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2022 Stroke Lecture (Updated Guidelines).pdf

Cerebrovascular disease is an umbrella term for any abnormality in the brain resulting from a vascular process such as vessel occlusion, altered blood flow, or vessel rupture. Stroke specifically refers to cerebrovascular disease caused by ischemia or hemorrhage. The presentation of stroke depends on the location and size of the brain lesion. Imaging such as CT scans are used to identify infarcts, bleeds, and other findings. Timely management of ischemic and hemorrhagic strokes involves prevention or treatment of secondary complications.

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A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS References: • Harrison’s Principle of Internal Medicine (21st Ed) • JNC 7 & 8 Hypertension Guidelines • Neurology & Neurosurgery Illustrated (5th Ed) • Stroke Society of the Philippines - Handbook of Stroke (6th Ed) • Tintinalli’s Emergency Medicine (9th Ed) M.M. Haradji Elino September 10, 2022 1:00 PM Multipurpose Hall SSGH
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH IMAGING MANAGEMENT PREVENTION I – INTRODUCTION Definition, Risk, Prevalence Classification by Types, Onset, Severity & Lesion Location II – CLINICAL APPROACH High Suspicion: F.A.S.T. Presentation by Lesion Stroke Mimickers III –IMAGING: THE BASICS AND THE STROKE ON CT The Basics on Plain Cranial CT Scan Infarct, Bleed, SAH, Hemorrhagic Conversion & Malignant Infarct Bleed volume estimation – Kothari Method IV – MANAGEMENT Ischemic (TIA & Infarct) Hemorrhagic (Intracerebral Bleed & SAH) V – PREVENTION Primordial & Primary Prevention Secondary Prevention Tertiary Prevention
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. Cerebrovascular disease (CVD) is the umbrella term for any abnormality in the brain resulting from a vascular pathologic process such as occlusion (by embolus or thrombus), alteration in blood flow, or vessel rupture. Stroke on the other hand, is specifically the type caused by cerebrovascular disease that results from two major mechanisms: ischemia and hemorrhage. IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. Term Definition Transient Ischemic Attack (TIA) a type of ischemic stroke with a transient episode of neurological dysfunction caused by focal brain, spinal, or retinal ischemia, without evidence of acute infarction in which clinical symptoms last within 24 hours, typically less than an hour Infarction (CVD Infarct) a type of ischemic stroke caused by vessel occlusion that causes the reduction or cessation of blood flow which eventually leads to tissue death or infarction of the brain parenchyma Intracerebral Hemorrhage (CVD Bleed) a type of hemorrhagic stroke in which the alteration of the blood flow is the bleeding from a ruptured blood vessel dissipating to the brain parenchyma Subarachnoid Hemorrhage (SAH) a type of hemorrhagic stroke in which the alteration of the blood flow is the bleeding from a ruptured saccular aneurysm, vascular formation or fistula, extending to subarachnoid space. IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. Stroke the second leading cause of death following ischemic heart disease and the third leading cause of disease burden worldwide. In the Philippines, mortality for Cerebrovascular Disease is 82.8 per 100,000 person-years. IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 HOSPITAL NUMBER ISCHEMIC STROKE HEMORRHAGIC STROKE Philippine General Hospital 1656 54% 46% St. Luke’s Medical Center-Quezon City 413 76% 24% The Medical City 665 83% 17% University of Santo Tomas Hospital 514 67% 33% Makati Medical Center 543 70% 30% Jose Reyes Memorial Medical Center 1056 59% 41% HOSPITAL BASED REGISTRY 2011 IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ONSET SEVERITY** LOCATION BY CLINICAL HYPERACUTE (0-6 hours) MILD NIHSS 0-5 GCS 13-15 TYPES (Parenchymal) CVD INFARCT (Parenchymal) CVD BLEED (Subarachnoid Space) SUBARACHNOID HEMORRHAGE ACA TERRITORY PCA TERRITORY MCA TERRITORY VERTEBRAL ARTERY TERRITORY BASILAR ARTERY TERRITORY MODERATE NIHSS 6-21 GCS 10-12 SEVERE NIHSS >22 GCS 3-9 ACUTE (6-72 hours) SUBACUTE (3days-3weeks) CHRONIC (>3weeks) Has own severity classification; Grade 1-5 Ischemic Stroke Hemorrhagic Stroke * sample: “Acute Moderate CVD Infarct vs Bleed, Left MCA Territory” ** NIHSS as the gold standard for severity classification vs GCS ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. SIMPLIFIED CLINICAL STROKE CLASSIFICATION* (Parenchymal) TRANSIENT ISCHEMIC ATTACK No severity classification LEFT OR RIGHT LATERALITY
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NIHSS 0-5: Mild Stroke NIHSS 6-21: Moderate Stroke NIHSS >22 : Severe Stroke 1A: Level of consciousness Alert; keenly responsive Arouses to minor stimulation Repeated stimulation to arouse Movements to pain Postures or unresponsive 0 1 2 2 3 1B: Ask month and age Both questions right 1 question right 0 questions right Dysarthric/intubated/trauma 0 1 2 1 1C: 'Blink eyes' & 'squeeze hands' Performs both tasks Performs 1 task Performs 0 tasks 0 1 2 2: Horizontal extraocular movements Normal Gaze palsy can be overcome Gaze palsy corrects with oculocephalic reflex Gaze palsy cannot be overcome 0 1 1 2 3: Visual fields No visual loss Partial hemianopia Complete hemianopia Patient is bilaterally blind+3 Bilateral hemianopia+3 0 1 2 3 3 4: Facial palsy Normal symmetry Flat nasolabial fold or smile asymmetry Paralysis (lower face only) Complete paralysis (upper/lower face 0 1 2 3 NATIONAL INSTITUTE OF HEALTH STROKE SCALE (1 of 3) ֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634.
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NATIONAL INSTITUTE OF HEALTH STROKE SCALE (2 of 3) 5A: Left arm motor drift No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 5B: Right arm motor drift 7: Limb Ataxia No ataxia Ataxia in 1 Limb Ataxia in 2 Limbs Does not understand Paralyzed Amputation/joint fusion 0 1 2 0 0 0 0 1 2 2 3 4 0 No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 0 1 2 2 3 4 0 6A: Left leg motor drift No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 6B: Right leg motor drift 0 1 2 2 3 4 0 No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 0 1 2 2 3 4 0 NIHSS 0-5: Mild Stroke NIHSS 6-21: Moderate Stroke NIHSS >22 : Severe Stroke ֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634.
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NATIONAL INSTITUTE OF HEALTH STROKE SCALE (3 of 3) 8: Sensation Normal; no sensory loss Mild-moderate loss: less sharp/more dull Mild-moderate loss: can sense being touched Complete loss: cannot sense being touched at all No response, quadriplegic, coma/unresponsive 0 1 1 2 2 9: Language/aphasia Normal; no aphasia Mild-moderate aphasia: some obvious changes, without significant limitation Severe aphasia: fragmentary expression, inference needed, cannot identify materials Mute/global aphasia: no usable speech/auditory comprehension; coma/unresponsive 0 1 2 3 10: Dysarthria Normal Mild-moderate dysarthria: slurring but can be understood Severe dysarthria: unintelligible slurring Mute/anarthric Intubated/unable to test 0 1 2 2 0 11: Extinction/inattention No abnormality Visual/tactile/auditory/spatial/personal inattention Extinction to bilateral simultaneous stimulation Profound hemi-inattention (ex: does not recognize own hand) Extinction to >1 modality 0 1 2 2 1 ֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634. NIHSS 0-5: Mild Stroke NIHSS 6-21: Moderate Stroke NIHSS >22 : Severe Stroke
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A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH DIAGNOSTIC APPROACH MANAGEMENT PREVENTION STROKE ! F A S T FACIAL ASSYMETRY Have the person smile or show his or her teeth. If one side doesn't move as well as the other or it seems to droop, that could be sign of a stroke. High Suspicion of Stroke The F.A.S.T. Slogan (Cincinnati Pre-hospital Stroke Recognition Tool) ARM DRIFT Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. Look for weakness or drift. SLURRED SPEECH Have the person say simple, familiar saying. If the person slurs the words or gets some words wrong, or is unable to speak, that could be sign of stroke. TIME If any of the above 3 is present, then patients are advised to seek immediate hospital consultation. "Anosognosia" Patients with stroke often do not seek medical assistance on their own because they may lose the appreciation that something is wrong.
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Presentation by Lesion (Simplified) You can probably determine the territory of lesion while awaiting for cranial imaging A. Brain Parenchyma (Infarct or Bleed) Brain Parenchyma Major Feature* Anterior Cerebral Artery Territory Contralateral weakness of the Lower Extremity is very prominent than Upper Extremity; (Weakness LE > UE); "ALEUE" Middle Cerebral Artery Territory Contralateral weakness of the Upper Extremity is very prominent than Lower Extremity; (Weakness UE > LE); “MUELE" Posterior Cerebral Artery Territory Bilateral visual loss or Visual Hallucinations or Hemianopia ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 *See SSP Handbook of Stroke 6th Edition for Comprehensive Guide IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Presentation by Lesion (Simplified) You can probably determine the territory of lesion while awaiting for cranial imaging B. Brainstem and Cerebellar (Infarct or Bleed) Other Deep Parenchyma Major Feature* Vertebral Artery Territory (Cerebellar) Vertigo symptoms, Ipsilateral extremity and Ipsilateral Tongue Deviation Basilar Artery Territory (Brainstem) Quadriplegia, Somnolence or Coma C. Subarachnoid Space (Bleed) Nonparenchymal Major Feature Subarachnoid Hemorrhage “Thunderclap” headache; some cases complains very pungent odor where in fact there is none" ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 *See SSP Handbook of Stroke 6th Edition for Complete Guide IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Bell’s Palsy Todd’s paralysis Syncope Meningitis/ encephalitis Upper and Lower Facial Hemiparesis are always present with no motor weakness. (Stroke is usually with lower facial hemiparesis may have upper facial, associated with motor deficits) Transient paralysis following a seizure disappears quickly; can be secondary to a chronic or post infarct No persistent or associated motor deficits; Regain full consciousness and functionality in minutes after event Fever, immunocompromised state may be present, meningismus; detectable on lumbar puncture Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Complicated migraine Brain neoplasm or abscess Epidural/subdural hematoma Hypoglycemia History of similar episodes, preceding aura, headache Chronic Fever, Chronic Headache, Focal neurologic findings; signs of infection; detectable by imaging History of trauma, anticoagulant use, bleeding disorder; detectable by imaging Can be detected by bedside glucose measurement; history of diabetes mellitus Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Hyponatremia Hyperglycemic crisis Wernicke’s encephalopathy Drug toxicity History of diuretic use, neoplasm, excessive free water intake. Extremely high glucose levels, history of diabetes mellitus. History of alcoholism or malnutrition; triad of ataxia, ophthalmoplegia, and confusion. detected by particular toxidromes and elevated blood levels. Phenytoin and carbamazepine toxicity may present with ataxia, vertigo, nausea, and abnormal reflexes. Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Labyrinthitis / Vertigo Ménière’s Disease Myasthenia Gravis Multiple sclerosis Predominantly vestibular symptoms; patient should have no other focal findings; can be confused with cerebellar stroke. History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness. Motor functions that gradually weakens overtime when on repeated use, then may regain strength when allowed to rest; associated with Thymic Tumor Gradual onset. Patient may have a history of multiple episodes of neurologic findings in multifocal anatomic distributions. Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION IMAGING Computerized tomography (CT) Scan uses Xrays to generate cross-sectional, two-dimensional images of the body. Images are acquired by rapid roation of the Xray tube 360o around the patient. CT findings are usually described by density as: isodense/ hypodense/hyperdense. Each pixel (2D image units) is displayed on an arbitrary scale Hounsfield units (HU). The higher the Hounsfield units the denser the image (hyperdense), and the lower the hounsfield units the darker the image (hypodense). ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 Basics of Cranial CT
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION IMAGING CSF Brain Bone Air 0 Hounsfield units -500 -1000 +1000 +500 CSF Water Blood (Acute) Bone Air White Matter Gray Matter Basics of Cranial CT ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION IMAGING Computerized tomography (CT) Scan • Higher the density = whiter is the appearance • Lower the density = darker the appearance • Brain is the reference density; anything that has same density is isodense ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 High Density Low Density Mixed Densities • Blood • Calcification - Tumor • Arteriovenous Malformation • Aneurysm • Hamartoma May occur in normal scans: • Calcification of the pineal gland, choroid plexus, basal ganglia and falx) • Infarction • Tumour • Abscess • Edema • Encephalitis • Resolving Hematoma/Hemorrhage • Tumour • Abscess • Arteriovenous Malformation • Contusion • Hemorrhagic Infarct Basics of Cranial CT
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean Cut 2. Worms Cut 3. Angry Cut 4. Happy Cut 5. Star Cut 6. X-factor Cut Coffee Bean Worms Angry Happy Xfactor Star ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Coffee Bean Frontal lobe Parietal lobe Falx Cerebri Gray Matter White Matter (Centrum semiovale) Gray-White Differentiation Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Sulcus with CSF Sulci with CSF ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Worms Frontal lobe Parietal lobe Occipital lobe Caudate Nucleus Lateral Ventricles with CSF (Occipital Horn) Lateral Ventricles with CSF (Frontal Horn) Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Angry Lateral Ventricles with CSF (Frontal Horn) Caudate Nucleus Internal Capsule Globus pallidus Putamen Thalamus Basal Ganglia Lateral Ventricles with CSF (Occipital Horn) ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Happy Lateral Ventricles with CSF (Frontal Horn) Third Ventricles with CSF Sylvian Cistern with CSF Quadrigeminal Cistern With CSF ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Suprasellar Cistern with CSF Sylvian Cistern with CSF 4th Ventricle with CSF Star Frontal Lobe Temporal Lobe Cerebellum Pons Cerebellopontine cistern with CSF ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Xfactor Sphenoid Bone Temporal Bone Temporal Lobe Cerebellum 4th Ventricle Pons Occipital Bone
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Coffee Bean Worms Angry Happy Xfactor Star ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Blood Supply of the Brain ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 Coffee Bean Worms Angry Middle Cerebral Artery (MCA) & its branches Anterior Cerebral Artery (ACA) & its branches Posterior Cerebral Artery (PCA) & its branches Basilar Artery & its branches Vertebral Artery & its branches
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Blood Supply of the Brain ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 Middle Cerebral Artery (MCA) & its branches Anterior Cerebral Artery (ACA) & its branches Posterior Cerebral Artery (PCA) & its branches Basilar Artery & its branches Vertebral Artery & its branches Happy Star Xfactor
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS A B C Asymmetry & Artifact Brain Parenchyma CSF Spaces S Skull The ABCs for Cranial Scan: A Basic Approach
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach A Asymmetry & Artifact Look for: • Total Cranial Assymetry due to improper head positioning • Motion Artifact or Machine Artifact • These may affect Diagnosis ֍ Barrett, J. F., & Keat, N. (2004). Artifacts in CT: recognition and avoidance. Radiographics : a review publication of the Radiological Society of North America, Inc, 24(6), 1679– 1691. https://doi.org/10.1148/rg.246045065 Motion Artifact in Cranial CT Cranial Imaging Asymmetry due to head not properly positioned
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach B Brain Parenchyma Look for • Brain Midline Displacement: (Falx Cerebri) – Cerebral Edema / Mass Effect on affected side. • Brain Sulcus A. Effacement of Sulcus – due to Mass Effect B. Widened and Shallow Sulcus – Increased CSF (in case of hydrocephalus) or Atrophy • Brain Gray-White Junction A. Loss of Gray and White Matter Differentiation – Infarction (Cell Death/ Cytotoxic Edema) B. Accentuation of the Border – Vasogenic Edema (Tumor/Abscess) • Brain Densities: Look for abnormal Hyperdensities and Hypodensities No Midline Displacement, Normal Sulcal Effacement, Normal Gray-White Border, No any other hypo/hyperdensities
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach C CSF Spaces (Cisterns, Fissures & Ventricles ) Look For • Hyperdensities in these areas, may confer Subarachnoid Hemorrhage • Relative Attenuation on these areas may suspect Hydrocephalus Normal Hypodense Cisterns, Fissures & Ventricles
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach s Skull Forbes, J. A., Reig, A. S., Tomycz, L. D., & Tulipan, N. (2010). Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion. Journal of neurosurgery. Pediatrics, 6(1), 23–28. https://doi.org/10.3171/2010.3.PEDS09441 Depressed Skull Fracture Depressed Skull Fracture on “Bone Window” View (Right) Look for • Osteolytic Process • Skull Depression or Fracture
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NORMAL Acute CVD Infarct PCA Territory Middle Cerebral Artery (MCA) territory Anterior Cerebral Artery (ACA) territory Posterior Cerebral Artery (PCA) territory
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NORMAL CVD Bleed (Pontine)
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NORMAL Subarachnoid Hemorrhage
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Malignant Acute CVD Infarct Right Middle Cerebral Artery Territory Cardioembolic NIHSS 8 Subacute CVD Infarct Right Middle Cerebral Artery Territory Cardioembolic NIHSS 5 After 6 days; Cleared to start Antithrombotics The term “Malignant Infarct” is applicable only for Stroke in MCA with >50% infarction on its territory in the hemisphere ACA PCA MCA MCA
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Acute CVD Infarct Right Frontal Lobe; and Right Occipital Lobe; Cardioembolic; NIHSS 10 Hemorrhagic Stroke Conversion in Right Frontal Lobe; Subacute CVD Infarct Right Occipital Lobe; NIHSS 20 After 6 days
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Kothari Method: The Bleed Volume Estimation KOTHARI METHOD Volume Estimation applicable only for Brain Parenchymal Bleed (not Intraventricular nor Subarachnoid) Choose the CT Scan Image Slice with Largest lesion, then get the following where: A - Width of the largest lesion (or any diameter of the largest lesion) in centimeters B - Length of the largest lesion (or diameter perpendicular to line A) in centimeters C - Total Number of CT scan slices with lesion: •Set value of 1 for each slice with >75% of the largest lesion; •Set value of 0.5 for each slice with 25-75% of the lesion •No value for slices with <25% of the lesion. Follow the formula Below Conversion units: 10mm = 1cm A x B x C 2
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Slice 1 Slice 5 Slice 6 Slice 7 Slice 8 Slice 2 Slice 3 Slice 4
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Slice 6 A : 24mm or 2.4cm B : 36mm or 3.6cm
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Slice 1: No Value Slice 5: Value = 1 Slice 6 Largest Lesion Slice 7: Value = 1 Slice 8: No Value Slice 2: No Value Slice 3: Value = 0.5 Slice 4: Value = 0.5 100% <25% 25%-75% 25%-75% No lesion <25% >75% >75%
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS A x B x C 2 2.4cm x 3.6cm x 3cm 2 Acquired Values: A = 2.4cm; B = 3.6cm; C= 3cm = Estimated volume = = 12.96 cc
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Initial Approach •Ensure ABC (Airway-Breathing Circulation) •Assess and Address Clinical Signs/Symptoms of Increase Intracranial Pressure •Identify and Control Comorbidities/Precipitants of Stroke •History and Thorough PE Mainstay Therapy •Start Antithrombotics for Transient Ischemic Attack and Infarct Noncardioembolic •Stabilize and Delay Antithrombotic based on Severity for Infarct Cardioembolic to prevent Hemorrhagic Conversion •Control Hypertension and Decompression for Hemorrhagic Stroke Monitoring and Severity Assessment •Determine Severity (NIHSS /GCS) •Monitor Neuro Vital Signs: Temperature Pulse Rate Respiratory Rate BP + MAP Pupils Size O2 saturation Secondary Insults & Complication Prevention •Ensure Neuroprotection A. Glucose (140-180mg/dL) B. Oxygenation >94% C. MAP within 110-130 D. Body temp 35-37°C •Preventive Measures for Complications: DVT, Aspiration, Stress Ulcers, Bedsores •Seizure Precaution CORE ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 | NIHSS – National Institutes of Health Stroke Scale | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | BP – Blood Pressure | DVT – Deep Vein Thrombosis IMAGING
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS TIA Ischemic Stroke Mild CVD Infarct Severity/Feature Moderate CVD Infarct Severe CVD Infarct • Neurodysfunction resolves within 24 hrs • No presence of Infarct NIHSS score: 0 – 5 ~ GCS 13-15 NIHSS score: 6 – 21 ~ GCS 10-12 NIHSS score: >22 ~ GCS 3-9 Initial Approach & Monitoring Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan; or • Cranial MRI-diffusion weighted imaging (DWI) • Further diagnostics if considering stroke mimics (Infection, Toxicology, Metabolic Imbalance etc) • Recommend carotid ultrasound (UTZ) to document extracranial stenosis; • Recommend transcranial Doppler (TCD) studies or CT or MR angiography (CTA/MRA) • For 2Decho, if suspect Valvular & Septal Defects, Dilated Cardiomyopathy NONCARDIOEMBOLIC • Start Antiplatelets Aspirin (ASA) 160-325 mg/day as early as possible and continue for 14 days. May be considered: ASA 80 mg + clopidogrel 75 mg • Ensure Neuroprotection A. Glucose (140-180mg/dL) B. Oxygenation >94% C. MAP within 110-130 D. Body temp 35-37°C E. Head Bed Elevation 15-30° • For CVD Infarct A. Ictus within 4.5hours: Consider IV thrombolysis with recombinant tissue plasminogen activator (rt-PA) B. Ictus within 4th to 6th hour: Consider intra- arterial (IA) thrombolysis (specialized centers). • Control/treat risk factors (i.e Cardiac Disease, Hyperlipidemia, Diabetes, etc) • Complication Prevention: DVT, Aspiration, Pressure sores, Stress Gastric Ulcer, Constipation, etc • Soft diet for alert patients; or nasogastric tube feedings otherwise, and with poor Gag reflex • Decompressive Craniectomy for Malignant Infarct ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) if signs and symptoms present due to cerebral infarct edema • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS; • Treat BP if MAP >130 (MAP = SBP + 2 DBP ÷ 3) • Avoid Precipitous drop (Avoid >15% drop from baseline MAP) within 24 hours, for CVD Infarcts Mainstay Therapeutics (Refer to Specialist) *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Ischemic Stroke Severity/Feature Initial Approach & Monitoring Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan; or • Cranial MRI-diffusion weighted imaging (DWI) • Further diagnostics if considering stroke mimics (Infection, Toxicology, Metabolic Imbalance etc) • Recommend carotid ultrasound (UTZ) to document extracranial stenosis; • Recommend transcranial Doppler (TCD) studies or CT or MR angiography (CTA/MRA) • For 2Decho, if suspect Valvular & Septal Defects, Dilated Cardiomyopathy Mainstay Therapeutics (Refer to Specialist) IF CARDIOEMBOLIC ! • Anticoagulation is the mainstay with or without Antiplatelets. NOACs is preferable. TIA - Start Anticoagulation after 1 day from Acute event NIHSS <8: Suggest repeat scan after 3 days from Acute event; if no Hemorrhagic conversion start Anticoagulation. NIHSS 8-15 Suggest repeat scan after 6 days from Acute event; if no Hemorrhagic conversion start Anticoagulation. NIHSS ≥16 - Suggest repeat scan after 12 days from Acute event; if no Hemorrhagic conversion start Anticoagulation. • May have Aspirin (ASA) 160-325 mg/day for 14 days, if Anticoagulation is contraindicated. • Ensure Neuroprotection • Control/treat risk factors (i.e Cardiac Disease, Hyperlipidemia, Diabetes, etc) • Complication Prevention: DVT, Aspiration, Pressure sores, Stress Gastric Ulcer, Constipation, etc • Soft diet for alert patients; or nasogastric tube feedings otherwise, and with poor Gag reflex ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. TIA Mild CVD Infarct Moderate CVD Infarct Severe CVD Infarct • Neurodysfunction resolves within 24 hrs • No presence of Infarct NIHSS score: 0 – 5 ~ GCS 13-15 NIHSS score: 6 – 21 ~ GCS 10-12 NIHSS score: >22 ~ GCS 3-9 • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) if signs and symptoms present due to cerebral infarct edema • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS; • Treat BP if MAP >130 (MAP = SBP + 2 DBP ÷ 3) • Avoid Precipitous drop (Avoid >15% drop from baseline MAP) within 24 hours, for CVD Infarcts *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Hemorrhagic Stroke Mild CVD Bleed Severity/Feature Moderate CVD Bleed Severe CVD Bleed NIHSS score: 0 – 5 ~ GCS 13-15 NIHSS score: 6 – 21 ~ GCS 10-12 NIHSS score: >22 ~ GCS 3-9 Initial Approach & Monitoring • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) due to bleed • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan • Lumbar Tap if CT is equivocal for SAH • Consider contrast CT scan, Four-vessel cerebral angiogram, Magnetic Resonance Angiogram if the patient is: A. < 45 years old B. Normotensive C.lobar ICH D.Uncertain cause of ICH E. Suspicion Aneurysm, AVM, or vasculitis Mainstay Therapeutics (Refer to Specialist) *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. GENERAL MANAGEMENT • ICP monitoring – recommended in patients with GCS ≤ 8. See management of Increased ICP • Early neurology and/or neurosurgery consult for all ICH cases. See criteria for surgical intervention • Monitor and maintain target SBP ≈140 mm Hg during the first week. • Ensure Neuroprotection A. Glucose (140-180mg/dL) B. Oxygenation >94% C. MAP within 110-130 D. Body temp 35-37°C E. Head Bed Elevation 15-30° • Prophylactic AEDs are generally not recommended; may give for clinical seizures and proven subclinical or electrographic seizures. • Monitor/correct for metabolic parameters and coagulation/ bleeding abnormalities • Complication Prevention: DVT, Aspiration, Pressure sores, Stress Gastric Ulcer, Constipation, etc • Soft diet for alert patients; or nasogastric tube feedings otherwise, and with poor Gag reflex • For Coagulation/Platelet disorder, refer to Specialist SAH Has its own classification of severity (See different slide)
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Hemorrhagic Stroke Severity/Feature Initial Approach & Monitoring • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) due to bleed • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan • Lumbar Tap if CT is equivocal for SAH • Consider contrast CT scan, Four-vessel cerebral angiogram, Magnetic Resonance Angiogram if the patient is: A. < 45 years old B. Normotensive C.lobar ICH D.Uncertain cause of ICH E. Suspicion Aneurysm, AVM, or vasculitis Mainstay Therapeutics (Refer to Specialist) ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. ADDITIONAL (SAH SPECIFIC) • Calcium Channel Blockers: Nimodipine 60 mg every 4 hours by mouth or via NGT for 3 weeks is recommended. • Management of Increased ICP: may have Mannitol 0.5 to 1.5g per body weight kg every 3-6 hours; may continue up to 7 days. See management of Increased ICP • Fludrocortisone or hypertonic saline for hyponatremia caused by syndrome of inappropriate antidiuretic hormone (SIADH) or salt-wasting. • Surgical Intervention • Obliteration of the aneurysm from the circulation as early as possible is the main goal of SAH treatment. This can be achieved through surgical clipping or endovascular coiling. • Early, immediate surgery is recommended for Grade I-III to minimize the risk of a devastating rebleed. Asymptomatic/mild headache, slight nuchal rigidity, normal mental status; no motor deficit Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy; no motor deficit Drowsiness, confusion or mild focal signs with motor deficits Stupor, moderate to severe hemiparesis, possibly early decerebrate signs; with or without motor deficits Deep coma, decerebrate rigidity, moribund appearance; with or without motor deficits SAH Grade I GCS 15 SAH Grade II GCS 13-14 SAH Grade III GCS 13-14 SAH Grade IV GCS score 7-12 SAH Grade V GCS 3-6 *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Clinical Features Any of the following: • Deteriorating level of sensorium • Cushing’s triad: Hypertension Bradycardia, Irregular respiration • Anisocoria unequal pupillary sizes • Nausea and Vomiting • Optic Disc Edema / Papilledema on Funduscopy Specific Therapies for ICP • Mannitol 20% IV. Give 1.5 g/kg for a deteriorating patient then 0.5-1.5 g/kg every 3-6 hours. May administer up to 7 days as indicated. Hypertonic saline is an option. • Serum osmolality at 300-320 mosmol/kg [2(Na) + Glucose/18 + BUN/2.8] • Maximize Bed Head Elevation to 30 to 45O to assist venous drainage. • Careful Intubation if with respiratory failure: Pulse oximetry SaO2 <90%, or ABG)PaO2 <60mmHg, or ABG PaCO2 > 55 mmHg • Short term Hyperventilation (6 hours) by adjusting tidal volume to achieve target pCO2 30–35 mmHg. • ICP catheter insertion for monitoring & therapeutic lowering: A. GCS ≤ 8 B. Significant IVH & hydrocephalus. Surgical Intervention? ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. SURGICAL EVACUATION /DECOMPRESSION May benefit from intervention if with: • Lobar, supratentorial, basal ganglia or thalamic hemorrhage with volume >30 cc • Cerebellar hemorrhage >3 cm • Intraventricular hemorrhage with moderate to severe hydrocephalus • Presence of Aneurysm, AV malformation or cavernous angioma NON-SURGICAL CANDIDATES • Patients with small hemorrhages (<10 cc) with minimal neurological deficits • Patients with GCS <5 except those who have cerebellar hemorrhage and brainstem compression • Patients with pontine or midbrain hemorrhage | ICP – Intracranial Pressure | CPP – Cerebral Perfusion Pressure | ABG – Arterial Blood Gas | Na – Sodium | GCS – Glasgow Coma Scale | IVH – Intraventricular Hemorrhage | BUN – Blood Urea Nitrogen Increased Intracranial Pressure CVD Infarct • gradually peaks up to 72 hours; • cerebral edema (cytotoxic and vasogenic) mass effect may extend up to 10 days CVD Bleed & SAH • usually progressive deterioration within 12 hours to 72 hours; • variable onset depending on Bleed Volume and concomitant cerebral edema
A VIEWPOINT AND MANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH DIAGNOSTIC APPROACH MANAGEMENT PREVENTION ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 Lifestyle Modifications and Post Stroke Rehabilitation & Complication Prevention For Deep Vein Thrombosis, Aspiration Pneumonia, Stress Ulcers, Bed Sores, Post Cicatrial Seizure, Muscle Atrophy, Fractures, Memory Related Disorders, and Malnutrition Lifestyle Modifications (Controlled BP, Sugar, Cholesterol, Stress Reduction, Antithrombotic for Cardiac Problems) Lifestyle Modifications (Controlled BP, Sugar, Cholesterol, Stress Reduction, Antithrombotic for Cardiac Problems) Health Education SECONDARY PREVENTION PRIMARY PREVENTION PRIMORDIAL PREVENTION TERTIARY PREVENTION To prevent development of Risk Factors To prevent development of Stroke To prevent recurrence of new Stroke To prevent complications of Stroke LEVELS OF STROKE PREVENTION NO RISK FACTORS PRESENT RISK FACTORS PRESENT STROKE HAS HAPPENED STROKE HAS HAPPENED For Complete Guide of Lifestyle Modification, see JNC 7 & JNC 8 Guideline for Hypertension For Complete Guide for Post Stroke Rehabilitation &Complication Preventions, see SSP Handbook of Stroke 6th Edition
Special thanks to the Sulu Sanitarium General Hospital – Public Health Unit for the distribution of this material

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2022 Stroke Lecture (Updated Guidelines).pdf

  • 1.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS References: • Harrison’s Principle of Internal Medicine (21st Ed) • JNC 7 & 8 Hypertension Guidelines • Neurology & Neurosurgery Illustrated (5th Ed) • Stroke Society of the Philippines - Handbook of Stroke (6th Ed) • Tintinalli’s Emergency Medicine (9th Ed) M.M. Haradji Elino September 10, 2022 1:00 PM Multipurpose Hall SSGH
  • 2.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH IMAGING MANAGEMENT PREVENTION I – INTRODUCTION Definition, Risk, Prevalence Classification by Types, Onset, Severity & Lesion Location II – CLINICAL APPROACH High Suspicion: F.A.S.T. Presentation by Lesion Stroke Mimickers III –IMAGING: THE BASICS AND THE STROKE ON CT The Basics on Plain Cranial CT Scan Infarct, Bleed, SAH, Hemorrhagic Conversion & Malignant Infarct Bleed volume estimation – Kothari Method IV – MANAGEMENT Ischemic (TIA & Infarct) Hemorrhagic (Intracerebral Bleed & SAH) V – PREVENTION Primordial & Primary Prevention Secondary Prevention Tertiary Prevention
  • 3.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. Cerebrovascular disease (CVD) is the umbrella term for any abnormality in the brain resulting from a vascular pathologic process such as occlusion (by embolus or thrombus), alteration in blood flow, or vessel rupture. Stroke on the other hand, is specifically the type caused by cerebrovascular disease that results from two major mechanisms: ischemia and hemorrhage. IMAGING
  • 4.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. Term Definition Transient Ischemic Attack (TIA) a type of ischemic stroke with a transient episode of neurological dysfunction caused by focal brain, spinal, or retinal ischemia, without evidence of acute infarction in which clinical symptoms last within 24 hours, typically less than an hour Infarction (CVD Infarct) a type of ischemic stroke caused by vessel occlusion that causes the reduction or cessation of blood flow which eventually leads to tissue death or infarction of the brain parenchyma Intracerebral Hemorrhage (CVD Bleed) a type of hemorrhagic stroke in which the alteration of the blood flow is the bleeding from a ruptured blood vessel dissipating to the brain parenchyma Subarachnoid Hemorrhage (SAH) a type of hemorrhagic stroke in which the alteration of the blood flow is the bleeding from a ruptured saccular aneurysm, vascular formation or fistula, extending to subarachnoid space. IMAGING
  • 5.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. Stroke the second leading cause of death following ischemic heart disease and the third leading cause of disease burden worldwide. In the Philippines, mortality for Cerebrovascular Disease is 82.8 per 100,000 person-years. IMAGING
  • 6.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 HOSPITAL NUMBER ISCHEMIC STROKE HEMORRHAGIC STROKE Philippine General Hospital 1656 54% 46% St. Luke’s Medical Center-Quezon City 413 76% 24% The Medical City 665 83% 17% University of Santo Tomas Hospital 514 67% 33% Makati Medical Center 543 70% 30% Jose Reyes Memorial Medical Center 1056 59% 41% HOSPITAL BASED REGISTRY 2011 IMAGING
  • 7.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ONSET SEVERITY** LOCATION BY CLINICAL HYPERACUTE (0-6 hours) MILD NIHSS 0-5 GCS 13-15 TYPES (Parenchymal) CVD INFARCT (Parenchymal) CVD BLEED (Subarachnoid Space) SUBARACHNOID HEMORRHAGE ACA TERRITORY PCA TERRITORY MCA TERRITORY VERTEBRAL ARTERY TERRITORY BASILAR ARTERY TERRITORY MODERATE NIHSS 6-21 GCS 10-12 SEVERE NIHSS >22 GCS 3-9 ACUTE (6-72 hours) SUBACUTE (3days-3weeks) CHRONIC (>3weeks) Has own severity classification; Grade 1-5 Ischemic Stroke Hemorrhagic Stroke * sample: “Acute Moderate CVD Infarct vs Bleed, Left MCA Territory” ** NIHSS as the gold standard for severity classification vs GCS ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. SIMPLIFIED CLINICAL STROKE CLASSIFICATION* (Parenchymal) TRANSIENT ISCHEMIC ATTACK No severity classification LEFT OR RIGHT LATERALITY
  • 8.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NIHSS 0-5: Mild Stroke NIHSS 6-21: Moderate Stroke NIHSS >22 : Severe Stroke 1A: Level of consciousness Alert; keenly responsive Arouses to minor stimulation Repeated stimulation to arouse Movements to pain Postures or unresponsive 0 1 2 2 3 1B: Ask month and age Both questions right 1 question right 0 questions right Dysarthric/intubated/trauma 0 1 2 1 1C: 'Blink eyes' & 'squeeze hands' Performs both tasks Performs 1 task Performs 0 tasks 0 1 2 2: Horizontal extraocular movements Normal Gaze palsy can be overcome Gaze palsy corrects with oculocephalic reflex Gaze palsy cannot be overcome 0 1 1 2 3: Visual fields No visual loss Partial hemianopia Complete hemianopia Patient is bilaterally blind+3 Bilateral hemianopia+3 0 1 2 3 3 4: Facial palsy Normal symmetry Flat nasolabial fold or smile asymmetry Paralysis (lower face only) Complete paralysis (upper/lower face 0 1 2 3 NATIONAL INSTITUTE OF HEALTH STROKE SCALE (1 of 3) ֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634.
  • 9.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NATIONAL INSTITUTE OF HEALTH STROKE SCALE (2 of 3) 5A: Left arm motor drift No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 5B: Right arm motor drift 7: Limb Ataxia No ataxia Ataxia in 1 Limb Ataxia in 2 Limbs Does not understand Paralyzed Amputation/joint fusion 0 1 2 0 0 0 0 1 2 2 3 4 0 No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 0 1 2 2 3 4 0 6A: Left leg motor drift No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 6B: Right leg motor drift 0 1 2 2 3 4 0 No drift for 10 seconds Drift, but doesn't hit bed Drift, hits bed Some effort against gravity No effort against gravity No movement Amputation/joint fusion 0 1 2 2 3 4 0 NIHSS 0-5: Mild Stroke NIHSS 6-21: Moderate Stroke NIHSS >22 : Severe Stroke ֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634.
  • 10.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NATIONAL INSTITUTE OF HEALTH STROKE SCALE (3 of 3) 8: Sensation Normal; no sensory loss Mild-moderate loss: less sharp/more dull Mild-moderate loss: can sense being touched Complete loss: cannot sense being touched at all No response, quadriplegic, coma/unresponsive 0 1 1 2 2 9: Language/aphasia Normal; no aphasia Mild-moderate aphasia: some obvious changes, without significant limitation Severe aphasia: fragmentary expression, inference needed, cannot identify materials Mute/global aphasia: no usable speech/auditory comprehension; coma/unresponsive 0 1 2 3 10: Dysarthria Normal Mild-moderate dysarthria: slurring but can be understood Severe dysarthria: unintelligible slurring Mute/anarthric Intubated/unable to test 0 1 2 2 0 11: Extinction/inattention No abnormality Visual/tactile/auditory/spatial/personal inattention Extinction to bilateral simultaneous stimulation Profound hemi-inattention (ex: does not recognize own hand) Extinction to >1 modality 0 1 2 2 1 ֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634. NIHSS 0-5: Mild Stroke NIHSS 6-21: Moderate Stroke NIHSS >22 : Severe Stroke
  • 11.
    FREE DOWNLOADABLE MOBILE APP iOS andAndroid For NIHSS For NIHSS
  • 12.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH DIAGNOSTIC APPROACH MANAGEMENT PREVENTION STROKE ! F A S T FACIAL ASSYMETRY Have the person smile or show his or her teeth. If one side doesn't move as well as the other or it seems to droop, that could be sign of a stroke. High Suspicion of Stroke The F.A.S.T. Slogan (Cincinnati Pre-hospital Stroke Recognition Tool) ARM DRIFT Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. Look for weakness or drift. SLURRED SPEECH Have the person say simple, familiar saying. If the person slurs the words or gets some words wrong, or is unable to speak, that could be sign of stroke. TIME If any of the above 3 is present, then patients are advised to seek immediate hospital consultation. "Anosognosia" Patients with stroke often do not seek medical assistance on their own because they may lose the appreciation that something is wrong.
  • 13.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Presentation by Lesion (Simplified) You can probably determine the territory of lesion while awaiting for cranial imaging A. Brain Parenchyma (Infarct or Bleed) Brain Parenchyma Major Feature* Anterior Cerebral Artery Territory Contralateral weakness of the Lower Extremity is very prominent than Upper Extremity; (Weakness LE > UE); "ALEUE" Middle Cerebral Artery Territory Contralateral weakness of the Upper Extremity is very prominent than Lower Extremity; (Weakness UE > LE); “MUELE" Posterior Cerebral Artery Territory Bilateral visual loss or Visual Hallucinations or Hemianopia ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 *See SSP Handbook of Stroke 6th Edition for Comprehensive Guide IMAGING
  • 14.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Presentation by Lesion (Simplified) You can probably determine the territory of lesion while awaiting for cranial imaging B. Brainstem and Cerebellar (Infarct or Bleed) Other Deep Parenchyma Major Feature* Vertebral Artery Territory (Cerebellar) Vertigo symptoms, Ipsilateral extremity and Ipsilateral Tongue Deviation Basilar Artery Territory (Brainstem) Quadriplegia, Somnolence or Coma C. Subarachnoid Space (Bleed) Nonparenchymal Major Feature Subarachnoid Hemorrhage “Thunderclap” headache; some cases complains very pungent odor where in fact there is none" ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 *See SSP Handbook of Stroke 6th Edition for Complete Guide IMAGING
  • 15.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Bell’s Palsy Todd’s paralysis Syncope Meningitis/ encephalitis Upper and Lower Facial Hemiparesis are always present with no motor weakness. (Stroke is usually with lower facial hemiparesis may have upper facial, associated with motor deficits) Transient paralysis following a seizure disappears quickly; can be secondary to a chronic or post infarct No persistent or associated motor deficits; Regain full consciousness and functionality in minutes after event Fever, immunocompromised state may be present, meningismus; detectable on lumbar puncture Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
  • 16.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Complicated migraine Brain neoplasm or abscess Epidural/subdural hematoma Hypoglycemia History of similar episodes, preceding aura, headache Chronic Fever, Chronic Headache, Focal neurologic findings; signs of infection; detectable by imaging History of trauma, anticoagulant use, bleeding disorder; detectable by imaging Can be detected by bedside glucose measurement; history of diabetes mellitus Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
  • 17.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Hyponatremia Hyperglycemic crisis Wernicke’s encephalopathy Drug toxicity History of diuretic use, neoplasm, excessive free water intake. Extremely high glucose levels, history of diabetes mellitus. History of alcoholism or malnutrition; triad of ataxia, ophthalmoplegia, and confusion. detected by particular toxidromes and elevated blood levels. Phenytoin and carbamazepine toxicity may present with ataxia, vertigo, nausea, and abnormal reflexes. Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
  • 18.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Labyrinthitis / Vertigo Ménière’s Disease Myasthenia Gravis Multiple sclerosis Predominantly vestibular symptoms; patient should have no other focal findings; can be confused with cerebellar stroke. History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness. Motor functions that gradually weakens overtime when on repeated use, then may regain strength when allowed to rest; associated with Thymic Tumor Gradual onset. Patient may have a history of multiple episodes of neurologic findings in multifocal anatomic distributions. Stroke Mimickers ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 IMAGING
  • 19.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION IMAGING Computerized tomography (CT) Scan uses Xrays to generate cross-sectional, two-dimensional images of the body. Images are acquired by rapid roation of the Xray tube 360o around the patient. CT findings are usually described by density as: isodense/ hypodense/hyperdense. Each pixel (2D image units) is displayed on an arbitrary scale Hounsfield units (HU). The higher the Hounsfield units the denser the image (hyperdense), and the lower the hounsfield units the darker the image (hypodense). ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 Basics of Cranial CT
  • 20.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION IMAGING CSF Brain Bone Air 0 Hounsfield units -500 -1000 +1000 +500 CSF Water Blood (Acute) Bone Air White Matter Gray Matter Basics of Cranial CT ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 21.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION IMAGING Computerized tomography (CT) Scan • Higher the density = whiter is the appearance • Lower the density = darker the appearance • Brain is the reference density; anything that has same density is isodense ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 High Density Low Density Mixed Densities • Blood • Calcification - Tumor • Arteriovenous Malformation • Aneurysm • Hamartoma May occur in normal scans: • Calcification of the pineal gland, choroid plexus, basal ganglia and falx) • Infarction • Tumour • Abscess • Edema • Encephalitis • Resolving Hematoma/Hemorrhage • Tumour • Abscess • Arteriovenous Malformation • Contusion • Hemorrhagic Infarct Basics of Cranial CT
  • 22.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean Cut 2. Worms Cut 3. Angry Cut 4. Happy Cut 5. Star Cut 6. X-factor Cut Coffee Bean Worms Angry Happy Xfactor Star ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 23.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Coffee Bean Frontal lobe Parietal lobe Falx Cerebri Gray Matter White Matter (Centrum semiovale) Gray-White Differentiation Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Sulcus with CSF Sulci with CSF ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 24.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Worms Frontal lobe Parietal lobe Occipital lobe Caudate Nucleus Lateral Ventricles with CSF (Occipital Horn) Lateral Ventricles with CSF (Frontal Horn) Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 25.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Angry Lateral Ventricles with CSF (Frontal Horn) Caudate Nucleus Internal Capsule Globus pallidus Putamen Thalamus Basal Ganglia Lateral Ventricles with CSF (Occipital Horn) ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 26.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Happy Lateral Ventricles with CSF (Frontal Horn) Third Ventricles with CSF Sylvian Cistern with CSF Quadrigeminal Cistern With CSF ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 27.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Suprasellar Cistern with CSF Sylvian Cistern with CSF 4th Ventricle with CSF Star Frontal Lobe Temporal Lobe Cerebellum Pons Cerebellopontine cistern with CSF ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 28.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Xfactor Sphenoid Bone Temporal Bone Temporal Lobe Cerebellum 4th Ventricle Pons Occipital Bone
  • 29.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Basics of Cranial CT Remember these guide terms 1. Coffee Bean 2. Worms 3. Angry 4. Happy 5. Star 6. X-factor Coffee Bean Worms Angry Happy Xfactor Star ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
  • 30.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Blood Supply of the Brain ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 Coffee Bean Worms Angry Middle Cerebral Artery (MCA) & its branches Anterior Cerebral Artery (ACA) & its branches Posterior Cerebral Artery (PCA) & its branches Basilar Artery & its branches Vertebral Artery & its branches
  • 31.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Blood Supply of the Brain ֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4 Middle Cerebral Artery (MCA) & its branches Anterior Cerebral Artery (ACA) & its branches Posterior Cerebral Artery (PCA) & its branches Basilar Artery & its branches Vertebral Artery & its branches Happy Star Xfactor
  • 32.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS A B C Asymmetry & Artifact Brain Parenchyma CSF Spaces S Skull The ABCs for Cranial Scan: A Basic Approach
  • 33.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach A Asymmetry & Artifact Look for: • Total Cranial Assymetry due to improper head positioning • Motion Artifact or Machine Artifact • These may affect Diagnosis ֍ Barrett, J. F., & Keat, N. (2004). Artifacts in CT: recognition and avoidance. Radiographics : a review publication of the Radiological Society of North America, Inc, 24(6), 1679– 1691. https://doi.org/10.1148/rg.246045065 Motion Artifact in Cranial CT Cranial Imaging Asymmetry due to head not properly positioned
  • 34.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach B Brain Parenchyma Look for • Brain Midline Displacement: (Falx Cerebri) – Cerebral Edema / Mass Effect on affected side. • Brain Sulcus A. Effacement of Sulcus – due to Mass Effect B. Widened and Shallow Sulcus – Increased CSF (in case of hydrocephalus) or Atrophy • Brain Gray-White Junction A. Loss of Gray and White Matter Differentiation – Infarction (Cell Death/ Cytotoxic Edema) B. Accentuation of the Border – Vasogenic Edema (Tumor/Abscess) • Brain Densities: Look for abnormal Hyperdensities and Hypodensities No Midline Displacement, Normal Sulcal Effacement, Normal Gray-White Border, No any other hypo/hyperdensities
  • 35.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach C CSF Spaces (Cisterns, Fissures & Ventricles ) Look For • Hyperdensities in these areas, may confer Subarachnoid Hemorrhage • Relative Attenuation on these areas may suspect Hydrocephalus Normal Hypodense Cisterns, Fissures & Ventricles
  • 36.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ABCs for Cranial Scan: The Basic Approach s Skull Forbes, J. A., Reig, A. S., Tomycz, L. D., & Tulipan, N. (2010). Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion. Journal of neurosurgery. Pediatrics, 6(1), 23–28. https://doi.org/10.3171/2010.3.PEDS09441 Depressed Skull Fracture Depressed Skull Fracture on “Bone Window” View (Right) Look for • Osteolytic Process • Skull Depression or Fracture
  • 37.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NORMAL Acute CVD Infarct PCA Territory Middle Cerebral Artery (MCA) territory Anterior Cerebral Artery (ACA) territory Posterior Cerebral Artery (PCA) territory
  • 38.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NORMAL CVD Bleed (Pontine)
  • 39.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS NORMAL Subarachnoid Hemorrhage
  • 40.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Malignant Acute CVD Infarct Right Middle Cerebral Artery Territory Cardioembolic NIHSS 8 Subacute CVD Infarct Right Middle Cerebral Artery Territory Cardioembolic NIHSS 5 After 6 days; Cleared to start Antithrombotics The term “Malignant Infarct” is applicable only for Stroke in MCA with >50% infarction on its territory in the hemisphere ACA PCA MCA MCA
  • 41.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Acute CVD Infarct Right Frontal Lobe; and Right Occipital Lobe; Cardioembolic; NIHSS 10 Hemorrhagic Stroke Conversion in Right Frontal Lobe; Subacute CVD Infarct Right Occipital Lobe; NIHSS 20 After 6 days
  • 42.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Kothari Method: The Bleed Volume Estimation KOTHARI METHOD Volume Estimation applicable only for Brain Parenchymal Bleed (not Intraventricular nor Subarachnoid) Choose the CT Scan Image Slice with Largest lesion, then get the following where: A - Width of the largest lesion (or any diameter of the largest lesion) in centimeters B - Length of the largest lesion (or diameter perpendicular to line A) in centimeters C - Total Number of CT scan slices with lesion: •Set value of 1 for each slice with >75% of the largest lesion; •Set value of 0.5 for each slice with 25-75% of the lesion •No value for slices with <25% of the lesion. Follow the formula Below Conversion units: 10mm = 1cm A x B x C 2
  • 43.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Slice 1 Slice 5 Slice 6 Slice 7 Slice 8 Slice 2 Slice 3 Slice 4
  • 44.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Slice 6 A : 24mm or 2.4cm B : 36mm or 3.6cm
  • 45.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Slice 1: No Value Slice 5: Value = 1 Slice 6 Largest Lesion Slice 7: Value = 1 Slice 8: No Value Slice 2: No Value Slice 3: Value = 0.5 Slice 4: Value = 0.5 100% <25% 25%-75% 25%-75% No lesion <25% >75% >75%
  • 46.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS A x B x C 2 2.4cm x 3.6cm x 3cm 2 Acquired Values: A = 2.4cm; B = 3.6cm; C= 3cm = Estimated volume = = 12.96 cc
  • 47.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH MANAGEMENT PREVENTION Initial Approach •Ensure ABC (Airway-Breathing Circulation) •Assess and Address Clinical Signs/Symptoms of Increase Intracranial Pressure •Identify and Control Comorbidities/Precipitants of Stroke •History and Thorough PE Mainstay Therapy •Start Antithrombotics for Transient Ischemic Attack and Infarct Noncardioembolic •Stabilize and Delay Antithrombotic based on Severity for Infarct Cardioembolic to prevent Hemorrhagic Conversion •Control Hypertension and Decompression for Hemorrhagic Stroke Monitoring and Severity Assessment •Determine Severity (NIHSS /GCS) •Monitor Neuro Vital Signs: Temperature Pulse Rate Respiratory Rate BP + MAP Pupils Size O2 saturation Secondary Insults & Complication Prevention •Ensure Neuroprotection A. Glucose (140-180mg/dL) B. Oxygenation >94% C. MAP within 110-130 D. Body temp 35-37°C •Preventive Measures for Complications: DVT, Aspiration, Stress Ulcers, Bedsores •Seizure Precaution CORE ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 | NIHSS – National Institutes of Health Stroke Scale | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | BP – Blood Pressure | DVT – Deep Vein Thrombosis IMAGING
  • 48.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS TIA Ischemic Stroke Mild CVD Infarct Severity/Feature Moderate CVD Infarct Severe CVD Infarct • Neurodysfunction resolves within 24 hrs • No presence of Infarct NIHSS score: 0 – 5 ~ GCS 13-15 NIHSS score: 6 – 21 ~ GCS 10-12 NIHSS score: >22 ~ GCS 3-9 Initial Approach & Monitoring Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan; or • Cranial MRI-diffusion weighted imaging (DWI) • Further diagnostics if considering stroke mimics (Infection, Toxicology, Metabolic Imbalance etc) • Recommend carotid ultrasound (UTZ) to document extracranial stenosis; • Recommend transcranial Doppler (TCD) studies or CT or MR angiography (CTA/MRA) • For 2Decho, if suspect Valvular & Septal Defects, Dilated Cardiomyopathy NONCARDIOEMBOLIC • Start Antiplatelets Aspirin (ASA) 160-325 mg/day as early as possible and continue for 14 days. May be considered: ASA 80 mg + clopidogrel 75 mg • Ensure Neuroprotection A. Glucose (140-180mg/dL) B. Oxygenation >94% C. MAP within 110-130 D. Body temp 35-37°C E. Head Bed Elevation 15-30° • For CVD Infarct A. Ictus within 4.5hours: Consider IV thrombolysis with recombinant tissue plasminogen activator (rt-PA) B. Ictus within 4th to 6th hour: Consider intra- arterial (IA) thrombolysis (specialized centers). • Control/treat risk factors (i.e Cardiac Disease, Hyperlipidemia, Diabetes, etc) • Complication Prevention: DVT, Aspiration, Pressure sores, Stress Gastric Ulcer, Constipation, etc • Soft diet for alert patients; or nasogastric tube feedings otherwise, and with poor Gag reflex • Decompressive Craniectomy for Malignant Infarct ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) if signs and symptoms present due to cerebral infarct edema • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS; • Treat BP if MAP >130 (MAP = SBP + 2 DBP ÷ 3) • Avoid Precipitous drop (Avoid >15% drop from baseline MAP) within 24 hours, for CVD Infarcts Mainstay Therapeutics (Refer to Specialist) *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
  • 49.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Ischemic Stroke Severity/Feature Initial Approach & Monitoring Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan; or • Cranial MRI-diffusion weighted imaging (DWI) • Further diagnostics if considering stroke mimics (Infection, Toxicology, Metabolic Imbalance etc) • Recommend carotid ultrasound (UTZ) to document extracranial stenosis; • Recommend transcranial Doppler (TCD) studies or CT or MR angiography (CTA/MRA) • For 2Decho, if suspect Valvular & Septal Defects, Dilated Cardiomyopathy Mainstay Therapeutics (Refer to Specialist) IF CARDIOEMBOLIC ! • Anticoagulation is the mainstay with or without Antiplatelets. NOACs is preferable. TIA - Start Anticoagulation after 1 day from Acute event NIHSS <8: Suggest repeat scan after 3 days from Acute event; if no Hemorrhagic conversion start Anticoagulation. NIHSS 8-15 Suggest repeat scan after 6 days from Acute event; if no Hemorrhagic conversion start Anticoagulation. NIHSS ≥16 - Suggest repeat scan after 12 days from Acute event; if no Hemorrhagic conversion start Anticoagulation. • May have Aspirin (ASA) 160-325 mg/day for 14 days, if Anticoagulation is contraindicated. • Ensure Neuroprotection • Control/treat risk factors (i.e Cardiac Disease, Hyperlipidemia, Diabetes, etc) • Complication Prevention: DVT, Aspiration, Pressure sores, Stress Gastric Ulcer, Constipation, etc • Soft diet for alert patients; or nasogastric tube feedings otherwise, and with poor Gag reflex ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. TIA Mild CVD Infarct Moderate CVD Infarct Severe CVD Infarct • Neurodysfunction resolves within 24 hrs • No presence of Infarct NIHSS score: 0 – 5 ~ GCS 13-15 NIHSS score: 6 – 21 ~ GCS 10-12 NIHSS score: >22 ~ GCS 3-9 • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) if signs and symptoms present due to cerebral infarct edema • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS; • Treat BP if MAP >130 (MAP = SBP + 2 DBP ÷ 3) • Avoid Precipitous drop (Avoid >15% drop from baseline MAP) within 24 hours, for CVD Infarcts *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
  • 50.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Hemorrhagic Stroke Mild CVD Bleed Severity/Feature Moderate CVD Bleed Severe CVD Bleed NIHSS score: 0 – 5 ~ GCS 13-15 NIHSS score: 6 – 21 ~ GCS 10-12 NIHSS score: >22 ~ GCS 3-9 Initial Approach & Monitoring • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) due to bleed • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan • Lumbar Tap if CT is equivocal for SAH • Consider contrast CT scan, Four-vessel cerebral angiogram, Magnetic Resonance Angiogram if the patient is: A. < 45 years old B. Normotensive C.lobar ICH D.Uncertain cause of ICH E. Suspicion Aneurysm, AVM, or vasculitis Mainstay Therapeutics (Refer to Specialist) *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. GENERAL MANAGEMENT • ICP monitoring – recommended in patients with GCS ≤ 8. See management of Increased ICP • Early neurology and/or neurosurgery consult for all ICH cases. See criteria for surgical intervention • Monitor and maintain target SBP ≈140 mm Hg during the first week. • Ensure Neuroprotection A. Glucose (140-180mg/dL) B. Oxygenation >94% C. MAP within 110-130 D. Body temp 35-37°C E. Head Bed Elevation 15-30° • Prophylactic AEDs are generally not recommended; may give for clinical seizures and proven subclinical or electrographic seizures. • Monitor/correct for metabolic parameters and coagulation/ bleeding abnormalities • Complication Prevention: DVT, Aspiration, Pressure sores, Stress Gastric Ulcer, Constipation, etc • Soft diet for alert patients; or nasogastric tube feedings otherwise, and with poor Gag reflex • For Coagulation/Platelet disorder, refer to Specialist SAH Has its own classification of severity (See different slide)
  • 51.
    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Hemorrhagic Stroke Severity/Feature Initial Approach & Monitoring • Ensure Airway-Breathing-Circulation • Address Increased Intracranial Pressure (ICP) due to bleed • History-PE Identify Comorbidities/Risk • Preferred IVF: NSS • NPO temporarily • Bedrest; maintain supine position; Head of bed elevation to 15 to 30 degrees • NVS: Temperature, Pulse Rate, Respiratory Rate, BP + MAP, Pupils Size, & O2 sat • Blood Glucose monitoring • Perform and Monitor Stroke Scale NIHSS (Gold Standard for Assessing Severity), GCS Diagnostics • CBC, RBS, PT, APTT, • ECG, CXR • Non-contrast Cranial CT (NCCT) scan • Lumbar Tap if CT is equivocal for SAH • Consider contrast CT scan, Four-vessel cerebral angiogram, Magnetic Resonance Angiogram if the patient is: A. < 45 years old B. Normotensive C.lobar ICH D.Uncertain cause of ICH E. Suspicion Aneurysm, AVM, or vasculitis Mainstay Therapeutics (Refer to Specialist) ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. ADDITIONAL (SAH SPECIFIC) • Calcium Channel Blockers: Nimodipine 60 mg every 4 hours by mouth or via NGT for 3 weeks is recommended. • Management of Increased ICP: may have Mannitol 0.5 to 1.5g per body weight kg every 3-6 hours; may continue up to 7 days. See management of Increased ICP • Fludrocortisone or hypertonic saline for hyponatremia caused by syndrome of inappropriate antidiuretic hormone (SIADH) or salt-wasting. • Surgical Intervention • Obliteration of the aneurysm from the circulation as early as possible is the main goal of SAH treatment. This can be achieved through surgical clipping or endovascular coiling. • Early, immediate surgery is recommended for Grade I-III to minimize the risk of a devastating rebleed. Asymptomatic/mild headache, slight nuchal rigidity, normal mental status; no motor deficit Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy; no motor deficit Drowsiness, confusion or mild focal signs with motor deficits Stupor, moderate to severe hemiparesis, possibly early decerebrate signs; with or without motor deficits Deep coma, decerebrate rigidity, moribund appearance; with or without motor deficits SAH Grade I GCS 15 SAH Grade II GCS 13-14 SAH Grade III GCS 13-14 SAH Grade IV GCS score 7-12 SAH Grade V GCS 3-6 *National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
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    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Clinical Features Any of the following: • Deteriorating level of sensorium • Cushing’s triad: Hypertension Bradycardia, Irregular respiration • Anisocoria unequal pupillary sizes • Nausea and Vomiting • Optic Disc Edema / Papilledema on Funduscopy Specific Therapies for ICP • Mannitol 20% IV. Give 1.5 g/kg for a deteriorating patient then 0.5-1.5 g/kg every 3-6 hours. May administer up to 7 days as indicated. Hypertonic saline is an option. • Serum osmolality at 300-320 mosmol/kg [2(Na) + Glucose/18 + BUN/2.8] • Maximize Bed Head Elevation to 30 to 45O to assist venous drainage. • Careful Intubation if with respiratory failure: Pulse oximetry SaO2 <90%, or ABG)PaO2 <60mmHg, or ABG PaCO2 > 55 mmHg • Short term Hyperventilation (6 hours) by adjusting tidal volume to achieve target pCO2 30–35 mmHg. • ICP catheter insertion for monitoring & therapeutic lowering: A. GCS ≤ 8 B. Significant IVH & hydrocephalus. Surgical Intervention? ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 ֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002. SURGICAL EVACUATION /DECOMPRESSION May benefit from intervention if with: • Lobar, supratentorial, basal ganglia or thalamic hemorrhage with volume >30 cc • Cerebellar hemorrhage >3 cm • Intraventricular hemorrhage with moderate to severe hydrocephalus • Presence of Aneurysm, AV malformation or cavernous angioma NON-SURGICAL CANDIDATES • Patients with small hemorrhages (<10 cc) with minimal neurological deficits • Patients with GCS <5 except those who have cerebellar hemorrhage and brainstem compression • Patients with pontine or midbrain hemorrhage | ICP – Intracranial Pressure | CPP – Cerebral Perfusion Pressure | ABG – Arterial Blood Gas | Na – Sodium | GCS – Glasgow Coma Scale | IVH – Intraventricular Hemorrhage | BUN – Blood Urea Nitrogen Increased Intracranial Pressure CVD Infarct • gradually peaks up to 72 hours; • cerebral edema (cytotoxic and vasogenic) mass effect may extend up to 10 days CVD Bleed & SAH • usually progressive deterioration within 12 hours to 72 hours; • variable onset depending on Bleed Volume and concomitant cerebral edema
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    A VIEWPOINT ANDMANAGEMENT ON CEREBROVASCULAR & RELATED DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE INTRODUCTION CLINICAL APPROACH DIAGNOSTIC APPROACH MANAGEMENT PREVENTION ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 Lifestyle Modifications and Post Stroke Rehabilitation & Complication Prevention For Deep Vein Thrombosis, Aspiration Pneumonia, Stress Ulcers, Bed Sores, Post Cicatrial Seizure, Muscle Atrophy, Fractures, Memory Related Disorders, and Malnutrition Lifestyle Modifications (Controlled BP, Sugar, Cholesterol, Stress Reduction, Antithrombotic for Cardiac Problems) Lifestyle Modifications (Controlled BP, Sugar, Cholesterol, Stress Reduction, Antithrombotic for Cardiac Problems) Health Education SECONDARY PREVENTION PRIMARY PREVENTION PRIMORDIAL PREVENTION TERTIARY PREVENTION To prevent development of Risk Factors To prevent development of Stroke To prevent recurrence of new Stroke To prevent complications of Stroke LEVELS OF STROKE PREVENTION NO RISK FACTORS PRESENT RISK FACTORS PRESENT STROKE HAS HAPPENED STROKE HAS HAPPENED For Complete Guide of Lifestyle Modification, see JNC 7 & JNC 8 Guideline for Hypertension For Complete Guide for Post Stroke Rehabilitation &Complication Preventions, see SSP Handbook of Stroke 6th Edition
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    Special thanks tothe Sulu Sanitarium General Hospital – Public Health Unit for the distribution of this material