Cerebrovascular accident
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It discuss about the basic knowledge of Stroke and management.
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Cerebrovascular accident
- 2. CEREBROVASCULAR ACCIDENT • Medical term for a stroke, also called “brain attack” • The sudden death of some brain cells due to lack of oxygen
- 3. •It occurs when blood flow to a part of your brain is stopped either by a blockage such as a floating clot or a stationary clot , or a rupture of a blood vessel, or compression. CEREBROVASCULAR ACCIDENT
- 5. SYMPTOMS • Symptoms of a stroke depend on the area of the brain affected.
- 6. SYMPTOMS • Symptoms of a stroke depend on the area of the brain affected. • Stroke symptoms signify a medical emergency.
- 8. Definition of Stroke Severity • MILD STROKE: – Alert patients with any or combinations of symptoms such as: • mild motor weakness of one side of the body, • sensory deficit, • slurred speech, • vertigo with incoordination • visual field defects alone – NIHSS score= 0-5
- 9. Definition of Stroke Severity • MODERATE SROKE: – Awake patient with significant motor and /or sensory and /or visual deficit, or – Disoriented, drowsy, or light stupor with purposeful response to painful stimuli, or – NIHSS Score= 6-21
- 10. Definition of Stroke Severity • SEVERE STROKE: – Deep stupor or comatose patient with non- purposeful response, decorticate, or decerebrate posturing to painful stimuli, or – Comatose patient with no response to painful stimuli , or – NIHSS Score= >22
- 11. Stages of CVA • Transient ischemic attack (TIA) – sudden and short-lived attack • Reversible ischemic neurologic deficit (RIND) similar to TIA, but symptoms can last up to a week • Stroke in evolution (SIE) - gradual worsening of symptoms of brain ischemia • Completed stroke (CS) – symptoms of stroke stable over a period and rehab can begin
- 12. CLASSIFICATION OF STROKE Stroke Primary Hemorrhagic (20% of Strokes) Primary Ischemic (80% of Strokes) Thrombotic 50% Embolic 30% Intracerebral Hemorrhage 15% Subarachnoid Hemorrhage 5% 12
- 13. Types of Stroke 85% Ischemic 15 % hemorrhagic
- 14. Transient Ischemic Attack • TIA was traditionally defined as a neurological deficit, the symptoms of which are defined CURED completely within 24 hours • The current definition of TIA is • Acute onset neurological dysfunction, due to focal brain ischemia, which completely resolves within 60 minutes • No evidence of cerebral ischemia
- 15. ISCHEMIC STROKE PATHOPHYSIOLOGY: The First Few Hours Penumbra Core Clot in Artery “TIME IS BRAIN: SAVE THE PENUMBRA” 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
- 16. What are the risks factors? • Modifiable Risks – HTN – CAD/Carotid Disease/PVD – Atrial Fibrillation – Diabetes – Weight – High Cholesterol/Diet – Lack of exercise – ETOH/Drug abuse – Coagulopathy- Cancer, Sickle Cell Anemia – PFO- Patent Foramen Ovale • Non-Modifiable Risks – Age->55 – Race- African Americans have 2x the risk of death and disability. Asians have 1.4x the risk of death and disability. – Sex- 9% greater chance in men. (61% of stroke deaths occur in women) – Previous Stroke or TIA – Family History of Stroke
- 17. Signs and Symptoms In embolism Usually occurs without warning Client often with history of cardiovascular disease In thrombosis Dizzy spells or sudden memory loss No pain, and client may ignore symptoms In cerebral hemorrhage May have warning like dizziness and ringing in the ears (tinnitus) Violent headache, with nausea and vomiting
- 18. Signs and Symptoms • Sudden-onset CVA – Usually most severe – Loss of consciousness – Face becomes red – Breathing is noisy and strained – Pulse is slow but full and bounding – Elevated BP – May be in a deep coma
- 19. Time is Critical! • The longer the time period that the person remains unresponsive, the less likely it is that the person will recover. • The first few days after onset is critical. • The responsive person may: – Show signs of memory loss or inconsistent behavior – May be easily fatigued, lose bowel and bladder control, or have poor balance.
- 20. Immediate Diagnostic Studies: Evaluation of a Patient With Suspected Acute Ischemic Stroke
- 21. Stroke Awareness The Cincinnati Prehospital Stroke Scale using the acronym "FAST" Facial Asymmetry Have the person smile or show his or her teeth. If one side doesn't move as well as the other or it seems to droop, that could be sign of a stroke. Arm Drift Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. Look for weakness or drift. Slurred Speech Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be sign of stroke. Time If any of the above 3 is present then patients are advised to seek immediate hospital consultation.
- 22. Stroke Test or FAST test A local version of "FAST" is "KAMBIO -- Sambitin at Gawin Upang Stroke ay Alamin" KAmay Itaas ang kamay at obserbahan kung may panghihina o "drift" Mukha Ipakita ang ngipin o mag-Smile. Tingnan kung may kaibahan ang kaliwa sa kanang mukha. Bigkas Bigkasin at ulitin "Kumukutikutitap ang lampara". Obserbahan kung may mali sa pananalita Oras Kapag may nakitang mali, huwag magpatumpiktumpik at humarurot sa ospital.
- 23. Stroke Scales • Glasgow Coma Scale
- 24. Stroke Scales National Institutes of Health (NIH) Stroke Scale
- 25. Stroke Scales Aphasia and Dysarthria Test
- 26. Stroke Scales Modified Rankin Scale
- 27. INVESTIGATIONS • full blood count, serum electrolytes, renal function tests, cardiac enzymes, and coagulation studies • Blood sugar is mandatory to exclude hypoglycemia or diagnose diabetes mellitus • Full blood count to detect Polycythaemia,ESR for endocarditis, • clotting studies for Hypercoagulable States • An electrocardiogram (ECG) : arrhythmias and myocardial infarction. Baseline ECG is recommended in all patients with stroke(AHA/ASA Guidelines) • Echocardiography : valve disease and intra-cardiac clot
- 28. NEUROIMAGING • Brain CT scan: CT is sensitive to the intracranial blood and is readily available. Normal early CT therefore rules out haemorrhagic stroke. CT Scan changes in ischemic stroke may take several days to develop. • MRI: MRI is better at detecting posterior fossa lesions especially in posterior circulation stroke such as Pons or cerebellum • It is also recommended that all patients with transient neurologic symptoms have a neuroimaging within 24 hours or as soon as possible.(Class 1,LOE B)
- 29. MEDICAL MANAGEMENT 1. supportive management- airway, temperature, blood pressure, blood glucose, cardiac assessement 2. thrombolysis – intravenous / intra arterial 3. antiplatelet drugs 4. anticoagulant drugs 5. hemodilution, vasodilators and induced hypertension 6. Neuroprotective agents
- 30. Stroke management algorithm Symptoms & signs suggestive of Stroke Symptoms & signs persist > 1 hour Acute Care Urgent Clinical Evaluation Urgent brain CT Blood tests ECG Ischaemic Stroke Brain CT normal or shows acute infarction Haemorrhagic Stroke ( ICH / SAH ) Brain CT shows haemorhage Specific Stroke therapy Thrombolytic therapy ( if no contraindications , Antiplatelet therapy Neurosurgical Evaluation & Treatment
- 31. Acute Stroke Care Stroke Unit ( if available ) Airway , Breathing , Circulation Hydration. Blood Pressure monitoring Neurological Status monitoring Anticipate & treat complications Begin rehabilitation Neurorehabilitation Multidisciplinary Team Approach Proper Positioning Early mobilization Physiotherapy Occupational therapy Speech therapy Treat spasticity Treat depression Further Investigations Establish Stroke subtype and underlying cause Cardio & Cerebrovascular Risk Assessment Education Patient & Caregiver Secondary Prevention Antiplatelet therapy Treat risk factors Treat specific underlying cause
- 32. Primary Prevention Factors recommendation Hypertension Treat medically if BP>140mmHg systolic and/or>90mmHg diastolic. Lifestyle changes if BP between 130-139mmHg systolic and/or 80-89mmHg diastolic. Target BP for diabetics is <130mmHg systolic and <80mmHg diastolic. Hypertension should be treated in the very elderly(age >70yrs) to reduce risk of stroke. Diabetes mellitus Strict blood pressure control is important in diabetics. Maintain tight glycaemic control. Hyperlipidaemia High risk group keep LDL<2.6mmol/l. 1 or more risk factors: keep LDL<3.4mmol/l. No risk faktor: keep LDL<4.2mmol/l. Smoking Cessation of smoking.
- 33. Aspirin therapy 100mg aspirin every other day may be useful in women above the age of 65 Post menopausal Hormone Replacement therapy Oestrogen based HRT is not recommended for primary stroke prevention Alcohol Avoid heavy alcohol consumption.
- 34. General Management of Acute Ischaemic Stroke Factors Recommendation Airway &Breathing Ensure clear airway and adequate oxygenation. Elective intubation may help some patients with severely increased ICP. Mobilization Mobilize early to prevent complications Blood Pressure Do not treat hypertension if<220mmHg systolic or<120mmHg diastolic. Mild hypertension is desirable at 160-180/90-100mmHg. Blood pressure reduction should not be drastic. Proposed substances: Labetolol 10-20 mg boluses at 10 minute intervals up to 150-300 mg or 1 mg/ml infusion, 1- 3 mg/min or Captopril 6.25-12.25 mg orally. Blood Glucose Treat hyperglycaemia (Random blood glucose>11mmol/l) with insulin. Treat hypoglycaemia (Random blood glucose<3mmol/l) with glucose infusion.
- 35. Nutrition Perform a water swallow test. Insert a nasogastric tube if the patient fails the swallow test. PEG is superior to nasogastric feeding only if prolonged enteral feeding is required. Infection Search for infection if fever appears and treat with appropriate antibiotics early. Fever Use anti-pyretics to control elevated temperatures. Raised Intracranial Pressure Hyperventilate to lower intracranial pressure. Mannitoll (0.25 to 0.5 g/kg) intravenously administered over 20 minutes lowers intracranial pressure and can be given every 6 hours. If hydrocephalus is present, drainage of cerebrospinal fluid via an intraventicular catheter can rapidly lower intracranial pressure. Hemicraniectomy and temporal lobe resection have been used to control intracranial pressure and prevent herniation among those patients with very large infarctions of cerebral hemisphere. Ventriculostomy and suboccipital craniectomy is effective in relieving hydrocephalus and brain stem compression caused large cerebellar infarctions.
- 36. Acute Stroke therapy Treatment Recommendations rt-Pa 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. Aspirin Start aspirin within 48 hours of stroke onset. Use of aspirin within 24 hours of rt-Pa is not recommended Anticoagulants The use of heparins (unfractionated heparin, low molecular weight heparin or heparinoids) is not routinely recommended as it does not reduce the mortality in patients with acute ischaemic stroke. Neuroprotective Agents A large number of clinical trials testing a variety of neuroprotective agents have been completed. These trials have thus far produced negative results. To date, no agent with neuroprotective effects can be recommended for the treatment of patient with acute ischaemic stroke at this time.
- 37. Anti Coagulation following Acute Cardioembolic Stroke Treatment Recommendations Aspirin All patients should be commenced on aspirin within 48 hours of ischaemic stroke Warfarin Adjusted-dose warfarin may be commenced within 2-4 days after the patient is both neurologically and medically stable. Heparin (unfractionated) Adjusted-dose unfractionated heparin may be sterted concurrently for patients at very high risk of embolism. Anticoagulation Anticoagulation may be delayed for 1-2 weeks if there has been substantial haemorrhage. Urgent routine anticoagulation with the goal of improving neurological outcomes or preventing early recurrent stroke is not recommended. Urgent anticoagulation is not recommended for treatment of patients with moderate-to-large cerebral infarcts because of a high risk of intracranial bleeding complications
- 38. Secondary Prevention Factors Treatment Recommendations Antiplatelets Single agent Aspirin Alternatives: Clopidogrel Ticlopidine Double therapy Aspirin+clopidogrel The recommended dose of aspirin is 75mg to 325mg daily. The recommended dose is 75mg daily. The recommended dose is 250mg twice a day. In selected high risk patients only when benefit outweighs risk Anti-hypertensive treatment ACE-inhibitor based therapy should be used to reduce recurrent stroke in normotensive and hypertensive patients. ARB-based therapy may benefit selected high risk populations.
- 39. Lipid lowering Lipid reduction should be considered in all subjects with previous ischaemic strokes. Diabetic control All diabetic patients with previous stroke should improve glycaemic control. Cigarette smoking All smokers should stop smoking.
- 40. Stroke in special circumstances Treatment Recommendations Aspirin Young Ischaemic stroke If the cause is not identified, aspirin is usually given. There are currently no guidelines on the appropriate duration of treatment. Heparin Warfarin Endovascular thrombolysis Cerebral Venous thrombosis Anticoagulation appears to be safe, and cerebral haemoffhage is not a contra-indication for anticoagulation. Simultaneous oral warfarin should be commenced. The appropriate length of treatment is unknown. It is currently considered for patients with extensive disease and clinical deterioration
- 41. SURGICAL TREATMENT • Surgical removal of hemorrhage with cerebellar decompression for patients with cerebellar hemorrhages, or with brainstem compression • Standard Craniotomy for patients with supratentorial ICH,
- 42. PREVENTION AND MANAGEMENT OF COMPLICATIONS • Management of complications improves both short-term and long-term prognosis. • Complications of stroke can be divided into General medical and Neurological complications. • They can also be divided into Acute(<7 days) or subacute(>7days) based on time of occurrence.
- 43. Steps Diet (low fat, high fiber) Quit smoking & alcohol intake Controlling diabetes Maintain healthy weight Exercise Avoiding illicit drugs PREVENTION
- 44. Key points • Young stroke patients • Time is at premium • Early identification • Early institution of Rx • Good and very satisfying result • Drug available ,Neuro-imaging available • Previous cases encouraging result
- 45. TIME is BRAIN Remember: Thank you!!!
Editor's Notes
- Cerebrovascular accident: is the medical term for a stroke, also called “brain attack”. A stroke occurs when blood flow to a part of your brain is stopped either by a blockage or a rupture of a blood vessel. Thus, there would be sudden death of some brain cells due to lack of oxygen due to the blockage of the brain's blood flow. A stroke is a medical emergency. Anyone suspected of having a stroke should be taken immediately to a medical facility for diagnosis and treatment.
- -As mentioned, it occurs when blood flow to a part of your brain is stopped either by a blockage such as a floating clot (embolus) or a stationary clot (Thrombosis), or a rupture of a blood vessel(Hemorrhage), or compression.
- . Symptoms of a stroke depend on the area of the brain affected. -The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. -Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even unconsciousness.
- . The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even unconsciousness. Stroke symptoms (for example, loss of arm or leg function or slurred speech) signify a medical emergency because without treatment, blood deprived brain cells quickly become damaged or die resulting in brain injury, serious disability, or death.
- -Stroke symptoms (for example, loss of arm or leg function or slurred speech) signify a medical emergency because without treatment, blood deprived brain cells quickly become damaged or die resulting in brain injury, serious disability, or death. Anyone should consider stroke if they experience any of these symptoms: 1. Sudden N\numbness or weakness of the face, arms or leg, especially on one side of the body 2. Sudden Confusion, trouble speaking or understanding 3. Sudden trouble seeing in one or both eyes 4. Sudden trouble walking, dizziness, loss of balance or coordination 5.Sudden, severe headache with no known cause -Similarly, it is important that the public are made aware on how to perform the Cincinnati Prehospital Stroke Scale which tests three signs that can indicate that the patient may be having stroke. If anyone of the three tests show an abnormal finding, the patient maybe having a stroke
- MILD STROKE: -Alert patients with any or combinations of symptoms such as: -mild motor weakness of one side of the body, defined as: >able to raise arm above shoulder >has clumsy hand or >can ambulate without assistance -sensory deficit, -slurred but intelligible speech, -vertigo with incoordination (e.g. gait disturbances, unsteadiness or clumsy hand) -visual field defects alone - NIHSS score= 0-5
- MODERATE SROKE: -Awake patient with significant motor and /or sensory and /or visual deficit, or -Disoriented, drowsy, or light stupor with purposeful response to painful stimuli, or -NIHSS Score= 6-21
- SEVERE STROKE: - Deep stupor or comatose patient with non-purposeful response, decorticate, or decerebrate posturing to painful stimuli, or - Comatose patient with no response to painful stimuli , or -NIHSS Score= >22
- Stroke Test or FAST test : Smile, Wave, Talk The F.A.S.T. test helps spot symptoms. It stands for: F means face: If one side of the face droops, it’s a sign of a possible stroke A means arms: If the person cannot hold both arms out, it’s another possible stroke sign S means speech: Slurring words and poor understanding of simple sentences is another possible stroke sign T means time: If any of the FAS signs are positive, it’s Time to call 9-1-1 immediately
- This is the Philippine version of FAST. Stroke: Time = Brain Damage, that is why it important to remember the FAST test for stroke; the T in FAST also means the longer time the blockage of blood (usually due to clot formation) to the brain, the more damage to the brain can occur. In some qualified patients, the use of a clot-busting drug may be used to dissolve the clot and restore blood flow. For many patients, the time span to diagnose and treat such a clot is usually 3 hours (some clinicians suggest a bit longer time). Often, patients do not qualify for this treatment. There are also some risks like bleeding associated with this treatment that may cause problems. Because treatments are sometimes difficult to qualify for and because damage to brain cells can happen quickly, strokes are a leading cause of long-term disability in people.
- The NIHSS has a Total Score=42; Mild Stroke: 0-5 Moderate Stroke: 6-21 Severe Stroke:>22
- Aphasia: ask the patient to describe what is happening on the picture and name items. Dysarthria : Ask the patient to read or repeat words from the list.
- Modified Rankin Scale: measures independence rather than performance of specific tasks. Scale consists of six grades from 0-5; 0 denotes no symptoms and 5 indicates severe disability. For clinical purpose, mild disability range is from 0-2; moderate disability ranges from 3-4 and 5 indicates severe disabilityModified Rankin Scale
- 1. supportive management- airway, temperature, blood pressure, blood glucose, cardiac assessement 2. thrombolysis – intravenous / intra arterial 3. antiplatelet drugs 4. anticoagulant drugs 5. hemodilution, vasodilators and induced hypertension 6. Neuroprotective agents
- MANAGEMENT OF SAH Bed rest Analgesic Blood pressure control TRIPLE – H therapy(hypervolemia , induced hypertension, hemodilution ) Oral nimodipine 60mg q6hx21 days Angiography for localization of bleeding If aneurysm Immediate surgical clipping for Grade 1-3 patient without contraindication Grade 4-5 with intracerebral clot and deterioratio
- Secondary prevention of stroke Management of hypertension (goal <140/85 mm Hg) Diabetes control (goal<126 mg/dL) Lipid management: Statins (goal cholesterol<200 mg/dL, LDL<100 mg/dL) Anticoagulants: Warfarin (target INR 2 to 3); esp. recommended in patients with cardioembolic stroke Appropriate life style modification (cessation of smoking, exercise, diet etc) Antiplatelet agents:Antiplatelet agents such as aspirin(300mg) reduce the risk of recurence of all ischaemic stroke & for patients with TIAs. Aspirin is not useful for preventing a first stroke in persons at low risk (Class III; Level of Evidence A).
- Secondary prevention of stroke Management of hypertension (goal <140/85 mm Hg) Diabetes control (goal<126 mg/dL) Lipid management: Statins (goal cholesterol<200 mg/dL, LDL<100 mg/dL) Anticoagulants: Warfarin (target INR 2 to 3); esp. recommended in patients with cardioembolic stroke Appropriate life style modification (cessation of smoking, exercise, diet etc) Antiplatelet agents:Antiplatelet agents such as aspirin(300mg) reduce the risk of recurence of all ischaemic stroke & for patients with TIAs. Aspirin is not useful for preventing a first stroke in persons at low risk (Class III; Level of Evidence A).
- Surgical removal of hemorrhage with cerebellar decompression should be performed for patients with cerebellar hemorrhages greater than 3 cm in diameter who are deteriorating, or who have brainstem compression and/or hydrocephalus due to ventricular obstruction For patients with supratentorial ICH, current guidelines suggest consideration of standard craniotomy only for those who have lobar clots >30 mL within 1 cm of the surface. Mortality at 30 days in general compared with conservative management is not different.