Cerebro Vascular Accident (CVA)


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discussion and updates on stroke

rsm, md

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Cerebro Vascular Accident (CVA)

  1. 1. Dr. Ronald Sanchez – Magbitang <ul><li>EDUCATIONAL ATTAINMENT </li></ul><ul><li>NEHS </li></ul><ul><li>UST – B.S. Biology (Pre-Med) </li></ul><ul><li>SLU – Doctor of Medicine (“Emeritus”) </li></ul><ul><li>TRAININGS </li></ul><ul><li>Dr. PJGMRMC – Internal Medicine </li></ul><ul><li>Children's Medical Center – Hematology </li></ul><ul><li>RITM – 1 st In-Country Training in HIV/AIDS </li></ul><ul><li>CONVENTIONS/SYMPOSIA </li></ul><ul><li>Philippine College of Physicians </li></ul><ul><li>Philippine Association of Hospital Administrators </li></ul><ul><li>Philippine Hospital Association </li></ul><ul><li>PRESENT POSITION </li></ul><ul><li>Chief of Hospital </li></ul><ul><li>Gov. Eduardo L. Joson Memorial Hospital </li></ul><ul><li>Daan Sarile, Cabanatuan City </li></ul>Dr. Ronald S. Magbitang
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  3. 3. <ul><li>Stroke is the third leading cause of death in America and the No. 1 cause of adult disability. </li></ul><ul><li>80% of strokes are preventable </li></ul><ul><li>YOU CAN PREVENT STROKE ! </li></ul>C erebro- V ascular A ccident
  4. 4. <ul><li>Study reports decrease in stroke incidence over last half century </li></ul><ul><ul><li>Framingham Study is a long-running project looking at risk factors and time trends in heart disease and stroke. A new report, involving over 9,000 original participants and their offspring, sheds some interesting light on trends in stroke over the past 50 years. The study covers three separate time periods: 1950-1977, 1978-1989 and 1990-2004. Stroke risk was assessed every two years and occurrence of stroke or death was recorded. </li></ul></ul><ul><ul><li>Lifetime risk of stroke had gone down from 19.5 per cent to 14.5 per cent for men and from 18.0 per cent to 16.1 per cent for women. But stroke severity seemed to stay about the same </li></ul></ul><ul><ul><li>The findings show that better control of risk factors may be reducing the overall incidence of stroke. Stroke mortality may be coming down among men compared to women because women are having more severe strokes and at an older age </li></ul></ul>Journal of the American Medical Association 27th December 2006 Volume 296 pages 2939-2946
  5. 5. <ul><li>According to the World Health Organization, 15 million people worldwide will suffer from stroke this year. Five million will die and another five million will be permanently disabled. </li></ul><ul><li>In the Philippines , stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos , according to Dr. Navarro in his study published in The Philippine Journal of Neurology. However, access to specialist care may be a problem. </li></ul>Copyright 2008 Inquirer
  6. 6. <ul><li>Once an individual develops signs and symptoms of stroke or brain attack, he should not delay going to the hospital ER because time is of the essence to prevent more severe complications. </li></ul><ul><li>The symptoms of stroke are sudden weakness of the facial muscles, arm or leg, usually on one side of the body. </li></ul><ul><li>One may also feel sudden numbness on one side of the body, confusion, difficulty in speaking or understanding speech, blurring of vision in one or both eyes, difficulty in walking, dizziness, loss of balance or a severe headache. </li></ul>Copyright 2008 Inquirer
  7. 7. What is Stroke ? <ul><li>A stroke or &quot;brain attack&quot; occurs when a blood clot blocks an artery (a blood vessel that carries blood from the heart to the body) or a blood vessel breaks (a tube through which the blood moves through the body), interrupting blood flow to an area of the brain.  </li></ul><ul><li>When either of these things happen, brain cells begin to die and brain damage occurs. </li></ul>
  8. 9. <ul><li>When brain cells die during a stroke, abilities controlled by that area of the brain are lost. </li></ul><ul><li>These abilities include speech, movement and memory. </li></ul>
  9. 10. <ul><li>How a stroke patient is affected depends on where the stroke occurs in the brain and how much the brain is damaged. </li></ul><ul><li>For example, someone who has a small stroke may experience only minor problems such as weakness of an arm or leg. </li></ul><ul><li>People who have larger strokes may be paralyzed on one side or lose their ability to speak. </li></ul><ul><li>Some people recover completely from strokes, but more than 2/3 of survivors will have some type of disability. </li></ul>
  10. 12. Absence of sensation in the right arm and the right side of the face Optic radiation Loss of the right half of the visual field of both eyes Facial and arm areas of the sensory cortex Paralysis of the right arm and leg and the right side of the face Facial and limb areas of the motor cortex on the left side of the brain Loss of coordination of the right arm and leg Parietal lobe on the left side of the brain Difficulty speaking and, sometimes, writing Broca's area (speech) Difficulty speaking understandably and comprehending speech; confusion between left and right; difficulty reading, writing, naming objects, and calculating Wernicke's area (central language area) Signs and Symptoms Region of the Cerebrum Damaged by Stroke
  11. 13. <ul><li>Stroke as the primary neurologic problem in the US and in the world </li></ul><ul><ul><li>15% Hemorrhagic </li></ul></ul><ul><ul><li>85% Ischemic/Non-hemorrhagic </li></ul></ul>
  12. 14. <ul><li>Stroke categories according to cause: </li></ul><ul><ul><li>Thrombosis 20% </li></ul></ul><ul><ul><li>Small penetrating thrombosis 25% </li></ul></ul><ul><ul><li>Cardiogenic embolic stroke, cryptogenic (unknown cause) 25% </li></ul></ul><ul><ul><li>Others ( cocaine use, coagulopathies, migraine, spontaneous dissection of the carotid or vetebral arteries 5% </li></ul></ul>
  13. 15. <ul><li>Stroke classified according to the time course: </li></ul><ul><ul><li>Transient ischemic attack (TIA) </li></ul></ul><ul><ul><li>Reversible ischemic neurologic deficit (RIND) </li></ul></ul><ul><ul><li>Stroke in evolution </li></ul></ul><ul><ul><li>Completed stroke </li></ul></ul>
  14. 17. Risk Factors <ul><li>Hemorrhragic strokes: arteriovenous malformations (AVM’s), aneurysm ruptures, certain drugs, uncontrolled hypertension, hemangioblastomas, and trauma </li></ul><ul><li>Ischemic strokes: cardiovascular disease (cerebral embolism may originate in the heart) and dysrhythmia (atrial fibrillation); risk factors for CAD; vasospasm, migraines, and coagulopathies (high hematocrit) </li></ul>
  15. 18. Risk Factors <ul><li>General cerebral ischemia maybe caused by excessive or prolonged drop in BP </li></ul><ul><li>Drug abuse (cocaine), particularly in adolescents and young adults </li></ul><ul><li>Alcohol consumption may also be a risk factor </li></ul>
  16. 19. Clinical Manifestations <ul><li>General signs and symptoms: </li></ul><ul><ul><li>Numbness or weakness of the face, arm, or leg </li></ul></ul><ul><ul><li>Confusion or change in mental status </li></ul></ul><ul><ul><li>Trouble speaking or understanding speech </li></ul></ul><ul><ul><li>Visual disturbances </li></ul></ul><ul><ul><li>Loss of balance </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Difficulty in walking </li></ul></ul><ul><ul><li>Sudden severe headache </li></ul></ul>
  17. 20. <ul><li>MOTOR LOSS </li></ul><ul><ul><li>Hemiplegia, hemiparesis </li></ul></ul><ul><ul><li>Flaccid paralysis and loss of or decrease in deep tendon reflexes (initial) and increased muscle tone (spasticity after 48 hrs) </li></ul></ul>
  18. 21. <ul><li>COMMUNICATION LOSS </li></ul><ul><ul><li>Dysarthria (difficulty in speaking) </li></ul></ul><ul><ul><li>Dysphasia or aphasia (defective or loss of speech) </li></ul></ul><ul><ul><li>Apraxia (inability to perform a prviously learned action) </li></ul></ul>
  19. 22. <ul><li>PERCEPTUAL DISTURBANCES AND SENSORY LOSS </li></ul><ul><ul><li>Visual perceptual dysfunctions (homonymous hemianopia – loss half of the visual field) </li></ul></ul><ul><ul><li>Disturbances in visuospatial relationship – left hemispheric damage </li></ul></ul><ul><ul><li>Sensory losses: impair touch or severe loss of propioception, difficulty in interrupting visual, tactile, and auditory stimuli </li></ul></ul>
  20. 23. <ul><li>IMPAIRED COGNITIVE AND PSYCHOLOGICAL EFFECTS </li></ul><ul><ul><li>Impaired learning capacity, memory, or other higher cortical intellectual functions common in frontal lobe damage – limited attention span, difficulties in comprehension, forgetfullness, and lack of motivation </li></ul></ul><ul><ul><li>Depression, other psychological problems: emotional lability, hostility, frustration, resentment, and lack of cooperation </li></ul></ul>
  21. 24. <ul><li>BLADDER DYSFUNCTION </li></ul><ul><ul><li>Transient urinary incontinence </li></ul></ul><ul><ul><li>Persistent urinary incontinence or urinary retention </li></ul></ul><ul><ul><li>Continuing bladder and bowel incontinence </li></ul></ul>
  22. 25. Assessment and Diagnostic Methods <ul><li>Complete Physical and Neurologic Examination </li></ul><ul><li>Non-contrast CT or MRI scan </li></ul><ul><li>Transthoracic or transesophageal echocardiogram </li></ul>
  23. 26. Assessment and Diagnostic Methods <ul><li>Carotid ultrasonography </li></ul><ul><li>Cerebral angiography </li></ul><ul><li>Transcranial Doppler flow studies </li></ul><ul><li>Electrocardiography </li></ul>
  24. 29. Prevention <ul><li>Help patient alter risk factors for stroke </li></ul><ul><li>Prepare and support patient through carotid endarterectomy </li></ul><ul><li>Administer anticoagulant agents as ordered </li></ul>
  25. 33. Medical Management <ul><li>Recombinant tissue plasminogen activator </li></ul><ul><li>(t-pA), unless contraindicated; monitor for bleeding </li></ul><ul><li>Management of increased ICP: osmotic diuretics, maintain PaCO 2 at 30 – 35 mmHg, avoid hypoxia, elevate head of bed, pulmonary toilet with supllemental oxygen, airway patency </li></ul>
  26. 34. Medical Management <ul><li>Intubation with an ET to establish patent airway, if necessary </li></ul><ul><li>Maintain cardiac output at 4 – 8 L/min </li></ul><ul><li>Anticoagulation therapy </li></ul><ul><li>Carotid endarterectomy (for managing TIA, and small stroke) </li></ul>
  27. 40. Management of Complications <ul><li>Cerebral hypoxia: administer supplemental oxygen, maintain hemoglobin and hematocrit at acceptable levels </li></ul><ul><li>Decreased cerebral blood flow and extension of the area of injury: adequate hydration, avoid hypertension or hypotension </li></ul>
  28. 45. Dr. Ronald Sanchez - Magbitang Thank You !