Basic overview of stroke and its management.

1. Radiological
Medical & Surgical
Management of stroke
Dr G Malleswara Rao
M.S. Mch
Prof. & HOD Neurosurgery
Mamata Superspecialty Hospital

3.  Stroke is defined by the World Health Organizationas
'a clinical syndrome consisting of rapidly developing
clinical signs of focal (or global in case of coma)
disturbance of cerebral function lasting more than 24
hours or leading to death with no apparent cause
other than a vascular origin.‘
 If <24 Hrs = TIA

4. Burden of Stroke
 Morbidity ( 12 country WHO study)
 Incidence : 0.2 -2.5/1000/yr.
 Mortality: leading cause of death & disability through out
world 33% cases die within 3 weeks, 48% die within 1yr

6. Dr Thomas Willis

7. Stroke
Brain attack
 Term increasingly being used to describe stroke and communicate urgency of
recognizing stroke symptoms and treating their onset as a medical emergency

8. Risk Factors
Nonmodifiable
 Age
 Gender (women more likely to die)
 Race (African Americans)
 Heredity

9. Risk Factors
Modifiable
 Asymptomatic carotid stenosis
 Diabetes mellitus
 Heart disease, atrial fibrillation
 Heavy alcohol consumption
 Hypercoagulability
 Hyperlipidemia

10. Risk Factors
Modifiable
 Hypertension
 Obesity
 Oral contraceptive use
 Physical inactivity
 Sickle cell disease
 Smoking

11. Etiology and Pathophysiology
 Brain requires continuous supply of O2 and glucose for neurons to
function
 If blood flow is interrupted
 Neurologic metabolism is altered in 30 seconds
 Metabolism stops in 2 minutes
 Cell death occurs in 5 minutes

12. Etiology and Pathophysiology
 Atherosclerosis is a major cause of stroke
 Can lead to thrombus formation and contribute to emboli

13. Sites for Atherosclerosis
Fig. 56-2

14. Etiology and Pathophysiology
 Around the core area of ischemia is a border zone of reduced
blood flow where ischemia is potentially reversible
 If adequate blood flow can be restored early (<3 hours) and
the ischemic cascade can be interrupted
 less brain damage and less neurologic function lost

15. Transient Ischemic Attacks (TIA)
 Temporary focal loss of neurologic function caused by
ischemia (analogous to angina in CAD)
 Most resolve within 3 hours
 May be due to micro-emboli that temporarily block blood
flow
 A warning sign of progressive cerebrovascular disease

16. Types of Stroke
 Classification based on underlying pathophysiologic findings
 Ischemic
 Thrombotic
 Embolic
 Hemorrhagic

17. Major Types of Stroke
Fig. 56-3

18. Ischemic Stroke
 Result of inadequate blood flow to brain due to partial or
complete occlusion of an artery
 Constitute 85% of all strokes
 Most patients with ischemic stroke do not have a
decreased level of consciousness in the first 24 hours
 Symptoms often worsen during first 72 hours d/t cerebral
edema

19. Ischemic Stroke
 Thrombotic stroke
Thrombosis occurs in relation to injury to a blood vessel
wall → blood clot
Result of thrombosis or narrowing of the blood vessel
Most common cause of stroke

20. Ischemic Stroke
Thrombotic stroke
Two-thirds are associated with HTN and diabetes
Often preceded by a TIA

21. Ischemic Stroke
Embolic stroke
Embolus lodges in and occludes a cerebral artery
Results in infarction and edema of the area supplied by
the vessel
Second most common cause of stroke

22. Ischemic Stroke
 Embolic stroke
Majority of emboli originate in heart, with plaque breaking
off from the endocardium and entering circulation
Associated with sudden, rapid occurrence of severe clinical
symptoms

23. Ischemic Stroke
 Embolic stroke
Patient usually remains conscious although may have
a headache
Recurrence is common unless the underlying cause is
aggressively treated

24. Hemorrhagic Stroke
Account for approximately 15% of all strokes
Result from bleeding into the brain tissue
itself or into the subarachnoid space or
ventricles

25. Hemorrhagic Stroke
 Intracerebral hemorrhage
Bleeding within the brain caused by a
rupture of a vessel
Hypertension is the most important
cause
Commonly occurs during activity

26. Hemorrhagic Stroke
 Intracerebral hemorrhage
Often a sudden onset of
symptoms that progress over
minutes to hours because of
ongoing bleeding
 Manifestations include neurologic deficits, headache, Nausea &
Vomiting
 decreased levels of consciousness, and HTN

27. Hemorrhagic Stroke
 Subarachnoid hemorrhage
 Bleeding into cerebrospinal space between the arachnoid and pia
mater
 Commonly caused by rupture of a cerebral aneurysm

28. Manifestations of Right-Brain and Left-Brain
Stroke
Fig. 56-6

29. Assessment findings
Altered level of consciousness GCS
Weakness, numbness, or paralysis
Speech or visual disturbances
Severe headache
↑ or ↓ heart rate
Respiratory distress
Unequal pupils

30. Assessment findings
Hypertension
Facial drooping on affected side
Difficulty swallowing
Seizures
Bladder or bowel incontinence
Nausea and vomiting
Vertigo

32. Imageology

36. Overview - Imaging modalities
 Unenhanced CT
• Can be performed quickly.
• Can help identify early signs of stroke, and can
help rule out hemorrhage.
 CT angiography can depict intravascular thrombi.
 CT perfusion imaging can demonstrate salvageable tissue which is
indicated by a penumbra.

38. MRI
 Acute infarcts may be seen early on conventional MR images.
 Diffusion weighted MR imaging is more sensitive for detection of hyperacute
ischemia.
 Becomes abnormal within 30 minutes
 Distinguish b/w old and new stroke
 New stroke: bright on DWI
 Old stroke: Low SI on DWI
 It detects irreversible infarcted tissue
 Gradient-echo MR sequences can be helpful for detecting a hemorrhage.

40. Ischemic Stroke
 Massive Rt MCA territory Infarct
 Midline Shift

42. Ischemic Stroke
 Massive Left MCA territory Infarct
 52 year old Male , Smoker ,
Alcoholic, DM+ , HTN +.
 Initial GCS 12 - E3V3M6
 Left Hemiplegia
 Worsened Symptomatically

43. Acute Intra Cerebral
Hemmorhage
 18/f admitted with GCS 9/15
 BP 230/150
 Capsulo Ganglionic Region
 Causing Mass Effect
 Effaced Ventricles
 Diffuse Cerebral Edema

44.  Left Capsulo Ganglionic
Hemorrhage in a 69/f , H/o
Hypertension.

45.  45/ f , H/o Headache , Vomitings.
 Acute Severe SAH
 Note : - Inter Hemispheric Hematoma
 Sub Arachnoid Hemorrhage in B/l
Sylvian Fissure

48.  Interventions – Initial: ABC
 Ensure patient airway
 Remove dentures
 Perform pulse oximetry
 Maintain adequate oxygenation
 IV access
 Maintain BP according to guidelines
 (treat if SBP > 220 or MAP > 130)
Management
Acute Care

49.  Interventions – Initial
Immediate CT scan to determine cause (ischemic vs
hemorrhagic)
Measures to control ICP
 Head & neck in alignment (avoid flexion)
 Elevate HOB 30 ° if no symptoms of shock or injury
Avoid hip, knee flexion
Pain management, euvolemia, diuretics if needed
Management
Acute Care

50.  Interventions – Initial
 Institute seizure precautions
 Avoid hyperthermia ( ↑s cerebral metabolism)
 Anticipate thrombolytic/fibrinolytic therapy for
ischemic stroke
Management
Acute Care

51. Management
Acute Care
 Thrombolytic/fibrinolytic therapy with
recombinant tissue plasminogen
activator (tPA) is used to
 Reestablish blood flow and prevent cell
death in patients of ischemic stroke

52. Collaborative Care
Acute Care
 Thrombolytic/fibrinolytic therapy given within 4
hours of the onset of symptoms
 ↓ disability
 But at the expense of ↑ in deaths within the first 7 to 10
days and ↑ in intracranial hemorrhage

53. Collaborative Care
Acute Care
 For ischemic strokes (24 hr after tPA):
 Antiplatelets
 Anticoagulants (Heparin, coumadin)
 Must maintain therapeutic levels
 PTT, INR

54. Management
Acute Care
 Interventions – Ongoing
Monitor vital signs and neurologic status
Level of consciousness
Motor and sensory function
Pupil size and reactivity
O2 saturation
Cardiac rhythm

55. Management
 Approximately 10-15% of patients who experience a stroke
will have seizures, usually within 24 hours

57. Surgical interventions:
 To Combat Life threatening raised ICP. – Decompressive
Hemicraniectomy
 To Divert Intraventricular Contents (blood / CSF) – External Ventricular
Drainage
 Endoscopic / Craniotomy for evacuation of Intra cerebral Hematoma
 Clip, wrap or coil aneurysm to prevent rebleed
 Excision of AV - Malformations

58. Surgery in Ischemic Stroke
 Large cortical infarcts (strokes) are invariably associated with brain swelling
 The brain shrinks with age and in older people there is usually enough space in
the skull for the brain to swell In young patients there is no spare space in the
skull and therefore the brain swelling causes compression of vital centres in the
brain stem
 Young patients with very large strokes are therefore at high risk of rapid
deterioration and death within the first 48 hours. Surgery may be required.
 This may be life saving, but will not reverse the damage the of the initial stroke.

59. Indications for Surgery
 Age < 60 years***
 Severe MCA infarct (NIHSS>15)
 Fall of conscious level to drowsy (e.g. a score of 1 or
greater on NIHSS 1a or GCS E+M <=9)
 Signs on CT of an infarct of at least 50% of MCA
territory or infarct volume >145 cm3
 Referral within 24 h of stroke onset, surgery no later
than 48 h after stroke onset

60. Age < 60 years*** • Severe MCA infarct (NIHSS>15) • Fall
of conscious level to drowsy (e.g. a score of 1 or greater
on NIHSS 1a or GCS E+M <=9) • Signs on CT of an infarct
of at least 50% of MCA territory or infarct volume >145
cm3 • Referral within 24 h of stroke onset, surgery no later
than 48 h after stroke onset

61. Ischemic Stroke:
Surgery
 Massive Left MCA territory Infarct
 Dasu - 52 year old Male , Smoker ,
Alcoholic, DM+ , HTN +.
 Initial GCS 12 - E3V3M6
 Left Hemiplegia
 Worsened Symptomatically

62.  Underwent Decompressive Craniotomy
 Post OP CT shows, residual edema
 Brain Bulging out of the calvarial defect
 4 days on ventilator support , pneumonia ,
tracheostomy .
 Discharged day 25.

63. Surgery :
Hemorhagic stroke
 Massive hemorrhage leads to
 Mass effect
 Raised ICP
 Brain Herniation
 Death
DECOMPRESSIVE HEMICRANECTOMY
WITHOUT HEMATOMA EVACUATION

64. Hemorrhagic stroke
• Decompressive Craniectomy
• Hematoma evacuated via
neuroendoscope

65. Intraventricular Hemorrhage :
Obstructive hydrocephalus
 Intraventricular Extension
 External Ventricular Drainage
 Temporary divert Blood
and CSF.
 Followed by shunt .

68. Decompressive Hemicraniectomy

69. INFILTRATION WITH XYLOCAINE ADR

70. INCISION

71. HEMOSTASIS AND FLAP REFLECTION

72. BONE FLAP ELEVATION

73. DURAL LAYER SEPARATION

74. Duroplasty
 Autologous Fascia Lata harvested for
repair of dural defect
 Large dural defect depicts the magnitude
of cerebral edema
 Biosynthetic grafts also available.

75. WOUND CLOSURE

76. ABC of Stroke Prevention
A- antiplatelet and anti coagulants
B- blood pressure lowering medication
C- cholesterol lowering, cessation of smoking
D- diet
E- exercise

77. Thank You