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Stroke and cerebrovascular accident


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Stroke and cerebrovascular accident

  2. 2. Definition<br />Transient Ischaemic Attack (TIA) – an acute focal neurological deficit resulting from cerebrovascular disease with resolution of signs and symptoms within 24 hours.<br />Reversible Ischaemic Neurological Deficit (RIND) – attack lasting longer than 24 hours but with complete clearance of signs and symptoms within 7 days.<br />Completed Stroke – neurological deficit lasts longer than 7 days.<br />
  3. 3. HOW YOU GIVE THE DIAGNOSIS?<br />The diagnosis should provide answers to the following questions:<br />1. What is the neurological deficit?<br />2. Where is the lesion?<br />3. What is the lesion?<br />4. Why has the lesion occurred?<br />5. What are the potential complications and prognosis?<br />
  4. 4. What Artery Involved?<br />Aphasia (dominant hemisphere)<br />Hemiparesis / plegia<br />Hemisensoryloss/disturbance<br />Homonymous hemianopia<br />Parietal lobe dysfunction, e.g. astereognosis, agraphaesthesia, impaired two-point discrimination, sensory and visual inattention, left-right dissociation and acalculia<br />
  5. 5. What Artery Involved?<br />Weakness of lower limb more than upper limb<br />
  6. 6. What Artery Involved?<br />Homonymous hemianopia<br />Cortical blindness<br />Ataxia<br />Dizziness or vertigo<br />Dysarthria<br />Diplopia<br />Dysphagia<br />Horner’s syndrome<br />Hemiparesis or hemisensory loss contralateral to the cranial nerves palsy<br />Cerebellar signs<br />
  7. 7. SO… BASIC IS IMPORTANT!!!!!!!!<br />
  8. 8. Brain Blood Supply Features:<br />High oxygen requirement. <br />Brain 2% of body weight - 15% of cardiac output <br />20% of total body oxygen. <br />Continuous oxygen requirement<br />Few minutes of ischemia - irreversible injury. <br />Neurons - Predominantly aerobic.<br />Sensitive areas:<br />Adults -Hippocampus, 3,5th & 6th layer of cortex, Purkinje cells. Border zone (watershed areas)<br />Brain stem nuclei in infants.<br />
  9. 9. Anatomy – Stroke. <br />
  10. 10. Brodman’s Cortical Map:<br />
  11. 11. Frontal[f*ck – motor] Lobe Functions:<br />High level cognitive functions. i.e reasoning, abstraction, concentration<br />Storage of information – memory<br />Control of voluntary eye movement<br />Motor control of speech in the dominant hemisphere.<br />Motor Cortex – Motor control of the contralateral side of the body<br />Urinary continence<br />Emotion and personality<br />
  12. 12. Parietal[p-sx – sensory] Lobe Functions:<br />Sensory cortex – sensory input is interpreted to define size, weight, texture and consistency (contralateral)<br />Sensation is localised, and modalities of touch, pressure and position are identified.<br />Awareness of the parts of body<br />Non-dominant – processes visuospatial information and<br />controls spatial orientation<br />Dominant is involved in ideomotor praxis (ability to perform learned motor tasks<br />
  13. 13. Temporal[t-telinga] Lobe Functions:<br />Primary auditory receptive areas<br />In dominant ability to comprehend speech (wernicke’s) – reception<br />Interpretive area – area at the junction of the temporal, parietal and occipital lobes.<br />Plays an important role in visual, auditory and olfactory perception<br />Important role in learning; memory and emotional affect.<br />
  14. 14. Occipital[O-optic] Lobe Functions:<br />Primary visual cortex<br />Visual association areas<br />Visual perception<br />Some visual reflexes (i.e. visual fixation)<br />Involuntary smooth eye movement<br />
  15. 15. Diencephalon Functions:<br />Brain Stem:<br />Midbrain, Pons & Medulla<br />10 of the 12 ranial nerves arise from the brainstem (ipsilateral signs)<br />Cortical pathway decussation contralateral signs.<br />Some major functions: eye movement, swallowing, breathing, blood pressure, heat beat, consciousness<br />Cerebellum:<br />movement – Balance & coordination<br />
  16. 16. Motor & Sensory Cortex:<br />
  17. 17. Diencephalon & Brain stem:<br />
  18. 18. Cranial Nerves:<br />
  19. 19. Stroke Types:<br />Clinical<br />Transient Ischemic Attack –TIA resolve <24h<br />Evolving stroke – increasing >24h. – Thromb.<br />Recurrent / multiple stroke – sec. factors.<br />Completed stroke – no change… embolic.<br />Pathological<br />Focal / Global<br />Ischemic & hemorrhagic (chronic/acute)<br />Venous infarcts. (young, infections)<br />
  20. 20. Common Types and Incidence:<br />Infarction: Incidence 80% - mortality20%<br />50% - Thrombotic – atherosclerosis<br />Large-vessel 30% (carotid, middle cerebral)<br />Small vessel 20% (lacunar stroke)<br />30% Embolic(heart dis / atherosclerosis) <br />Young, rapid, extensive.<br />Venousthromboembolism (rare)<br />Hemorrhage:Incidence20% - mortality80%<br />Berry aneurysm, Microaneurysm, Atheroma.<br />Intracerebral or subarachnoid.<br />
  21. 21. Stroke location and incidence:<br />
  22. 22. Clinical Categories:<br />Global Ischemia.<br />Hypoxemic encephalopathy<br />Hypotension, hypoxemia, anemia.<br />Focal Ischemia.<br />Obstruction to blood supply to focal area.<br />Thrombosis, embolism or hemorrhage.<br />
  23. 23. GLOBAL ISCHAEMIA<br />
  24. 24. Global Ischemia:<br />Etiology:<br />Impaired blood supply - Lung & Heart disorders.<br />Impaired O2 carrying – Anemia/Blood dis.<br />Impaired O2 utilization – Cyanide poisoning.<br />Morphology:<br />3rd, 5th and 6th layers of the cortex, hippocampus and in the Purkinje cells in the cerebellum <br />Laminar necrosis, Hippocampus, Purkinje cells.<br />Border zone infarcts – “Watershed”<br />Sickle shaped band of necrosis on cortex.<br />ClinicalFeatures:<br />Mild transient confusion state to<br />Severe irreversible brain death. Flat EEG, Vegetative state. Coma.<br />
  25. 25. Morphology in Global Ischemia<br />Watershed zone (Acute - ACA-MCA)<br />Laminar necrosis - (chronic- short penetrating arteries)<br />Sommer sector of hippocampus.<br />Purkinje cells of cerebellum.<br />
  26. 26. Watershed/Boundary zone infarcts:<br />Carotid thrombosis<br />
  27. 27. Lamellar necrosis in global ischemia.<br />Chronic<br />
  28. 28. Local infarction:<br />Cell death ~ 6min<br />central infarct area or umbra, <br />surrounded by a penumbra of ischemic tissue that may recover <br />
  29. 29. Infarct Pathogenesis:<br />Reduced blood supply – hypoxia/anoxia.<br />Altered metabolism  Na/K pump block. <br />Glutamate receptor act.  calcium influx.<br />ischemic injury – Red neuron, vacuolation.<br />cell death, karyorrhexis.<br />Inflammation – edema.<br />Macrophages - > 5d.<br />Liquifaction cavity – >1wk<br />Glial proliferation – >1wk. (astrocytes)<br />Hours<br />1-day<br />3-day<br />1 wk.<br />>4wk<br />
  30. 30. Infarct Stages:<br />Immediate – <24 hours<br />No Change gross, micro  Na/K loss, Ca+ influx.<br />Acute stage – < 1week <br />Oedema, loss of grey/white matter border.<br />Inflammation, Red neurons, necrosis, neutrophils<br />Intermediate stage – 1- 4 weeks.<br />Clear demarcation, soft friable tissue, cysts<br />Macrophages, liquifactive necrosis<br />Late stage – > 4 weeks.<br />Removal of tissue by macrophages<br />Fluid filled cysts with dark grey margin (gliosis)<br />Gliosis – proliferation of glia at periphery. <br />
  31. 31. FOCAL ISCHAEMIA<br />
  32. 32. Brain Stem Stroke: Common Pattern<br />Pure Motor - Weakness of face and limbs on one side of the body without abnormalities of higher brain function, sensation, or vision (MCA/ACA)<br />Pure Sensory - Decreased sensation of face and limbs on one side of the body without abnormalities of higher brain function, motor function, or vision   (PCA).<br />
  33. 33.
  34. 34. MCA [most common] Features:<br />Paralysis of the contralateral face, arm and leg<br />Sensory impairment over the contralateral face, arm & leg<br />Homonymous hemi or quadrantonopia<br />Paralysis of gaze to the opposite side<br />Aphasia (dominant) and dysarthria [broca/wernicke]<br />Penetrating - contralateral hemiplegia/paresis, slurred speech.<br />Impaired spatial perception<br />
  35. 35. MCA stroke.<br />
  36. 36.
  37. 37. MCA stroke.<br />Wikipedia: GNU Free Documentation license <br />
  38. 38. MCA stroke.<br />Wikipedia: GNU Free Documentation license <br />
  39. 39. ACA stroke.<br />Paralysis of contralateral foot and leg<br />Sensory loss over toes, foot and leg<br />Impairment of gait and stance<br />Abulia (slowness and prolonged delays to perform acts)<br />Flat affect, lack of spontaneity, slowness, distractibility<br />Cognitive impairment, such as perseveration and amnesia<br />Urinary incontinence<br />Wikipedia: GNU Free Documentation license <br />
  40. 40.
  41. 41. PCA stroke.<br />Peripheral (cortical)<br />Homonymous hemianopia<br />Memory deficits<br />Perseveration<br />Several visual deficits (cortical blindness, lack of depth perception, hallucinations)<br />Central (penetrating)<br />Thalamus - contralateral sensory loss, spontaneous pain, mild hemi<br />Cerebral peduncle - CN III palsy with contralateral hemiplegia<br />Brain stem - CN palsies, nystagmus, pupillary abnormalities<br />Wikipedia: GNU Free Documentation license <br />
  42. 42. Posterior Cerebral Artery<br />Visual disturbances<br />contralateral homonymous hemianopsia<br />(central vision is often spared) <br />L. Hemi: lesions alexia <br />(with or without agraphia) <br />Bilateral lesions: cortical blindness <br />patients unaware they cannot see <br />(Anton's syndrome)<br />Memory impairment if temporal lobe is affected ~<br />Proximal occlusion<br />contralateral hemisensory loss, <br />spontaneous pain and dysesthesia if thalamus affected <br />(thalamic pain syndrome) <br />contralateral severe proximal chorea <br />(hemiballism) ~<br />
  43. 43.
  44. 44.
  45. 45. Haemorrhagic - Arterial embolus<br />Embolic stroke: sudden, pin point hemorrhages over a triangular area.<br />
  46. 46. Infarct with Punctate hemorrhage<br />
  47. 47. Cerebral Infarction - Late<br />
  48. 48. Cerebral Infarction - Late<br />
  49. 49. Hypertensive CVD<br />Intraerebral/Subarachnoid Hemorrhage<br />Microaneurysm hemorrhages – Basal ganglia. Putamen(60%), thalamus, ventricles.<br />Berry aneurysm hemorrhages– subarachnoid.<br />Chronic Hypertension: (dementia) <br />Slit hemorrhages. Microhemorrhages heal as slit with pigment.<br />Lacunar infarcts: Brain stem - pale infarcts. A.sclerosis<br />Hypertensive encephalopathy-Malignant.<br />Headache, confusion, vomiting – Raised ICP.<br />
  50. 50.
  51. 51. Central Pontine Hemorrhage - Herniation<br />
  52. 52. Subarachnoid Hemorrhage:<br />
  53. 53. Ruptured Berry Aneurism<br />
  54. 54. Fusiform atherosclerotic aneurysm<br />
  55. 55. Saccular(berry) Aneurysm: <br />
  56. 56.
  57. 57.
  58. 58. Intracerebral Hemorrhage:<br />
  59. 59. Lacunar Infarct in pons <br />
  60. 60. Left (Dominant) Hemisphere Stroke: Clinical<br />Aphasia<br />Righthemiparesis<br />Right-sided sensory loss <br />Right visual field defect <br />Poor right conjugate gaze <br />Dysarthria <br />Difficulty reading, writing, or calculating<br />L affect R<br />Diagnosis: Recent cerebral infarction in left MCA distribution.<br />Left cerebral hemisphere shows swelling with compression of the lateral ventricle mainly in the frontal area, due to recent infarct in the Middle Cerebral Artery (MCA) distribution. The brain in the MCA area shows discoloration of the cortex and also blurring between the cortex and white matter. <br />
  61. 61. Right (Non-dominant) - Hemisphere Stroke:<br />Defect of left visual field <br />Extinction of left-sided stimuli <br />Left hemiparesis<br />Left-sided sensory loss <br />Left visual field defect <br />Poor left conjugate gaze <br />Dysarthria <br />Spatial disorientation <br />R affect L<br />
  62. 62. CNS AV Malformations:<br />Many types:<br />AV Malformation *<br />Cavernous angioma<br />Telangiectasia<br />Venous angioma<br />Cause of Seizure disorders & hemorrhage.<br />Most common congenital vascular malformation.<br />Typically located in the outer cerebral cortex underlying white matter.<br />
  63. 63.
  64. 64. Pathological Review:<br />Stroke: Ischemic / Thrombotic / Hemorrhagic<br />Acute neurological deficit - Clinical<br />Cerebro Vascular Accident – Pathology.<br />Etiology: Thrombosis, Embolism, Hemorrhage.<br />Risk factors: AS, Hypertension, Smoking.<br />Global – Systemic Hypoxia – Watershed & lamellar infarct<br />Focal – Basal ganglia, Putamen, Int. capsule (MCA) <br />Pathogenesis: Infarction  Liquifaction necrosis  Cyst formation with peripheral gliosis. (loss of neural function)<br />Hypertension & CVA:<br />Atherosclerosis - Thrombosis<br />Haemorrhage (Intra/subarachnoid), <br />chronic benign: Lacunar infarcts & slit hemorrhages. <br />Hypertensive Encephalopathy, <br />
  65. 65. Stroke – Risk Factors<br />Modifiable<br />Hypertension<br />Tobacco use<br />Excess Alcohol<br />Hx of TIA’s<br />Heart Disease<br />Diabetes Mellitus<br />Hypercoagulopathy<br />Pregnancy, cancer, etc.<br />Sickle Cell and increased RBC<br />Hx of carotid Bruit<br />Unmodifiable<br />Age<br />Gender<br />Race<br />Previous CVA<br />Heredity<br />
  66. 66.
  67. 67. Stroke – Signs and Symptoms<br />Ischemic<br />Carotid Circulation<br />Unilateral paralysis (opposite side)<br />Numbness (opposite side)<br />Language disturbance<br />Aphasia – difficult comprehension, nonsense, difficult reading/writing<br />Dysarthria – slurred speech, abnormal pronunciation.<br />Visual disturbance (opposite side)<br />Monocular blindness (same side)<br />
  68. 68. Stroke – Signs and Symptoms<br />Ischemic<br />Vertebrobasilar Circulation<br />Vertigo<br />Visual disturbance<br />Both eyes simultaneously<br />Diplopia<br />Ocular palsy – inability to move to one side<br />Dysconjugate gaze – asynchronous movement<br />Paralysis<br />Numbness<br />Dysarthria<br />Ataxia<br />
  69. 69. Stroke – Signs and Symptoms<br />Hemorrhagic<br />Subarachnoid hemorrhage<br />Sudden severe HA<br />Transient LOC<br />Nausea/Vomiting<br />Neck pain<br />Intolerance of noise/light<br />AMS<br />Intracerebral hemorrhage<br />Focal sx w/ LOC, N/V<br />
  70. 70. History<br />Detailed history from relative or friend or patient if he is able to speak.<br />Rapidity of onset – sudden onset of a focal neurological deficit.<br />Time course of symptoms – maximum deficit over seconds or minutes before starting to improve.<br />Headache, coma at onset and vomiting at onset are more common in haemorrhage but also occur with infarction.<br />Sudden onset of severe generalised headache associated with neck stiffness – subarachnoid haemorrhage.<br />Specific record should be made about the presence of vascular risk factors.<br />
  71. 71. Examination<br />General Examination<br />BP – should be taken in both arms.<br />Stroke may cause an acute rise in BP and therefore hypertension should not be diagnosed in the first few days after a stroke unless left ventricular hypertrophy of fundal changes are present.<br />Pulse – for arrhythmias particularly atrial fibrillation.<br />Peripheral pulses.<br />Auscultation for a carotid bruit.<br />Heart – for valvular heart disease especially mitral stenosis.<br />Neck stiffness – subarachnoid haemorrhage or meningitis.<br />Identify the anatomical localization of the lesion and record the degree of disability.<br />
  72. 72. Oxfordshire Community Stroke Project Classification<br />OCSP<br />
  73. 73.
  74. 74.
  75. 75.
  76. 76. Causes of ischaemic stroke<br />
  77. 77. Causes of ischaemic stroke 2<br />
  78. 78. Causes of ischaemic stroke 3<br />
  79. 79. Causes of intracranial haemorrhage<br />
  80. 80. Subarachnoid haemorrhage<br />Initial headache or coma – sudden rise in intracranial pressure.<br />Focal symptoms if aneurysm ruptures into underlying brain.<br />Cerebral vasospasm causes delayed cerebral infarction 4-14 days after onset in 30% of patients.<br />Recurrent haemorrhage and hydrocephalus are other complications.<br />
  81. 81. Intracerebral Haemorrhage<br />Sudden rupture of microaneurysms caused by hypertensive vascular disease.<br />Characteristically occurs in the basal ganglia, pons and cerebellum.<br />Elderly patients – cerebral amyloid angiopathy, a degenerative disorder affecting the walls of the artey – subcortical haematomas.<br />Cryptic av malformations are suspect especially in younger patients < 40 yrs and when the haemotoma is Lobar (frontal, temporal, parieto-occipital).<br />
  82. 82. Investigations <br />Confirm the diagnosis<br />CT Scan<br /><ul><li>To establish the site, size and pathological diagnosis by showing infarction or haemorrhage.
  83. 83. To exclude other conditions that may mimic stroke like subdural haematoma, intracranial tumour.</li></li></ul><li>Y CT Scan?<br />There is doubt about the diagnosis.<br />Symptoms progress or fluctuate.<br />Conscious level is depressed or patient is in coma.<br />If thrombolytic therapy or anticoagulant treatment is considered.<br />Neck stiffness is present.<br />Has severe headache.<br />Deteriorates unexpectedly.<br />Haemorrhage can be seen within a few minutes as an area of increased attenuation.<br />Infarction as a low density lesion which conforms to a vascular territory usually wedge shaped.<br />It is not immediately visible on CT but in most patients becomes apparent in 4-7 days.<br />
  84. 84.
  85. 85.
  86. 86.
  87. 87. MRI Scan<br />Posterior circulation strokes are more readily identified than by CT.<br />
  88. 88. General Investigations<br />identify conditions which may predispose towards premature cerebrovasculardisease.<br />Full blood count – polycythemia, thrombocytopoenia.<br />Blood glucose – diabetes mellitus.<br />Serum lipids – hypercholesterolemia.<br />Blood cultures – SBE.<br />
  89. 89. General Investigations II<br />HIV screen – AIDS.<br />Syphilis serology – VDRL.<br />Clotting Screen.<br />Thrombophilia Screen – Protein C, Protein S, Antithrombin III.<br />Anticardolipin antibodies – SLE.<br />Lumbar Puncture – subarachnoid haemorrhage.<br />
  90. 90. DD Stroke<br />Differential Diagnosis of Stroke<br />Head/Cervical trauma<br />Meningitis/encephalitis<br />Hypertensive encephalopathy<br />Intracranial mass<br />Tumor<br />Sub/epi dural hematoma<br />Todd’s paralysis<br />Migraine w/ neuro sx<br />Metabolic<br />Hyper/hypo glycemia<br />Post arrest ischemia<br />Drug OD<br />
  91. 91. Differential Diagnosis<br />Space occupying lesion<br />5% of people with stroke like symptoms have a subdural haematoma, tumour or cerebral abscess. <br />Distinction is readily made on CT or MRI. <br />If there is any doubt repeat the scan after 6 weeks.<br />
  92. 92. Differential Diagnosis II<br />Multiple sclerosis<br />May present with hemiparesis, sensory impairment or brainstem symptoms that mimic stroke. <br />Symptoms occur gradually over a few days.<br />Hypoglycaemia<br />May cause hemiparesis.<br />Migraine<br />
  93. 93. Complications I<br />Cerebral oedema<br />Should be suspected in a patient with a large infarct or haemorrhage experiences a lucid interval of 24-48 hours and then shows a decline in consciousness.<br />
  94. 94. Complication II<br />Haemorrhagic transformation<br />Can occur as a result of thrombolysis.<br />Pneumonia<br />In patients with swallowing difficulties as a result of aspiration.<br />Pressure sores<br />Develop rapidly and may be exacerbated because of incontinence.<br />Oedema of Weak Limbs<br />Is common and has a partially autonomic basis.<br />
  95. 95. Complication III<br />Anxiety and Depression<br />Common reactions to stroke but depression may have an organic basis related to damage of the frontal and limbic systems.<br />Emotional Lability<br />Precipitated by minor emotional stimuli.<br />
  96. 96. Management I<br />Has the following aims<br />Confirmation of the diagnosis, anatomical site of the lesion, pathology and aetiology.<br />Acute care.<br />Rehabilitation of persistent disability and handicap.<br />Prevention of recurrence.<br />
  97. 97. Management II<br />Acute Care<br />Treatment aims<br />Prevent progression of present event.<br />Prevent immediate complication.<br />Prevent the development of subsequent events.<br />To rehabilitate the patient.<br />
  98. 98. Management III<br />General Measures<br />Around the edge of the infarct, ischaemic tissue is at risk, but is potentially recoverable. <br />This must be protected by ensuring a good supply of glucose and oxygen.<br />Maintain hydration, oxygenation and blood pressure.<br />
  99. 99. Specific MeasuresMedical Treatment<br />Anticoagulation<br />Patient with high risk of developing deep vein thrombosis.<br />Thromboembolic stroke - started as soon as possible, except in large infarcts where it may be wise to delay anticoagulation for 2 weeks.<br />Stroke in a patient with myocardial infarct - due to mural thrombus.<br />Stroke in evolution.<br />Exclude a haemorrhage by doing a CT scan first.<br />
  100. 100. Medical Treatment IIAntiplatelet Agents<br />Especially in TIA.<br />Thrombolysis<br />I/V thrombolysis espcially recombinant tissue plasminogen activator rTPA to be given only within the first 3 hours after onset to those patients who have not developed CT abnormalities especially in patients with basilar artery occlusion.<br />Risk – haemorrhage.<br />
  101. 101. Hypertension<br />Treated cautiously in acute stroke.<br />A reduction in blood pressure may lower cerebral blood flow in the regions surrounding the infarct below a critical level at which further ischaemic brain damage will occur.<br />Mild to moderate elevations in BP – no treatment unless they are maintained for several days after admission.<br />
  102. 102. If stroke associated with hypertensive encephalopathy or if diastolic BP is persistently above 120 mm Hg.<br /> The BP should be lowered cautiously using oral agents. <br />Sudden precipitious fall in BP should be avoided.<br />Hypertension II<br />
  103. 103. Medical TreatmentCalcium Antagonist<br />Nimodipine prevents ischaemic brain damage and reduces the number of patients remaining disabled after subarachnoid haemorrhage.<br />Prescribed as soon as diagnosis is made (within 12 hours).<br />
  104. 104. Neurosurgery<br />Should be considered in subaracnoid and intracerebral haemorrhage.<br />Evacuation of cerebellar haematoma.<br />Evacuation of supratentorial haematomas should only be considered in younger patients with superficial cortical haematomas causing mass effect with a deteriorating level of conciousness.<br />
  105. 105. Nursing Care and Rehabilitation<br />Physiotherapy, proper positioning and early mobilization – prevent pressure sores.<br />Support stockings – prevent deep vein thrombosis and pulmonary embolism.<br />Swallowing difficulties.<br />Lead to silent aspiration – aspiration pneuomonia.<br />Nasogastric tube feeding.<br />Percutanious endoscopic gastrostomy.<br />
  106. 106. Rehabilitation<br />Physiotherapy, occupational therapy, speech therapy and psychology input – multidisciplinary stroke rehabilitation team.<br />Home visit by occupational therapist to plan adaptations to home before discharge.<br />
  107. 107. Secondary Preventation<br />Control hypertension and diabetes mellitus.<br />Correct lipid abnormality.<br />Stop cigarette smoking.<br />Stop thrombogenic drugs e.g. oral contraceptives.<br />
  108. 108. Secondary Preventation II<br />Give platlet antiaggregation drugs to reduce the rate of reinfarction.<br />Low dose aspirin (75 mg – 150 mg), if <br /> patient allergic or has gastrointestinal<br /> side effects give ticlopidine. Regular<br /> blood tests because of a small risk of<br /> neutropoenia.<br />Remove or treat embolic source (long term anticoagulation in atrial fibrillation).<br />Treat inflammatory or vascular inflammatory diseases.<br />
  109. 109. Secondary Preventation III<br />Carotid Endarterectomy – preventing stroke in symptomatic patients with recent TIA and stroke and severe stenosis of the internal carotid artery (at least 70%). <br />
  110. 110. Chain of Survival Stroke<br />Stroke Chain of Survival<br />Detection<br />Early sx recognition<br />Dispatch<br />Prompt EMS response<br />Delivery<br />Transport, approp, prehospital care, prearrival notification<br />Door<br />ER Triage<br />Data<br />ER evaluation incl, CT, etc.<br />Decision<br />Appropriate therapies<br />Drug/Therapy<br />
  111. 111. Detect & Dispatch<br />Detection: Early Recognition<br />Public education of Stroke sx<br />Early access to medical care<br />Dispatch: Early EMS and PDI’s<br />Caller triage<br />EMD recognition of Stroke sx<br />
  112. 112. How to detect?<br />Delivery: <br />Pre-hospital Transport and Management<br />How we scale the pre-hospital management of the patient?<br />
  114. 114. CINCINNATI STROKE SCALE<br />Identifies patients with strokes.<br />It evaluates three major physical findings.<br />Facial droop<br />Motor arm weakness<br />Speech abnormalities<br />
  115. 115. CSS - Facial Droop<br />Have the patient show their teeth or smile.<br />Normal – both sides of the face move equally well<br />Abnormal – one side of the face does not move as well as the other side<br />
  116. 116.
  117. 117.
  118. 118. Arm Drift<br />Have the patient close his/her eyes and hold both arms out.<br />Normal – both arms move the same way, or both arms do not move at all.<br />Abnormal – one arm does not move or one arm drifts down compared to the other arm.<br />Other findings such as pronator grip, may be helpful<br />
  119. 119.
  120. 120.
  121. 121. Speech<br />Have the patient say “You can’t teach an old dog new tricks.” – “Perlambagaan Malaysia”<br />Normal – patient uses correct words with no slurring.<br />Abnormal – patient slurs words, uses inappropriate words, or is unable to speak<br />
  122. 122. “You can’t teach an old dog new tricks.”<br />
  123. 123.
  124. 124. Cincinnati PrehospitalStroke Scale<br />Patients with 1 of these 3 findings -as a new event - have a 72% probability of an ischemic stroke.<br />If all 3 findings are present the probability of an acute stroke is more than 85%<br />Immediately contact medical control and the destination ED and provide prearrival notification.<br />
  125. 125. Stroke – Management In Review:<br />Prehospital Critical Actions<br />Assess and support cardiorespiratory function<br />Assess and support blood glucose<br />Assess and support oxygenation and ventilation<br />Assess neurologic function<br />Determine precise time of symptom onset <br />Determine essential medical information<br />Provide rapid emergent transport to ED<br />Notify ED that a possible stroke patient is en route<br />
  126. 126. Stroke - Management<br />Door: ER Triage<br />Stroke evaluation targets for stroke patients who are thrombolytic candidates<br /> Door-to–doctor first sees patient…….………… 10 min<br /> Door-to–CT completed …….………………….. 25 min<br /> Door-to–CT read ...…………..………………… 45 min<br /> Door-to–fibrinolytic therapy starts …………….. 60 min<br /> Neurologic expertise available*…..…………… 15 min<br /> Neurosurgical expertise available* …………… 2 hours<br /> Admitted to monitored bed ..……...…………… 3 hours<br /> *By phone or in person<br />
  127. 127. Stroke - Management<br />Data: ER Evaluation and Management<br />Assessment Goal: in first 10 minutes<br />Assess ABCs, vital signs<br />Provide oxygen by nasal cannula<br />Obtain IV access; obtain blood samples (CBC, ’lytes, coagulation studies)<br />Obtain 12-lead ECG, check rhythm, place on monitor<br />Check blood sugar; treat if indicated<br />Alert Stroke Team: neurologist, radiologist, CT technician<br />Perform general neurologic screening assessment<br />
  128. 128. Stroke - Management<br />Assessment Goal: in first 25 minutes<br />Review patient history<br />Establish symptom onset (<6 hours required for fibrinolytics)<br />Perform physical examination<br />Perform neurologic exam<br />Determine level of consciousness (Glasgow Coma Scale) <br />Determine level of stroke severity (NIHSS or Hunt and Hess Scale)<br />Order urgent non-contrast CT scan/angiogram if non-hemorrhage (door-to–CT scan performed: goal <25 min from arrival)<br />Read CT scan (door-to–CT read: goal <45 min from arrival)<br />Perform lateral cervical spine x-ray (if patient comatose/trauma history)<br />
  129. 129. Stroke - Management<br />ER Diagnostic Studies<br />CT scan – done w/in 25 mins, read w/in 45 mins<br />r/o hemorrhage<br />Often normal early in ischemic stroke<br />Lumbar puncture<br />EKG<br />Changes may be caused by or cause of stroke<br />MRA (Magnetic Resonance Angiography)<br />Cerebral Angiography<br />
  130. 130. Hypodense area:<br /><ul><li>Ischemic area with edema, swelling
  131. 131. Indicates >3 hours old
  132. 132. No fibrinolytics!</li></li></ul><li>(White areas indicate <br />hyperdensity = blood)<br />Large left frontal<br />intracerebral hemorrhage.<br />Intraventricularbleeding <br />is also present<br />No fibrinolytics!<br />
  133. 133. Acute subarachnoid hemorrhage<br />Diffuse areas of white (hyperdense) images<br />Blood visible in ventricles<br />and multiple areas on surface of brain<br />
  134. 134. Stroke - Management<br />Decision: Specific Therapies<br />General Care<br />ABC’s, O2<br />IV w/ BSS<br />Treat hypotension<br />Avoid over-hydration<br />Monitor input/output<br />Normalize BGL<br />Manage Elevated BP?<br />
  135. 135. Stroke - Management<br />Indications for Antihypertensive therapy<br />In general:<br />Consider: absolute level of BP?<br />If BP: >185/>110 mm Hg = fibrinolytic therapy contraindicated<br />Consider: other than BP, is patient candidate for fibrinolytics? <br />If patient is candidate for fibrinolytics: treat initial BP >185/>110 mm Hg<br />Consider: response to initial efforts to lower BP in ED? <br />If treatment brings BP down to <185/110 mm Hg: give fibrinolytics<br />Consider: ischemic vs hemorrhagic stroke?<br />Treat BP in the 180-230/110-140 mm Hg range the same<br />The obvious: no fibrinolytics for hemorrhagic stroke<br />
  136. 136. Stroke - Management<br />Decision: Specific Therapies (cont.)<br />Management of Seizures<br />Benzodiazepines<br />Long-acting anticonvulsants<br />Management of Increased ICP<br />Maintain PaCO2 30mm Hg<br />Mannitol/Diuretics<br />Barbiturates<br />Neurosurgical decompression<br />
  137. 137. Stroke - Management<br />Drugs: Thrombolytic Therapy<br />Fibrinolytic Therapy Checklist Ischemic Stroke<br />Candidates for Neurointerventional Therapy <br /> Age 18 years or older<br /> Acute signs and symptoms of CVA <6 hours onset.<br /> No contraindications.<br />
  138. 138. Stroke - Management<br />Contraindications for Interventional Therapy<br />Absolute<br /> Evidence of intracranial hemorrhage on non-contrast head CT<br /> Patient with early infarct signs on CT scan.<br />Relative<br /> Recent (w/in 2 mo’s) cranial or spinal surgery, trauma, or injury <br /> Known bleeding disorder and/or risk of bleeding including:<br /> - Current anticoagulant therapy, prothrombin time >15 sec.<br /> - Heparin within 48 hrs of admission, PTT elevated<br /> - Platelet count <100,000/mm<br /> Active internal bleeding w/in the previous 10 days<br /> Known or suspected pregnancy<br />  History of stroke w/in past 6 weeks<br />
  139. 139. Stroke - Management<br />Contraindications for Interventional Therapy (cont.)<br />Relative<br /> Patient comatose<br /> >85 years old<br /> Diabetic hemorrhagic retinopathy or other opthalmic hemorrhagic disorder<br /> Advanced liver or kidney disease<br /> Other pathology with a propensity for bleeding<br /> Infectiouse endocarditis<br /> Severe EKG disturbance, uncontrolled angina or acute MI<br />
  140. 140. Stroke - Management<br />Thrombolytic Agents<br />TPA<br />NINDS trial<br />Streptokinase<br />VEGGIE trial<br />Anticoagulant Therapy<br />Heparin<br />ASA/Warfarin/Ticlodipine<br />
  141. 141. Stroke - Management<br />Management of Hemorrhagic Stroke<br />Subarachnoid<br />Neurosurgical intervention<br />Nimodipine<br />Intracerebral<br />Management of ICP<br />Neurosurgical decompression<br />Cerebellar<br />Surgical evacuation <br />Often associated with good outcome<br />Lobar<br />Surgical evacuation<br />
  142. 142. 141<br />
  143. 143. THE END<br />
  144. 144. If they come to you with stroke, what investigation what you like to do?<br />
  145. 145.
  146. 146. QUIZ ON STROKE<br />MOHD HANAFI RAMLEE<br />
  147. 147. ANSWER GILIR2 TAU<br />
  148. 148. QUESTION 1<br />On the history of a patient with suspected or known stroke, what should you ask about?<br />
  149. 149. ANSWER 1<br /><ul><li>Ask about the presenting symptoms of stroke initially, for example</li></ul>Unilateral weakness or clumsiness<br />Difficulty understanding or expressing spoken language<br />Altered sensation unilaterally<br />Partial or complete loss of vision in one eye <br />
  150. 150. ANSWER 1<br /><ul><li>Questions to focus on the causes of stroke</li></ul>Atherosclerosis, e.g. enquire about vascular risk factors (smoking, DM, hyperlipids, PVDs, etc…)<br />History of heart disease, e.g. recent myocardial infarction, history of AF requiring anticoagulation, palpitations<br />History of hypertension (lacunar infarcts due to arteriosclerosis of small penetrating arteries of the brain)<br />Migraine<br />Manipulation of neck (precipitating cause for dissection of carotid artery or vertebral artery)<br />Any recent cessation of anticoagulation <br />Family history of stroke<br />History of connective tissue disease (e.g. SLE, vasculitis, etc…)<br />
  151. 151. ANSWER 1<br />History of connective tissue disease (e.g. SLE, vasculitis, etc…)<br /><ul><li>Medication history, esp. those that increase risk of stroke include oral contraceptives, some antihypertensives
  152. 152. Ask about alcohol consumption and recent falls (may have caused an intracranial haemorrhage)
  153. 153. Enquire about premorbid as well as the current level of independence and mobility
  154. 154. If patient is incapacitated, ask about social support available at home
  155. 155. Don’t forget to screen for depression</li></li></ul><li>QUESTION 2<br />On examination, what features should you be looking for?<br />
  156. 156. ANSWER 2<br />A complete examination of the neurological and cardiovascular systems is essential<br /><ul><li>Check the fundi for evidence of emboli, hypertensive changes, diabetic changes and ischaemic neuropathy
  157. 157. Test the visual fields for homonymous hemianopia
  158. 158. Listen for bruit over the carotids and orbits (commonly heard in the side opposite the carotid occlusion, due to increased contralateral flow)
  159. 159. Decide whether patient is in AF
  160. 160. Assess BP and test for postural drop
  161. 161. Listen for murmurs (e.g. AS, infective endocarditis, rheumatic heart disease or prosthetic valve)
  162. 162. Note presence of electronic pace maker and assess whether it’s working
  163. 163. Perform peripheral vascular examination
  164. 164. Look for complications, e.g. pressure sores, limb contractures and disuse atrophy of the paralysed limbs
  165. 165. See if patient has a percutaneous gastrostomy (PEG) feeding tube inserted and, if present, inspect for cellulitis or pus around the insertion site</li></li></ul><li>QUESTION 3<br />What clinical features are suggestive of a carotid arterial stroke?<br />
  166. 166. ANSWER 3<br /><ul><li>Transient aphasia
  167. 167. Ipsilateralamaurosisfugax
  168. 168. Contralateral hemiplegia/monoplegia
  169. 169. Contralateral hemi or monoparesis
  170. 170. Carotid bruits (a/w >50% stenosis)</li></li></ul><li>QUESTION 4<br />What clinical features are suggestive of vertebrobasilar insufficiency?<br />
  171. 171. ANSWER 4<br />All the Ds<br /><ul><li>Dizziness (vertigo and ataxia)
  172. 172. Diplopia +/- blindness
  173. 173. Dysphagia
  174. 174. Dysarthria
  175. 175. ‘Demi-anaesthesia’ – ipsilateral face, contralateral limb
  176. 176. Quadraparesis – indicates basilar artery involvement</li></ul> <br />
  177. 177. QUESTION 5<br />What clinical features are suggestive of a middle cerebral artery stroke?<br />
  178. 178. ANSWER 5<br /><ul><li>Contralateral hemiplegia, hemiparesis, homonymous hemianopia
  179. 179. UMN face, arm > leg, eyes deviated to side of lesion
  180. 180. Aphasia (if dominant lobe)</li></ul>Expressive dysphasia, arm + leg involvement – anterior MCA<br />Receptive dysphasia, visual fields defects – posterior MCA<br /><ul><li>If non-dominant – speech + comprehension intact</li></li></ul><li>QUESTION 6<br />What clinical features are suggestive of a posterior cerebral artery stroke?<br />
  181. 181. ANSWER 6<br /><ul><li>Homonymous hemianopia (complete)
  182. 182. Cortical blindness
  183. 183. Hemisensory loss
  184. 184. Ipsilateral III nerve palsy</li></li></ul><li>QUESTION 7<br />What clinical features are suggestive of an anterior cerebral artery stroke?<br />
  185. 185. ANSWER 7<br /><ul><li>Contralateral monoplegia (UMN)
  186. 186. Confusion, behaviour disturbance
  187. 187. Grasp reflex
  188. 188. Urinary incontinence</li></li></ul><li>QUESTION 8<br />What clinical features are suggestive of a lacunar syndrome?<br />
  189. 189. ANSWER 8<br /><ul><li>Clumsy hand/dysarthria syndrome – lesion in mid pons
  190. 190. Leg paresis + ataxia – pons or internal capsule
  191. 191. Pure sensory stroke – usually thalamic
  192. 192. Pure motor stroke (arm>leg) - pons or internal capsule</li></li></ul><li>QUESTION 9<br />What investigations would you perform in a stroke patient? – MAINLY TO DIAGNOSE ANY STROKE….<br />
  193. 193. ANSWER 9<br />CT or MRI of the head, looking for ischaemic infarcts, haemorrhage, or mass lesions<br />
  194. 194. QUESTION 10<br />What investigations would you perform in a stroke patient? MAINLY TO FIND THE CAUSE OF STROKE<br />
  195. 195. ANSWER 10<br /><ul><li>Doppler scan of the carotid arteries – if duplex scan suggest significant carotid stenosis, esp. in patients <75, ask for results of carotid angiography, carotid digital substraction angiography or MR angiography
  196. 196. If patient is in AF, ask for results of transoesophageal echo, looking for thrombus or spontaneous atheromatous plaques in ascending aorta and arch of aorta that may have contributed to stroke
  197. 197. ECG for AMI and AF
  198. 198. FBE, looking at Hb (to exclude polycythemia) and platelet count (rarely, essential thrombocytopenia can contribute to stroke)
  199. 199. ESR (to exclude an inflammatory arteritic/vasculitic process
  200. 200. CXR (for cardiomegaly/neoplasm)
  201. 201. Urea, creatinine and electrolytes </li></li></ul><li>QUESTION 11<br />What investigations would you perform in a stroke patient?<br />MAINLY IN YOUNGER PATIENT?<br />
  202. 202. QUESTION 11<br /><ul><li>Drug screen, looking for narcotic agents
  203. 203. Vasculitic screen (if there are features of vasculitis)
  204. 204. Blood cultures and cardiac imaging if endocarditis is suspected
  205. 205. Cardiac event monitor looking for paroxysmal AF and
  206. 206. Thrombophilic screen</li></li></ul><li>What 3 specific strategies in the management of acute stroke that have been proven to improve outcomes?<br />The 3 main strategies are<br /><ul><li>Administration of iv tissue plasminogen activator (tPA) within 3hrs of stroke onset
  207. 207. Giving aspirin (100mg) within first 48hrs of ischaemic stroke
  208. 208. Managing patient in a stroke unit</li></ul>Note that tPA and aspirin are never given before brain imaging to exclude intracranial haemorrhage<br />
  209. 209. What are the strategies for secondary prevention of stroke?<br />There are now at least 4 early strategies for secondary prevention in improving long term outcomes after TIAs or stoke <br /><ul><li>Antiplatelet therapy, e.g. aspirin, clopidogrel, aspirin with dipyridamole
  210. 210. Blood pressure lowering
  211. 211. Warfarin (indicated for patients with AF)
  212. 212. Carotid endarterectomy (indicated when stenosis >70%)
  213. 213. Lipids lowering is the fifth strategy to consider</li></li></ul><li>A patient just had a stroke, what criteria do you look for to select this patient for rehab. <br />Patients must be medically stable (i.e. no aspiration pneumonia, AMI, DVT, etc…)<br />They have a functional disability<br />They have the intellectual capability to learn<br />There are defined goals to be achieved<br />There are non or minimal co-morbidities, e.g. recurrent stroke, AMI, COAD, etc…<br />They are not clinically depressed (this can affect motivation to rehabilitate)<br />They didn’t suffer from a dense stroke or ones that causes hemi-neglect (e.g. a right hemisphere stroke)<br />
  214. 214. What are some of the common predictors of poor functional outcome after a stroke?<br /><ul><li>A dense stroke, a recurrent stroke, or a stroke resulting in hemi-neglect
  215. 215. Impairment of bladder and bowel function
  216. 216. Depression or cognitive deficits
  217. 217. Delayed acute medical care or delayed rehabilitation
  218. 218. Co-morbidities and poor social support</li>