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
6. SYMPTOMS
• Symptoms of a stroke depend on the area of
the brain affected.
• Stroke symptoms signify a medical
emergency.
7.
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
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.
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.
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)
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.
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
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
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.