Acute stroke syndrome

1. Dr Kazi Ashraful Islam
Assistant Professor
Institute of Paediatric Neurodisorder & Autism,
BSMMU

2. Hemiplegia
Acute Chronic
 ASS
 ICSOL
 ADEM
 ICSOL
 RE
 HHE
 CP

3. ASS
Ischemic Hemorrhagic
 Coagulopathy
 Protein C,Protein S
deficiency, Factor V laden
 Iron deficiency
 Dehydration
 Arteriopathy – Moya moya
 Matabolic
 MELAS
 Homocystenuria
 Factor deficiency –
hemophilia A, B
 Thrombocytopenia –ITP
 Rupture of AV malformation

4. History
 Duration
 Onset
 Progression
 Vomiting – ICSOL, Hemorrhage
 Headache – ICSOL, Hemorrhage, CSVT
 Fever – Abscess, Tuberculoma
 H/O fever – ADS
 Similar illness in the past – Alternating hemiplegia in
infancy, MELAS, Homocystenuria, Moyamoya
 Family history – CVD,
 Past medical illness CHD, NS, SLE, Blood transfusion,
Dirrhoea, Veircela infection

5. Physical findings
 Temp
 Pulse
 BP
 Speech - dysarthria
 Cranial nerve palsy
 LL/UL – UMNL
 Cerebellar sign
 Gait – hemiplegic

6. Definition
 Stroke is defined as sudden occlusion or rupture of
cerebral arteries or veins resulting in focal cerebral
damage and clinical neurological deficit.
 According to WHO
 Rapidly developing clinical signs of focal (or global)
disturbances of cerebral function, lasting more than 24
hours or leading to death with no apparent cause other
than vascular origin.

7.  Brain received blood via –
 Cerebral hemisphere – through circle of Willis formed
by the paired anterior cerebral arteries, paired middle
cerebral arteries (anterior circulation from ICA) and
paired posterior cerebral arteries ( posterior circulation
from vertebral arteries/basilar artery)
 Basal ganglia, thalamus & midline brain stem – through
perforating arteries
 Lateral brain stem & cerebellum – circumferential
arteries – AICA, PICA & superior cerebellar arteries

9. Blood supply of Brain

11. Epidemiology
 Incidence 5/100000/yr
 1 in 2000 newborn

12. Risk factors for AIS
 Arteriopathy
 Congenital heart disease
 Hematological
 Metabolic & genetic

13. AIS
 Formation of thrombus
 Occlusion of vessels
 Cerebral damage

14. Risk Factors CSVT
 Prothromboitic conditions
 Dehydration
 Iron deficiency anaemia
 Drugs & Toxins
 Acute systemic illness
 Chronic systemic illness
 Nephrotic syndrome
 Inborn errors of metabolism

16. Cortical
 Weakness more in the legs

17. Capsular
 Complete hemiplegia
 Facial palsy
 Hemianaesthesia
 Homonymous hemianopia

18. Thalamic
 Hemianaesthesia
 Involuntary Movement

19. Midbrain
 Ophthalmoplegia (ipsilateral)
 Facial palsy (contralateral)

20. Pontine
 Horner’s syndrome
 Facial palsy (LMN)
 Weakness and loss of pain - contralateral
Ipsilateral

23. General examination
 Vital signs
 Pulse, BP, Temp
 Anaemia, Cyanosis
 Skin survey

24. Investigations
 CT/MRI
 CBC
 PBF
 Echocardiogram
 Protein C, Protein S, Anti thrombin III
 Lipid profile
 ANA
 Metabolic screening
 MRA, MRV, MRS

25. Others investigations
 According to initial report & etiology

26. Infarction

27. Hemorrhage

28. T1 T2
Hyper acute
<24
Iso Iso to hyper
Acute
1 – 3 days
Iso to hypo Hypo
Early subacute
3 – 7 days
Hyper Hyper
Late subacute
7 – 28 days
Hyper

29. Relevant Investigations
 PT
 APTT
 Factor Assay

31. Tuberculoma

32. Abscess

36. AIS - Imaging
•CT scan – Low detection rate for ischaemia (16% - 56%)
better to exclude hemorrhage
•MRI – Imaging of choice for AIS
DWI – showed hyperintencity
ADC – showed hypointensity
T2/FLAIR – hyperintensity (appears latter)

37. MRA
• MRA –
• Abrupt cutoff – embolic
• Narrowing or irregularity - arteriopathy
• Contrast MRA – concentric vessels wall enhancement arteriopathy
• CA –
• Sting, double lumen, intimal flap – dissection
• Sting of beads – vasculitis/arteriopathy

39. CSVT - Imaging
•CT scan – Filling defect (better for deep CSVT)
•Contrast CT – Empty delta sign
•MRI –
•FLAIR – vasogenic edema
•DWI – cytotoxic edema/infarction
•SWI - hemorrhage
•MRV – Filing defect

41. MRA

43. MRI

44. Management
 Neuropotection
 Control of seizure
 Maintain temperature
 Maintain normal glycaemic status
 Oxygen inhalation
 Thrombolytic & anti coagulant
 Physiotherapy
 Treatment of cause

45. MMS
• Rx
• Surgical
• Didect revascularization (synangiosis) doing
anastomosis of extra cranial (superficial temporal with
branch of affected vessels (MCA) ; indirect
revascularization placement of superficial temporal
artery on the surface of brain: pial synangiosis
• Symptomatic
• Associated symdrome – DS, NF1, Post radiation,
congenital

46. Counseling
 Rehabilitation

47. Moyamoya Disease
(Steno occlusive disease)
•Occlusion of branch of IC artery at circle of willis and
developedment of extensive collaterals at the base of the skull :
lenticulostrait branch
•Occlusion may occur in distal ICA, MCA
•Stroke in water shed zone
•C/F
•Headache, HTN, TIAs
•Sign of ischemia
•Aphasia
•Dysarthia
•Hemiparesis
•seizure
•Inv
•MRI - multiple infarct, vascular flow void
•MRA – absent involved vessels (conventional angiography to
see collaterals)