Epidemiology, Pathophysiology Clinical signs and symptoms Management of stroke

1. STROKE
Submitted by:
Sumi Varghese
M.Sc. Respiratory Therapy – Adult Respiratory Care

2. INTRODUCTION
 Stroke can be defined as any vascular injury that reduces cerebral blood flow to a specific region of the
brain causing neurologic impairment
 It is the third leading cause of death and a leading cause of long-term disability
 The definition of stroke is clinical and laboratory studies including brain imaging are used to support the
diagnosis
 The clinical manifestations are highly variable because of the complex anatomy of the brain and its
vasclature

3. STROKE – CLASSIFICATION

4. ETIOLOGY
Brain ischemia
Thrombosis
Large vessel Small vessel
Embolism
Systemic
hypoperfusion
Blood
disroders

5. THE “TOAST” CLASSIFICATION

6. PATHOPHYSIOLOGY

7. STROKE SYNDROMES
 Large vessel stroke within the anterior circulation
 Large vessel stroke within the posterior circulation
 Small vessel disease of either vascular bed

8. CEREBRAL CIRCULATION

9. STROKE WITHIN ANTERIOR CIRCULATION
 Anterior cerebellar artery
- Contralateral paresis
- Cognitive or personality changes
 Middle cerebellar artery
- Contralateral paresis and sensory loss in the face and the arm
- Homonymous hemianopsia
- Aphasia
- Neglect
- Gaze preference towards the side of lesion

10. STROKE WITHIN POSTERIOR CIRCULATION
 Posterior cerebellar artery
- Diplopia
- Dizziness
- Dysphagia
- Dysarthria
 Basal ganglia lacunar
- Pure motor or sensory stroke
- Dysarthria

11. EVALUATION AND MANAGEMENT OF ACUTE ISCHEMIC STROKE
 Initial history
- Last known well time
- Symptom chronology
- Reviewing potential eligibility for IV rtPA
 Initial examination
- Formulate the neurologic syndrome
- LOC
- ABCs and vitals
- Glucose levels

12. EVALUATION AND MANAGEMENT OF ACUTE ISCHEMIC STROKE
 National Institute of Health Stroke Scale
- It is a standardized, reproducible, clinical assessment tool that provides a quantitative measure of stroke
related neurological deficits
- Frequently used to evaluate the severity of a stroke, to help determine appropriate treatment, to monitor
patients for neurologic worsening or improvement, and as a predictor of outcome.

13. EVALUATION AND MANAGEMENT OF ACUTE ISCHEMIC STROKE
 Initial brain imaging
- Non contrast CT
- Other imaging techniques
o CT angiography
o Perfusion CT
o Perfusion weighted imaging (PWI)
o MRA

14. EVALUATION AND MANAGEMENT OF ACUTE ISCHEMIC STROKE

15. EVALUATION AND MANAGEMENT OF ACUTE ISCHEMIC STROKE
 Specific management
- The concept of penumbra

16. INTERVENTIONS IN ACUTE STROKE
 Thrombolysis
- ECASS 3 trial
- PROACT 2 trial

17. INTERVENTIONS IN ACUTE STROKE

18. INTERVENTIONS IN ACUTE STROKE
 Endovascular mechanical thrombectomy

19. INTERVENTIONS IN ACUTE STROKE
 Antithrombotic treatment
- Aspirin
- Only drug that has been found to be effective in acute stroke

20. INTERVENTIONS IN ACUTE STROKE
 Fluids:
• Elderly people are volume depleted ; can worsen ischemia
• Isotonic saline without dextrose is the agent of choice for intravascular fluid repletion and maintenance fluid
therapy4
• Hypotonic fluids may exacerbate cerebral edema in acute stroke
• Fluid management must be individualized

21. INTERVENTIONS IN ACUTE STROKE
 Blood glucose:
• Multiple studies have shown adverse outcomes with hyperglycemia5,6
• Mechansims : acidosis from anaerobic metabolism, free radical generation, and increased blood brain barrier
permeability
• American Heart Association/American Stroke Association recommends glucose levels 140 -180 mg/dl

22. INTERVENTIONS IN ACUTE STROKE
 Blood pressure management
• Blood pressure management in acute ischemic stroke is different from hemorrhagic stroke
• Ischemic penumbra’s perfusion is dependent on systemic pressure
• Systemic BP can go up due to sympathetic stimulation
• Transient, as blood pressure falls by 20/10 mmHg within 10 days
• Should not be brought down acutely; especially in the first 24 hrs ( unless BP > 220/120 mm of hg)
• Indications : active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure
• Common agents used are labetalol , nicardipine

23. REFERENCES
 Smith SW. Cerebrovascular diseases In J.Loscalzo , editor. Harrison's; Principles of Internal Medicine.:
McGraw Hill; 2015. p 3210-3299
 Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome
after acute stroke? Results of a long-term follow up study. BMJ
 Zonneveld TP, Nederkoorn PJ, Westendorp WF, Brouwer MC, van de Beek D, Kruyt ND; PASS
Investigators. Hyperglycemia predicts poststroke infections in acute ischemic stroke. Neurology.
 Southerland MA, Clinical Evaluation of the Patient with Acute Stroke; continuum (Minneap Minn) 2107;
23(1):40-61
 Burns JD, Green DM, Metivier K, DeFusco C. Intensive care management of acute ischemic stroke.
Emerg Med Clin North Am. 2012 Aug