Ischemic CVA by house officer

1. “It is impossible to cure a severeattack of apoplexy,
and difficultto cure a mild one”
HippocraticAphorism~~~
Cerebrovascular
accident (Ischemic
Stroke):
by: Dr Aamir Ismail
Medicine 4 Ward.

2. Definition by WHO:
'The World Health Organization defined stroke as
‘rapidly developed clinical signs of focal (or global)
disturbance of cerebral function, lasting more than 24
hours or leading to death, with no apparent cause other
than of vascular
origin.‘
Definition by AHA/ASA:
In 2013, the American Heart Association / American
Stroke Association updated their endorsed definition of
stroke to one that includes silent infarctions (inclusive of
cerebral, spinal and retinal) and silent hemorrhages.

3. Clinical Types ofstroke:
TIA
Ischemic stroke
Hemorrhagicstroke
 Transient Ischemic attack:
A sudden, focal neurologic deficit that lasts for less than
24 hours, is presumed to be of vascular origin, and is
confined to an area of the brain or eye perfused by a
specific artery.
• Progressing stroke (or stroke in evolution):
A stroke in which the focal neurological deficit
worsens after the patient first presents.
• Completed stroke:
The focal deficit persists and is not progressing.

4. Pathophysiology of Stroke

5. Pathophysiology Of Stroke

7.  Ischemic stroke:
It occurs when a vessel supplying blood to the
brain is obstructed. It accounts for about 87 % of all
strokes.
• Common Causes of Ischemic stroke:
1. Thrombosis
Lacunar stroke (small vessel)
Large-vessel thrombosis
Dehydration
2. Embolic occlusion
(Artery-to-artery)
Carotid bifurcation
Aortic arch
Arterial dissection

8. 3 Cardioembolic:
Atrial fibrillation
Mural thrombus
Myocardial infarction
Dilated cardiomyopathy
4 Valvular lesions
Mitral stenosis
Mechanical valve
Bacterial endocarditis
4 Paradoxical embolus
Atrial septal defect
Patent foramen ovale
Atrial septal aneurysm
Spontaneous echo contrast
6 Stimulant drugs: cocaine, Amphetamine.

9. Anatomic location of Ischemic stroke:
1. Cerebral Hemisphere, Lateral Aspect
(Middle Cerebral A):
Hemiparesis
Hemisensory deficit
Motor aphasia (Broca’s)—hesitant speech
with word-finding difficulty and preserved
comprehension
Sensory aphasia (Wernicke’s)—anomia, poor
comprehension, jargon speech
Unilateral neglect, apraxias
Homonymous hemianopia or quadrantanopia
Gaze preference with eyes deviated toward side
of lesion

10. 2. Cerebral Hemisphere, Medial Aspect (Anterior
Cerebral A):
Paralysis of foot and leg with or without paresis of arm
Cortical sensory loss over leg
Grasp and sucking reflexes
Urinary incontinence
Gait apraxia
3. Cerebral Hemisphere, Posterior Aspect (Posterior
Cerebral A):
Homonymous hemianopia
Cortical blindness
Memory deficit
Dense sensory loss, spontaneous pain, dysesthesia,
choreoathetosis

11. 4. Brainstem, Midbrain (Posterior Cerebral A):
Third nerve palsy and contralateral hemiplegia
Paralysis/paresis of vertical eye movement
Convergence nystagmus, disorientation
5. Brainstem, Pontomedullary Junction (Basilar A):
Facial paralysis
Paresis of abduction of eye
Paresis of conjugate gaze
Hemifacial sensory deficit
Horner’s syndrome
Diminished pain and thermal sense over half body (with
or without face)
Ataxia

12. 6. Brainstem, Lateral Medulla (Vertebral A):
Vertigo, nystagmus
Horner’s syndrome (miosis, ptosis, decreased
sweating)
Ataxia, falling toward side of lesion
Impaired pain and thermal sense over half body
with or without face.
7. Lacunar Syndromes (Small-Vessel Strokes) Most
common are:
•Pure motor hemiparesis of face, arm, and leg (internal
capsule or pons)
• Pure sensory stroke (ventral thalamus)
• Ataxic hemiparesis (pons or internal capsule)
•Dysarthria—clumsy hand (pons or genu of internal
capsule)

13. Sign and symptoms of
stroke:
 Trouble speaking and understanding
what others are saying.
 Paralysis or numbness of the face, arm or
leg.
 Problems seeing in one or both eyes.
 Headache.
 Trouble walking.
 Seizures.
 Coma.

14. Seek immediate medical attention if you
notice any signs or symptoms of a
stroke, even if they seem to come and
go or they disappear completely. Think
"FAST" and do the following:
 Face: Ask the person to smile. Does one side
of the face droop?
 Arms: Ask the person to raise both arms.
Does one
arm drift downward? Or is one arm unable to
rise?
 Speech: Ask the person to repeat a simple
phrase. Is his or her speech slurred or
strange?
 Time: If you observe any of these, call for
help
immediately.

16. Investigations
1) Physical exam:
 Checking the GCS
 Checking plantars
 Checking pupils
 Auscultating
 Listening to the heart sounds
 Checking Blood pressure
 Neurological examination i.e Tone, power, and reflexes etc.
2) Blood tests:
 CBC
 PT, APTT, INR
 Blood glucose level
 Lipid profile
 ANCA antibodies etc

17. 3) Non-contrast (CT) scan:
 Best initial test in patient with stroke.
 Differentiate b/w hemorrhagic and ischemic stroke.
 More sensitive for detecting blood in the brain.
 Often negative for Ischemia within the first 48 hrs.
4) Diffusion weighted-MRI Gold standard:
 Most accurate for detecting ischemia.
 More sensitive than CT in detecting strokes of
brainstem and cerebellum.
 Less readily available and costly.
 MRI is mostly used when there is an uncertainty in
the diagnosis or to see the delayed presentation.
 Contraindications to MRI are cardiac pacemaker,
claustrophobic patient etc.

18. 5) Carotid ultrasound:
 This test shows buildup of fatty deposits (plaques)
and blood flow in the carotid arteries.
6) Cerebral angiogram:
 In this uncommonly used test in which a thin, flexible
tube (catheter) is inserted through a small incision,
usually in the groin, and guides it through the major
arteries and into the carotid or vertebral artery.
7) Echocardiogram:
 An echocardiogram can find a source of clots in the
heart that may have traveled from the heart to the
brain and caused a stroke.

19. When To Refer?
All Patients should be referred.
When To Admit?
All patients should be hospitalized preferably in a
stroke care unit.

21. Treatment Options
Treatment is broken into the “treat right now” and
“secondary prevention”
(TREAT RIGHT NOW)
1)Thrombolytic agents: (The Big-To-Do, The Clot Buster)
An IV injection of recombinant tissue plasminogen activator
(TPA) — also called alteplase (Activase) or tenecteplase
(TNKase) — is the gold standard treatment for ischemic
stroke.
An injection of TPA is usually given through a vein in the
arm within the first three hours.
Sometimes, TPA can be given up to 4.5 hours after stroke
symptoms started.

22. Contraindications to TPA:
Stroke/head trauma-3 months
MI past 3 months
GIT/GUT pas 21 days
Major surgery within 14 days
A/L.puncture within 7 days
Lab findings:
Platelets: < 1 lac/mm3
S. glucose <2.8mmol/L
INR>1.7 if on warfarin

23. 2. Mechanical Thrombectomy:
Mechanical thrombectomy is now considered is a standard of care in
acute stroke management within 24 hours.

24. Secondary Prevention
1) Anti-platelet therapy:
Aspirin:
Should be started immediately
Dosage: 300mg once for 14 days, then 75mg daily. Should
be withheld for at least 24hrs if tPA is given. Decreases
mortality and recurrence rate.
If patient is already on Aspirin:
Add dipyridamole (200mg twice daily) OR
Switch to clopidogrel (75mg) daily.
2) Carotid revascularization:
Carotid endarterectomy is the procedure. It
reduces the risk of stroke if:
Symptomatic ipsilateral stenosis of 70-99%-most
benefit.
Asymptomatic ipsilateral stenosis of 70-90% and age is
<75 years.
Endarterectomy has no role for milder stenosis<50%