1.
Stroke
Weill Medical School
DR VICTOR MWEBAZA
Ugandan

2.
Definition: Stroke

3.
Two types of stroke:
ischemic (80%) and hemorrhagic (20%)

4.
Examples of Stroke: Ischemic
A 70 yo man with
hypertension, DM, and
smoking history,
presents with sudden
onset of R face and arm
weakness and
confusion.

5.
Examples of Stroke: Hemorrhagic
A 70 yo woman with HTN
presents with sudden
onset headache and L
sided weakness.

6.
What if you do not have a CT scan?
Ischemic Stroke
↑ Blood pressure
Greatest deficit in
beginning, then
improves
Fits a vascular territory
Hemorrhagic Stroke
↑ ↑ ↑ Blood pressure
Usually gets worse
Headache, N/V
May not fit a vascular
territory

7.
Definition: TIA
• Transient Ischemic Attack (TIA)
Focal loss of cerebral function
Tissue ischemia
Lasting <24 hours
Increased risk for stroke: identify risk factors and
treat them to prevent future stroke!

8.
Stroke Risk Factors
• Age>60
• Hypertension
• Atrial Fibrillation
• Peripheral vascular disease
• High cholesterol
• Diabetes
• Smoking

9.
Example
A 65 woman with history of diabetes,
hypertension, gout, and obesity presents with
sudden onset of difficulty speaking, lasting 5
minutes.
Is this a stroke or a TIA?
What are her risk factors?

10.
Stroke: Causes
• Thrombus (40%)
Large artery (dissection, atherosclerosis)
Penetrating artery (hypertensive remodeling)
Venous thrombus
• Embolic (20%)
Cardiac (Afib, Aflutter, rheumatic heart disease,
endocarditis)
Paradoxical embolus (PFO)
Artery to artery embolus (atherosclerosis)
Air, Fat, Amniotic fluid, septic

11.
Causes of Stroke

12.
Stroke: Causes
• Coagulopathy (5%)
• Low Flow (<5%)
“Watershed infarct”
Systemic hypotension w severe
atherosclerosis
• Vasculopathy (5%)
Infectious, vasculitis
• Unknown (30%)

13.
Major Causes of Stroke in Africa
• Hypertension (hemorrhagic stroke)
• Atherosclerosis
• Rheumatic heart disease (embolic)
• Hemoglobinopathies (Sickle Cell)
• HIV

14.
How do you recognize a stroke?
• Sudden onset
• Focal neurologic deficit
What would you call
this if it only lasted 3
minutes?

15.
How do you recognize a stroke?
• Sudden onset
• Focal neurologic deficit
– Aphasia
– Neglect
– Visual field cut
– Hemiparesis
– Hemisensory loss

16.
Symptoms unlikely to be due to stroke
(especially ischemic)
• Sudden loss of consciousness
• Memory loss
• Bilateral limb weakness; paraparesis
• Bilateral limb numbness
• Limb pain
– Pain can develop days after a thalamic stroke, but
this is rare, and does not occur acutely
• Any neurologic deficit that has a gradual onset
(over days-weeks or longer)

17.
Which is the stroke?
A. 70 yo woman with hypertension, diabetes,
presents with a headache.
B. 65 yo man with hypertension, atrial fibrillation
presents with sudden onset R arm weakness.
C. 30 yo woman smoker, hypertension presents with
gradual onset of L arm numbness.
Answer: B

18.
Stroke: History
• Age
• Timing of Onset
• Neurologic deficit
• Headache
• N/V
• Risk factors
• Meds: warfarin, aspirin, oral contraceptives

19.
Stroke Evaluation: Neurologic Exam
1. Mental Status (level of arousal, language)
2. Cranial Nerves
3. Motor Exam
4. Reflexes
5. Coordination
6. Sensory
7. Gait

20.
Stroke: Evaluation
What tests should you order?
• Random blood glucose
• Head CT
• Full blood picture
• Lipid Panel
• EKG
• Echocardiogram
• Carotid Ultrasound

21.
Stroke: Differential Diagnosis
• Seizure (post-octal phase)
• Hypoglycemia
• Space occupying lesion
– Neoplasm
– Infection (toxo, fungal, abscess)
• Encephalitis
• Subdural hematoma
• Meningitis

22.
Management of Ischemic Stroke
• ABCs
• Initial 48 hrs:
– Permissive hypertension (SBP 140-180) to perfuse
penumbra
– IV fluids
– Keep head of bed flat
– Maintain normothermia and normoglycemia
• Aspirin 300 mg qd
• Simvastatin 40 mg qd

23.
Management of Hemorrhagic Stroke
• ABCs
• CT Head
• Emergent BP control: SBP < 150 (depending
on patient’s baseline BP)
• Position HOB to 30º
• Neurosurgery consult
• Hypertonic saline or mannitol if there is
cerebral edema
• Hold anti-platelet or anti-coagulation agents

24.
Management of Stroke
After 48 hours:
• Physiotherapy
• Slowly lower the blood pressure to SBP <130,
add BB or AceI first
• Continue ASA 300 mg x 2 weeks, then ASA 75
mg OD lifelong
• Smoking cessation
• Adjust simvastatin dose based on LDL; goal
LDL<70

25.
Stroke Disability

26.
Summary
• A stroke is characterized by a sudden onset of
a focal deficit caused by permanent damage
to the brain.
• A TIA is a transient focal neurologic deficit that
increases one’s risk for stroke: it is important
to identify and treat risk factors

27.
Summary
• Risk factors include age, HTN, DM, smoking,
atrial fibrillation, high cholesterol, and PVD.
• It is essential to differentiate between an
ischemic and hemorrhagic stroke with a CT
scan.

28.
Summary
• For ischemic stroke, you should allow the
blood pressure to be moderately elevated so
the brain can perfuse ischemic territory and
give aspirin.
• For hemorrhagic stroke, the most important
action is to lower the blood pressure.