follow-up (≈ 74%)
Thus, the results do not support early anticoagulant treatment of acute
cardioembolic stroke
Paciaroni M, et al. Stroke 38.2 (2007): 423-430.
108. Progressing stroke
(Stroke in evolution)
• Heparin was once widely used to treat patients who
continued to have neurologic deterioration in the first
hours or days after ischemic stroke.
• Urgent anticoagulation, with the goal of preventing early
recurrent stroke, halting neurological worsening, or
improving outcomes after acute ischemic stroke, is not
recommended for treatment of patients with acute
ischemic stroke (Class III; Level of Evidence A).
JAMA 1998; 279:1265.
Rödén-Jüllig A &Britton M. J Intern Med 2000; 248:287.
109. Anti Platelets following Acute Stroke
Recommendations
ASA/AHA, 20131 NICE, 20082
Oral administration of aspirin (initial dose
is 325 mg) within 24 to 48 hours after
stroke onset is recommended for
treatment of most patients (Class I; Level
of Evidence A).
The usefulness of clopidogrel for the
treatment of acute ischemic stroke is not
well established (Class IIb; Level of
Evidence C).
The use of aspirin is reasonable for
treatment of patients who cannot receive
anticoagulants for prophylaxis of deep
vein thrombosis (Class IIa; Level of
Evidence A).
All people presenting with acute stroke
who have had a diagnosis of primary
intracerebral haemorrhage excluded by
brain imaging should, as soon as possible
but certainly within 24 hours, be given:
aspirin 300 mg orally if they are not
dysphagic or
aspirin 300 mg rectally or by enteral
tube if they are dysphagic.
People with disabling ischaemic stroke
who are in atrial fibrillation should be
treated with aspirin 300 mg for the first
2 weeks before considering anticoagulation
treatment.
1- Stroke. 2013;44:870-947.
2- National Institute for Health and Clinical Excellence (NICE) (2008):
Stroke: Diagnosis and initial management of acute stroke and transient
ischaemic attack (TIA)
110. Anti Platelets following Acute Stroke
Recommendations
ACCP, 2012
In patients with acute ischemic stroke or transient ischemic attack (TIA), we recommend
early (within 48 h) aspirin therapy at a dose of 160 to 325 mg over no aspirin therapy
(Grade 1A).
In patients with acute ischemic stroke or TIA, we recommend early (within 48 h) aspirin
therapy with an initial dose of 160 to 325 mg over therapeutic parenteral anticoagulation
(Grade 1A).
In patients with a history of ischemic stroke or TIA and atrial fibrillation, including
paroxysmal AF, who are unsuitable for or choose not to take an oral anticoagulant (for
reasons other than concerns about major bleeding), we recommend combination
therapy with aspirin and clopidogrel over aspirin (Grade 1B).
Chest . 2012;141(2_suppl):e601S-e636S.
111. Single antiplatelet agents
Chinese Acute Stroke Trial (CAST)2International Stroke Trial (IST)1
21,100 patients19.435 patients with suspected acute
ischemic stroke
Patients allocated to aspirin (300 mg)
within 48 hours of symptom onset
60 mg of aspirin daily or placebo, also
within 48 hours of the onset of acute
ischemic stroke
Aspirin-allocated patients experienced
a 14 percent reduction in total
mortality at four weeks (3.3 versus 3.9
percent).
significant reductions in the 14-day
recurrence of ischemic stroke (2.8
versus 3.9 percent) and in the
combined outcome of nonfatal stroke
or death (11.3 versus 12.4 percent).
IST and CAST trials3
The combined data demonstrated a reduction of 13 per 1000 patients after
several weeks to six months of follow-up
1- Lancet 1997; 349:1569. 2- Lancet 1997; 349:1641. 3- Stroke 2000; 31:1240.
112. Dual antiplatelet agents
Circulation 2013; 128:1656.
A 2013 meta-analysis of early dual antiplatelet therapy versus monotherapy for
patients with noncardioembolic acute ischemic stroke or TIA identified 14 trials
with over 9000 adults.
Dual antiplatelet therapy significantly reduced risk of stroke recurrence (risk
ratio, 0.69; 95% confidence interval, 0.60-0.80; P<0.001) and the composite
outcome of stroke, TIA, acute coronary syndrome, and all death (risk ratio,
0.71; 95% confidence interval, 0.63-0.81; P<0.001) when compared with
monotherapy, and non significantly increased risk of major bleeding (risk ratio,
1.35; 95% confidence interval, 0.70-2.59, P=0.37).
113. Treatment (cont.)
II- General Management of Acute hemorrhagic Stroke
Factors Recommendation
Airway
&Breathing
Supplemental oxygen should be provided to maintain
oxygen saturation >94% (Class I; Level of Evidence C).
Supplemental oxygen is not recommended in nonhypoxic patients
with acute ischemic stroke (Class III; Level of Evidence B).
Mobilization Early mobilization of less severely affected patients and measures
to prevent subacute complications of stroke are recommended
(Class I; Level of Evidence C).
Blood Glucose Glucose should be monitored. Both hyperglycemia and
hypoglycemia should be avoided (Class I; Level of Evidence C).
Nutrition A formal screening procedure for dysphagia should be performed
in all patients before the initiation of oral intake to reduce the risk of
pneumonia (Class I; Level of Evidence B).
Insert a nasogastric tube if the patient fails the swallow test.
Consider PEG only if prolonged enteral feeding is required (Class
I; Level of Evidence B).
Stroke. 2015; 46: 3020-3035
114. Infection and
fever
Treatment of fever after ICH may be reasonable (Class IIb; Level of
Evidence C).
Sources of hyperthermia (temperature >38°C) should be identified and
treated, and antipyretic medications should be administered to lower
temperature in hyperthermic patients with stroke (Class I; Level of
Evidence C).
Routine use of prophylactic antibiotics has not been shown to be
beneficial (Class III; Level of Evidence B).
Patients with suspected pneumonia or urinary tract infections should be
treated with appropriate antibiotics (Class I; Level of Evidence A).
Seizures Clinical seizures should be treated with antiseizure drugs (Class I;
Level of Evidence A).
Prophylactic antiseizure medication is not recommended (Class III;
Level of Evidence B).
Treatment (cont.)
115. Prolonged
recumbency
As regard ICH, After documentation of cessation of bleeding, lowdose
subcutaneous low-molecular-weight heparin or unfractionated heparin
may be considered for prevention of venous thromboembolism in
patients with lack of mobility after 1 to 4 days from onset (Class IIb;
Level of Evidence B).
Patients with ICH should have intermittent pneumatic compression for
prevention of venous thromboembolism beginning the day of hospital
admission (Class I; Level of Evidence A).
Hemostasis
and
Coagulopathy
Patients with a severe coagulation factor deficiency or severe
thrombocytopenia should receive appropriate factor replacement therapy
or platelets, respectively (Class I; Level of Evidence C).
Patients with ICH whose INR is elevated because of VKA should have
their VKA withheld, receive therapy to replace vitamin K–dependent
factors and correct the INR, and receive intravenous vitamin K (Class I;
Level of Evidence C).
Treatment (cont.)
116. Hypertension in acute stroke a
management dilemma (cont.)
Hemorrhagic stroke
The conflict1
:
(1) Severe elevations in BP may worsen ICH.
(2) Enlargement of the hematoma is associated with neurologic deterioration and
worse outcomes. These observations indicate that significant improvements in
patient outcome from ICH can be achieved by minimizing hematoma
enlargement.
1- Stroke 2007; 38:1072–1075.
117. Hypertension in acute stroke a
management dilemma (cont.)
The guidelines:
For ICH patients presenting with SBP between 150 and 220 mm Hg and without
contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe
(Class I; Level of Evidence A) and can be effective for improving functional
outcome (Class IIa; Level of Evidence B).
For ICH patients presenting with SBP >220 mmHg, it may be reasonable to
consider aggressive reduction of BP with a continuous intravenous infusion and
frequent BP monitoring (Class IIb; Level of Evidence C).
Stroke. 2015; 46: 3020-3035
118. Hypertension in acute stroke a
management dilemma (cont.)
Studies have been carried out in that respect:
(1) In a randomized controlled trial [INTensive Blood Pressure Reduction in Acute
Cerebral Hemorrhage trial (INTERACT1)]1 on 404 patients with acute
spontaneous ICH, intensive BP lowering treatment (target SBP 140 mmHg),
compared with traditional management (target SBP 180 mmHg), was associated
with a reduction in hematoma growth at 24 h (14 vs. 26%). The study showed
that SBP greater than 140–150 mmHg within 12 h of ICH is associated with more
than double the risk of subsequent death or dependency. Most recently, the main
phase [(INTERACT2)]2 trial has shown no increase in death or serious adverse
events from early intensive BP lowering in eligible patients with elevated SBP.1
(2) The Antihypertensive Treatment in Acute Cerebral Hemorrhage (ATACH) trial
further confirmed these findings.3
1- Stroke. 2012;43:2236–2238. 2- N Engl J Med. 2013;368:2355–2365. 3- Neurocrit Care 2007; 6:56–66.
119. 3- Secondary Prevention
The major treatable atherosclerotic risk factors for stroke are the following:
●Hypertension
●Diabetes mellitus
●Smoking
●Dyslipidemia
Factors
Treatment
Recommendations
Hypertension
Initiation of BP therapy is indicated for previously untreated patients
with ischemic stroke or TIA who, after the first several days, have an
established BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic (Class I;
Level of Evidence B).
Resumption of BP therapy is indicated for previously treated patients
with known hypertension for both prevention of recurrent stroke and
prevention of other vascular events in those who have had an ischemic
stroke or TIA and are beyond the first several days (Class I; Level of
Evidence A).
ASA/AHA. Stroke. 2014; 45: 2160-2236
120. 3- Secondary Prevention (cont.)
Factors
Treatment
Recommendations
Hypertension
(cont.)
Goals for target BP level or reduction from pretreatment baseline
are uncertain and should be individualized, but it is reasonable to
achieve a systolic pressure <140 mm Hg and a diastolic pressure
<90 mm Hg (Class IIa; Level of Evidence B).
For patients with a recent lacunar stroke, it might be reasonable
to target a systolic BP of <130 mm Hg (Class IIb; Level of
Evidence B).
Glucose
disorders
After a TIA or ischemic stroke, all patients should probably be
screened for DM with testing of fasting plasma glucose, HbA1c, or
an oral glucose tolerance test. (Class IIa; Level of Evidence C).
121. 3- Secondary Prevention (cont.)
Factors
Treatment
Recommendations
Dyslipidemia Statin therapy with intensive lipid-lowering effects is recommended to
reduce risk of stroke and cardiovascular events among patients with
ischemic stroke or TIA presumed to be of atherosclerotic origin and an
LDL-C level ≥100 mg/dL with or without evidence for other
ASCVD (Class I; Level of Evidence B).
Statin therapy with intensive lipid-lowering effects is recommended to
reduce risk of stroke and cardiovascular events among patients with
ischemic stroke or TIA presumed to be of atherosclerotic origin, an
LDL-C level <100 mg/dL, and no evidence for other clinical
ASCVD (Class I; Level of Evidence C).
Obesity All patients with TIA or stroke should be screened for obesity with
measurement of BMI (Class I; Level of Evidence C).
122. 3- Secondary Prevention (cont.)
Factors
Treatment
Recommendations
Intracranial
atherosclero
sis
For patients with recent stroke or TIA (within 30 days) attributable to severe
stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel
75 mg/d to aspirin for 90 days might be reasonable(Class IIb; Level of
Evidence B).
For patients with a stroke or TIA attributable to 50% to 99% stenosis of a
major intracranial artery, maintenance of systolic BP below 140 mm Hg and
high-intensity statin therapy are recommended(Class I; Level of Evidence
B).
AF For patients who have experienced an acute ischemic stroke or TIA with no
other apparent cause, prolonged rhythm monitoring (≈30 days) for AF is
reasonable within 6 months of the index event (Class IIa; Level of Evidence
C).
VKA therapy (Class I; Level of Evidence A), apixaban (Class I; Level of
Evidence A), and dabigatran (Class I; Level of Evidence B) are all indicated
for the prevention of recurrent stroke in patients with nonvalvular AF, whether
paroxysmal or permanent.
123. 3- Secondary Prevention (cont.)
Factors
Treatment
Recommendations
AF (cont.)
Rivaroxaban is reasonable for the prevention of recurrent stroke in
patients with nonvalvular AF (Class IIa; Level of Evidence B).
For patients with ischemic stroke or TIA and AF who are unable to take
oral anticoagulants, aspirin alone is recommended (Class I; Level of
Evidence A). The addition of clopidogrel to aspirin therapy, compared with
aspirin therapy alone, might be reasonable (Class IIb; Level of Evidence
B).
For most patients with a stroke or TIA in the setting of AF, it is
reasonable to initiate oral anticoagulation within 14 days after the onset of
neurological symptoms (Class IIa; Level of Evidence B).
In the presence of high risk for hemorrhagic conversion (ie, large infarct,
hemorrhagic transformation on initial imaging, uncontrolled hypertension,
or hemorrhage tendency), it is reasonable to delay initiation of oral
anticoagulation beyond 14 days (Class IIa; Level of Evidence B).
124. 3- Secondary Prevention (cont.)
Factors
Treatment
Recommendations
Antiplatelet
For patients with noncardioembolic ischemic stroke or TIA, the use of
antiplatelet agents rather than oral anticoagulation is recommended to
reduce the risk of recurrent stroke and other cardiovascular events (Class
I; Level of Evidence A).
Aspirin (50–325 mg/d) monotherapy (Class I; Level of Evidence A) or
the combination of aspirin 25 mg and extended-release dipyridamole 200
mg twice daily (Class I; Level of Evidence B) is indicated as initial
therapy after TIA or ischemic stroke for prevention of future stroke.
Clopidogrel (75 mg) monotherapy is a reasonable option for secondary
prevention of stroke in place of aspirin or combination aspirin/dipyridamole
(Class IIa; Level of Evidence B).
The combination of aspirin and clopidogrel might be considered for
initiation within 24 hours of a minor ischemic stroke or TIA and for
continuation for 21 days (Class IIb; Level of Evidence B).
126. Treatment (cont.)
The Merci Retrieval System
Removal of the clot may be attempted in
those where it occurs within a large blood
vessel and may be an option for those who
either are not eligible for or do not improve
with intravenous thrombolytics.
127. Treatment (cont.)
The Merci Retrieval System
The guidelines: Patients eligible for intravenous r-tPA should receive
intravenous r-tPA even if endovascular treatments are being considered
(Class I; Level of Evidence A).
As with intravenous r-tPA, reduced time from symptom onset to reperfusion
with endovascular therapies is highly associated with better clinical outcomes.
To ensure benefit, reperfusion should be achieved as early as possible and
within 6 hours of stroke onset (Class I; Level of Evidence B).
Use of stent retrievers is indicated in preference to the MERCI device. (Class
I; Level of Evidence A).
AHA/ASA Stroke. 2015; 46: 3020-3035
128. Treatment (cont.)
Known Factors That Cause Stroke Progression
• Hypotension
• Hyperglycemia
• Hyperthermia
• Infection
• Cerebral hypoperfusion
These factors affect penumbra………………
129. ACS vs. Stroke
The success of thrombolytic therapy in coronary occlusive syndromes
created high expectations for thrombolytic therapy in acute, ischemic stroke,
and these expectations prompted a massive effort to create “stroke centers”
in major hospitals, each with a “stroke team” to direct the management of
acute stroke. The following is an accounting of what this effort has
accomplished:
Number of strokes each year in the United States 700,0001
Number of ischemic strokes (88% ) 616,000
Number of stroke patients who receive lytic therapy (2%) 12,320
Number of patients who benefit from lytic therapy (1 in 9) 1,369
% of strokes that benefit from lytic therapy (1369/700,000) 0.2%
True Story….
1- Mozzafarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the
American Heart Association.Circulation. 2015:e29–322.
130. Overall Bottom Line
Remember
• “Time is brain”
• Stroke awareness: health care team, info for everyone
• Common mistakes may lead to fatal consequences
• “There is no Stroke Motel”: Patients will receive best care; if
length of stay shortened
132. Yasser Arafat
Palestinian leader
Died on 11 November 2004 at the age of 75 of
what French doctors called a massive
hemorrhagic cerebrovascular accident
(hemorrhagic stroke).
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference