Stroke Lecture with Consolidated Guidelines

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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.

10. 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

11. FREE
DOWNLOADABLE
MOBILE APP
iOS and Android
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NIHSS
For
NIHSS

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. A VIEWPOINT AND MANAGEMENT ON
CEREBROVASCULAR & RELATED DISORDERS
FOR ALLIED HEALTH WORKERS AND PRACTITIONERS
NORMAL CVD Bleed (Pontine)

39. A VIEWPOINT AND MANAGEMENT ON
CEREBROVASCULAR & RELATED DISORDERS
FOR ALLIED HEALTH WORKERS AND PRACTITIONERS
NORMAL Subarachnoid Hemorrhage

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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%

46. 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

47. 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

48. 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

49. 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

50. 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)

51. 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

52. 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

53. 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

54. Special thanks to the
Sulu Sanitarium General Hospital – Public Health Unit
for the distribution of this material