A 60-year-old right handed man presents with inability to move the right upper and lower limbs of 1 hour duration. The document discusses the definitions, pathophysiology, risk factors, presentation, diagnosis and management of ischemic and hemorrhagic stroke. For acute ischemic stroke, management includes brain imaging to rule out hemorrhage followed by thrombolysis with rt-PA if indicated. For hemorrhagic stroke, management is largely supportive and focuses on controlling blood pressure to reduce hematoma expansion and improve outcomes. Long term prevention emphasizes control of modifiable risk factors like hypertension, diabetes and lifestyle changes.

2. Case Vignette
A 60-year-old right handed man presents with
inability to move the right upper and lower limbs
of 1 hour duration.
Take a history from him to establish a
diagnosis……………..

3. What are the likely findings on physical examination?

4. Brain CT Scan

5. How will you manage the patient?

6. Definitions : Previous Concepts
• Stroke: Sudden onset focal or global neurological deficit of no
apparent cause other than vascular lasting more than 24 hours or
resulting in death. ………. WHO 1975
NB: Included in this definition are: CI, ICH, SAH
• TIA: Neurologic deficit resolves within 24 hrs.
• RIND: >24 hrs but < 3/52
SIREN launching to lofty heights6

7. Current concepts: TIA vs Stroke
Rationale for Change in Definition
24 hrs time-based definition:
Confusing and misleading
Does not suggest medical emergency (Brain attack).
Does not corroborate the mantra “time’s neurone”
Does not take into cognizance the use of thrombolytics within 180 mins.
TIA not benign
Most (90%) TIA lasts 10 mins; resolve within 30 mins
However,
10- 20% dev stroke within 90 days
Up to 50% develop stroke within in 24 –48 hrs
SIREN launching to lofty heights7

8. Current Concepts
TIA:
• Transient episode of neurologic dysfunction caused by focal brain,
spinal cord, or retinal ischemia, without evidence of acute infarction.
• No objective evidence of acute infarction in the affected region of
brain or retina.
Stroke :
• Sudden global or focal neurological deficit resulting from spontaneous
hemorrhage or infarction of the central nervous system with objective
evidence of infarction irrespective of duration of clinical symptoms.
• Note: CT/MRI is necessary to increase diagnostic accuracy.
• CITS: Cerebral Infarction with Transient Symptoms
• CIND: Cerebral Infarction No Deficit, silent stroke
Sacco RL et al Stroke. 2013; 44:2064-2089.

9. SIREN launching to lofty heights 9

10. SIREN launching to lofty heights 10

11. SIREN launching to lofty heights 11

12. What are the pathologic types?
Ischaemic Stroke
Haemorrhagic Stroke
• Intracerebral/intraparencyhmal haemorrhag
• Subarachnoid haemorrhage

13. Ischaemic Stroke

14. Haemorrhagic Stroke
Intracerebral haemorrhage Subarachnoid haemorrhage
(C) Google images

15. Stroke Epidemiology

16. The Epidemic is here!
Over a period of two decades between 1990 and 2010, the
global burden of stroke significantly increased with most of
the burden in LMICs which were responsible for:
68.6% of global incident strokes,
52.2% of prevalent strokes,
70.9% of stroke mortality and
77.7% of disability adjusted life years (DALYs).
Stroke incidence decreased by 42% in high-income countries
in the last four and half decades, the incidence of the disease
increased by >100% in the LMICs during the same period.

17. Terrible Statistics!!!
• 1 in 6 people worldwide will have a stroke in their lifetime!
• EVERY 6 SECONDS stroke kills someone.
• EVERY OTHER SECOND stroke attacks a person – regardless of age or
gender.
• 17 MILLION PEOPLE experience a stroke each year; 6 million of them
do not survive.

18. Behind these numbers are
REAL LIVES!

20. Age-standardized annual prevalence (per 100,000) of ischemic stroke in 2013

21. Age-standardized annual prevalence (per 100,000) of hemorrhagic stroke in 2013

22. Stroke Epidemiology in AFRICA
• Prevalence 58-316/100,000
Prevalence increases with age
• Incidence 26-319/100,000
• Hospital data: 0.9 - 4.9% of hospital admissions
6.5 – 68% of CNS admissions
2.8 – 8.4% of hospital deaths
• Case fatality rate averages 35%, ranges from 14.9% to 77% (ICH)
• Ogun et al reported a 30-day case fatality as high as 40%.
22

23. Stroke Epidemiology in AFRICA contd.
• Stroke incidence decreasing in whites (up to 40%) but not in blacks
(Kleindorfer, Stroke,2010)
• 28-day case fatality 30% in blacks
• 3-year fatality of up to 84% in Africa.
• Model-based estimated age-adjusted stroke mortality rates ranged
between 168 and 179 per 100 000 population
• Hemorrhagic stroke up to 57% , now about 34% vs 9% in developed
countries (INTERSTROKE)
• Leading cause of medical admissions

24. • Stroke accounts for:
• Up to 4% of hospital admissions
• Up to 45% of neurological admissions
• 5-17% of medical deaths
• Prevalence rate = 1.14 per 1,000 (Danesi et al. Neuroepidemiology 2007;
28 (4): 216-23)
Epidemiology and Outcome of Stroke in Nigeria

25. Risk Factors for Stroke

26. •Non-modifiable Risk Factors
•Modifiable Risk Factors

27. Dominant Risk Factors for Stroke among
Africans in SIREN Study

28. Risk Factors in White and Chinese

29. Risk Factors for Stroke in SIREN and INTERSTROKE

30. Proportion of Risk Factors in SIREN-REGARDS
0
10
20
30
40
50
60
70
80
90
100
Hypertension Dyslipidemia Diabetes Cardiac Dx
Indigenous Africans African Americans European Americans

31. 0
10
20
30
40
50
60
Obesity Smoking Alcohol Exercise
Indigenous Africans African Americans European Americans

32. Pathophysiology of Ischaemic Stroke
 Vessel occlusion
 Failure of energy production
 Anaerobic glycolysis and lactic acidosis
 Failure of the ion pumps
 Neuronal depolarization and intracellular calcium overload.
 Release of neurotoxic substances such as:
 Excitatory neurotransmitters (chiefly glutamate),
 Inflammatory mediators (eg. prostaglandins, leukotrienes),
 Free radicals (eg. nitric oxide) and
 Activated lytic enzymes (lipases, proteases)
 Neuronal death.

33. The Ischaemic Cascade

34.  Ischaemic damage depends on
the degree and the duration of
ischaemia.
 Following complete occlusion of
a vessel, a central core of
densely ischaemic tissue is
irreversibly damaged (infarction)
within minutes.

35.  Ischaemic damage depends on
the degree and the duration of
ischaemia.
 Following complete occlusion of
a vessel, a central core of
densely ischaemic tissue is
irreversibly damaged (infarction)
within minutes.

36. Presentation

37. Five Major Stroke Syndromes
for Rapid Recognition in the ED
All Occur Suddenly in Stroke Patients
• Left (dominant) cerebral hemisphere
• Right (nondominant) cerebral hemisphere
• Brainstem
• Cerebellum
• Hemorrhage
Note: The dominant cerebral hemisphere is the side that controls
language function.

38. Left (Dominant)
Cerebral Hemisphere
• Aphasia
• L gaze preference
• R visual field deficit
• R hemiparesis
• R hemisensory loss

39. Right (Nondominant)
Cerebral Hemisphere
• Neglect (= L hemi-inattention)
• R gaze preference
• L visual field deficit
• L hemiparesis
• L hemisensory loss

40. Brainstem
• Hemi- or quadriparesis
• Sensory loss in hemibody or all 4 limbs
• Crossed signs (face 1 side, body other side)
• Diplopia, dysconjugate gaze, gaze palsy
• Vertigo, tinnitus
• Nausea, vomiting
• Hiccups, abnormal respirations
• Decreased consciousness

41. Cerebellum
• Truncal = gait ataxia
• Limb ataxia

42. Hemorrhage
Symptoms only suggestive of hemorrhage.
CT or LP needed for definitive diagnosis.
• Headache
• Neck stiffness
• Neck pain
• Light intolerance
• Nausea, vomiting
• Decreased consciousness

43. Differential Diagnosis
Space occupying lesion (tumor, infection/ abscess,
Epidural, Subdural Hematomas)
Seizures
Hypoglycemia
Migraine
Syncope
Labyrinthine disorders

44. Stroke Management

45. Strategies of Acute Stroke Management
Ragoschke-Schumm et al. Intern J Stroke 2014; 9:333-340

46. Diagnostic procedures in acute stroke patients
First level
Routine laboratory tests
RBS, FBS, FLP, FBC, E&U+Cr
Coagulation status
ECG
CT scan/ MRI
Doppler ultrasonography (Extra- and transcranial)
Chest X-ray
Others as may be necessary

47. General management of acute stroke patient
Support of vital functions and prevention of general
complication
Airway support and ventilation
Cardiac monitoring and care
Observation of water and electrolytes abnormalities
Maintenance of adequate nutritional status
Control of blood glucose
Blood pressure monitoring
Use of antiplatelets
Use of statins

48. Frequent position changes to prevent bed sores and muscle
contractures
Early physical therapy and rehabilitation
Urinary care
Control of fever and early diagnosis and treatment of infections
Use of sedation

49. Treatment of acute neurological complications
Cerebral edema and increased intracranial pressure
Seizures
Hydrocephalus
General management of acute stroke patient

50. Phases of Stroke Management
PHASE PERIOD
FROM
ONSET
ACTIVITIES PREFERRED
LOCATION
Acute
(Emergency)
care
1st
-7th
day a) Assessment
b) Specific Rx
c) Early supportive
care
Hospital (Stroke
Unit preferably)
Early sub-acute
(Supportive)
care
2nd
– 4th
week a) Prevention of
complications,
b) Early
rehabilitation
Hospital
Late sub-acute
(Maintenance)
care
2nd
-6th
month a) Rehabilitation
b) Psychological
support
c) Prevent recurrence
Hospital/Community
Long-term
(Chronic) care
7th
month
onwards
a) Rehabilitation
b) Psychological
support
c) Social support
d) prevent recurrence
Community
Modified From: Odusote K. Nig. Med. Pract. 1996; 32(5/6):54-62

51. Management of Ischaemic Stroke
• Thrombolysis with recombinant tissue plasminogen activator (rt-PA) is
the only approved and causal therapy for acute ischemic stroke.
• Benefit is extremely time sensitive.
• Before rt-PA can be administered, a complex diagnostic workup,
including neurological examination, imaging studies, and laboratory
tests, is necessary to exclude hemorrhage or other contraindications
to rt-PA therapy.
Ahmed N, Wahlgren N, Grond Met al.. Lancet Neurol 2010; 9:866–74.

52. Int. J. Stroke 2010; 5:381-382
No more than 2% to 7% of all acute stroke patients
currently receive thrombolytic therapy.

53. Management of Haemorrhagic Stroke
• No specific Evidence-based treatment
• Management largely supportive
• Active management of BP to reduce haematoma expansion and
worse outcome (INTERACT study)

54. Implications of INTERACT2 and Other Clinical Trials
by Craig S. Anderson, and Adnan I. Qureshi
Stroke
Volume 46(1):291-295
December 22, 2014
Copyright © American Heart Association, Inc. All rights reserved.

55. Treatment effects on absolute hematoma growth (mL) from baseline to 24 hours, by study.
Craig S. Anderson, and Adnan I. Qureshi Stroke.
2015;46:291-295
Copyright © American Heart Association, Inc. All rights reserved.

56. Systolic blood pressure levels at and over 24 hours postrandomization in INTERACT2 (Intensive
Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial).
Craig S. Anderson, and Adnan I. Qureshi Stroke.
2015;46:291-295
Copyright © American Heart Association, Inc. All rights reserved.

57. Prevention
•Take care of identified modifiable or
potentially modifiable risk factors

58. Questions
???