This document provides an overview of the approach to managing cerebrovascular accidents (CVAs), also known as strokes. It begins with definitions, epidemiology, and risk factors. It then discusses the clinical presentation and neurological deficits associated with different blood vessels. Common complications are also reviewed. The approach to initial management focuses on resuscitation, history and examination, investigations, and acute treatment including medications, monitoring, and prevention of secondary complications. Long-term management involves rehabilitation, lifestyle modifications, and managing risk factors to prevent further strokes. Prognosis varies depending on the stroke subtype but overall many patients experience disability or death.

1. CEREBROVASCULAR ACCIDENT
& INITIAL APPROACH TO
MANAGEMENT
DR KEMI DELE-IJAGBULU
Dept. Of Family Medicine
Dora Nginza Hospital
October 2017

2. CONTENT
• Introduction/Epidemiology
• Aetiological Classification
• Anatomy
• Clinical Picture
• Complications
• Management Options

3. Introduction: Definition of Terms
• TIA (transient Ischemic Attack): a focal neurological deficit due to a compromise in
cerebral circulation that lasts less than 24 hours with complete clinical recovery.
• STROKE: a focal neurological deficit due to a compromise in cerebral circulation. The
onset is sudden and the symptoms last more than 24 hours, if the patient survives.
• Progression: Up to 15% of patients with TIA may have a STROKE in the first 2 weeks

4. Epidemiology
• 3rd most common cause of death after HIV/AIDS and Ischaemic Heart
disease in South Africa
• A leading cause of adult disability
• Prevalence and cost implication rises with increasing aging population.
• A medical emergency with high morbidity and mortality.
• Mortality of 125 per 100000 deaths

5. AETIOLOGICAL
CLASSIFICATION

6. Aetiological Classification Of Stroke
• Causes of Stroke are heterogeneous with different pathophysiology
• They can however be broadly categorized into 2:
Haemorrhagic and Ischemic Stroke
• Haemorrhagic Stroke: Characterized by too much blood within the closed cranial
cavity, secondary to rupture of blood vessels
• Ischemic Stroke: Characterized by too little blood to supply an adequate supply of
oxygen and nutrition to a part of the brain as a result of Thrombosis, Embolism
or Systemic hypoperfusion.

7. Aetiological Types
1. Ischaemic Stroke
80% of all strokes
Anterior circulation ischemic stroke accounts for approximately 70% of all ischemic
strokes.
2. Haemorrhagic Stroke
Intracerebral (or parenchymal) haemorrhage – bleeding onto the brain tissue
Subarachnoid Haemorrhage (SAH) – bleeding into the subarachnoid space into the CSF

8. RISK FACTORS

9. Risk factors: Non-Modifiable
• Age (risk rises exponentially with age)
• Sex (more common in males at all ages)
• Race (African American > Asian > Caucasian)
• Geography (Eastern Europe > Western Europe > Asia > rest of Europe or
North America)
• Genetic risk factors (eg stroke or heart disease in individuals younger than 60
yr; familial syndromes, such as cerebral autosomal arteriopathy [CADASIL]

10. Potentially modifiable risk factors
• Hypertension (diastolic or isolated
systolic)
• Diabetes mellitus type 1 or 2
• Atrial fibrillation
• Smoking
• Coronary artery disease
• Hypercholesterolemia
• Alcohol abuse
• Drug abuse (eg, cocaine)
• Oral contraceptive use
• Pregnancy

11. Risk factors (Stroke and TIA)
• Hypertension
• Diabetes mellitus
• Cardiac disease
• Valvular
• Arrhythmias
• Presence of coronary artery disease
• Hyperlipidaemia
• Smoking
• Diet and obesity
• Family history
• Oral contraceptives
• HIV infection

12. WHICH BLOOD
VESSEL?
& the NEUROLOICAL
DEFICITS

14. Middle Cerebral Artery Stroke
• Contralateral hemiparesis
• Contralateral hypoesthesia
• Ipsilateral hemianopsia
• Agnosia
• Receptive or expressive aphasia, especially if the lesion is in the dominant hemisphere
• Neglect, inattention.
• Flat affect
• MCA supply upper extremity motor strip. Hence, weakness of arm and face is worse than
lower limbs

15. Anterior Cerebral Artery Stroke
Affects mainly the frontal lobe function
• Disinhibition and speech perseveration
• Primitive reflexes
• Altered mental status
• Impaired judgement
• Contralateral weakness (greater in legs than arms
• Contralateral cortical sensory deficit
• Urinary incontinence
• Gait apraxia

16. Posterior Cerebral Artery Stroke
• Mostly affect vision and thoughts.
• Contralateral homonymous hemianopsia
• Cortical blindness
• Visual agnosia
• Altered mental status
• Impaired memory

17. Vestibulobasilar Artery
• Wide variety of cranial nerve, cerebellar and brainstem deficit, often vague
• Vertigo
• Diploplia
• Nystagmus
• Syncope
• Ataxia
• Dysphagia
• Dysarthria
• Visual fields defects

18. Lacunar syndromes
It affects the smaller branches of MCA, more common in Hypertension.
Not usually associated with impaired cognition, memory, speech or level of consciousness
5 categories:
1. Pure motor hemiparesis:
• Contralateral - Usually affects the face and upper and lower extremities equally
• Also associated with dysarthria
• No sensory or visual loss
• No cognitive impairment

19. 2. Pure sensory stroke:
• Contralateral loss of all sensory modalities - Equally affects the face and upper and
lower extremities
• No motor signs, dysarthria, visual loss, or cognitive impairment
3. Homolateral ataxia and crural paresis:
• Paresis of the contralateral leg and side of the face
• Prominent ataxia of the contralateral leg and arm

20. 4. Isolated motor/sensory stroke:
• Paralysis and sensory loss of the contralateral leg, arm, and face
• No visual loss or cognitive impairment
5. Dysarthria-clumsy hand syndrome:
• Dysarthria
• Dysphagia
• Contralateral tongue and facial weakness and paresis
• Clumsiness of the contralateral arm and hand

21. CLINICAL
PRESENTATION

22. Clinical Presentation
• Abrupt onset of any of the following:
• Hemiparesis, monoparesis or rarely quadriparesis
• Hemisensory deficits
• Monocular or binocular visual loss or visual fields defect / Diplopla
• Dysarthria / Ataxia / Aphasia
• Facial droop
• Sudden decrease in the level of consciousness, from confusion to coma

23. COMPLICATIONS

24. Complications
Neurologic complications
• these include cerebral oedema, haemorrhagic transformation of
cerebral infarction, seizures, hydrocephalus, increased intracranial
pressure, and depression.
Respiratory complications
• these include aspiration, pneumonia, airway obstruction,
hypoventilation, and atelectasis.

25. Complications (contd.)
Cardiovascular complications
• these include myocardial infarction, congestive heart failure,
hypertension, orthostatic hypotension, deep venous thrombosis,
and pulmonary embolism.
Orthopaedic and dermatologic complications
• these include pressure sores, contractures, adhesive capsulitis of
the shoulder, and falls with fractures.

26. Complications (contd.)
Urinary complications
• these include incontinence and urinary tract infections.
Nutritional, metabolic, and gastrointestinal complications
• these include stress ulcers, gastrointestinal bleeding, constipation,
dehydration, electrolyte disturbances, malnutrition, and
hyperglycaemia.

27. Differential Diagnoses
• Hypoglycaemia and other toxic metabolic disorders
• Mass lesions e.g. brain abscess or brain tumour
• Benign positional vertigo
• Post ictal phase in epilepsy
• Migraine
• Multiple sclerosis
• Transient global amnesia
• Systemic Infections

28. Approach To
Management

29. Approach To Management: Resuscitation
• ABCDE (CAB)
• HGT
• ?Do not resuscitate orders
for patients with acute stroke
Due to severity of neurological
deficit

30. Approach To Management: History
Emphasis on:
• Time of onset (if less than 4.5 hrs can still use
tPA)
• Premorbid functioning (to structure rehab goals)
• Risk factors and previous medication
• Current clinical presentation

31. Approach To Management: Examination
• Confirm adequate airway and maintain
• Do vitals and support adequately
• Neurological examination
• Assess the level of consciousness, cortical dysfunction, cranial nerves,
hemianopia, weakness, sensory loss, cerebellar function
• Localize lesion based on clinical picture
• Exclude AF, carotid bruits

32. Approach To Management: Special investigations
• Blood workup: FBC, UEC, Trop I, Hgt
• ECG
• CXR
• CT Brain
• Other may include:
TSH, HbA1C, Lipid profile, Echo, Carotid Doppler,
INR,

33. Approach To Management, contd.
• Cardiac monitoring
• Head elevation <30 degrees
• Maintain hydration
• BP reduction only if more than 220/120, then lower by no more than 15-
20%. All patients will benefit from blood pressure control subsequently.
• Osmotic diuresis to reduce intracranial pressure/cerebral oedema
IVI Mannitol 0.25-0.5mg/kg bolus repeat 6x up to 2g/kg/day
• Glucose control, sliding scale if >10, treat hypoglycaemia

34. Approach To Management, contd.
• Early seizure control: diazepam or lozarepam
• Then load with phenytoin if warranted. Anticonvulsant of choice is Phenytoin
• All patients to receive an antiplatelet agent after excluding haemorrhagic stroke
• Aspirin 75-150mg daily
• Clopidogrel 75mg daily if contraindications to aspirin or high risk
• Warfarin if Atrial Fibrillation is present
• Pulmonary embolus or DVT: low dose heparin 5000 IU bd s/c

35. Approach To Management, contd.
• Monitor level of consciousness: decreasing levels may be due to large infarct
with cerebral oedema
• Prevent aspiration pneumonia: NPO until swallowing deficit is excluded
• Statin 10mg nocte irrespective of baseline cholesterol
• Temperature management, if increase may increase infarct size

36. Approach To Management, contd.
• Invasive procedures, e.g.
• In symptomatic carotid stenosis, i.e. >70% occlusion, stenting before end
carotid arteriectomy in Acute ischemic stroke
• Surgical evacuation of hematoma in haemorrhagic stroke
• Patient on warfarin: IV Vitamin K, FFP
• Early mobilization/rehabilitation: physio, OT, speech therapy

37. Approach To Management, contd.
Prevent Further Stroke
• S = statins
• W = warfarin
• A = aspirin
• B = BP control
• S = surgery

38. Approach To Management, contd.
• Long term management
• Multidisciplinary team
• Lifestyle modification:
• Ongoing rehabilitation
• Manage depression: especially if dominant hemisphere is affected, as this
may hinder rehabilitation. Refer psychiatry for treatment

39. Prognosis
• After transient ischaemic attack, the risk of stroke is 10.5% over the next 3 months,
with the highest risk in the 2 days following a TIA.
• Stroke is the third leading cause of death in the United States and the leading cause
of adult disability.
• High rates of morbidity and mortality are associated with all types of stroke, but the
prognosis varies among subtypes; e.g.,
• mortality rates after intracerebral haemorrhage are as high as 30% at 1 month.
• the ischemic lacunar syndromes quite often are associated with a good prognosis and
have a better prognosis than MCA syndromes.

40. • Overall, at 6 months after a stroke, as many as 30% of patients have died,
20-30% are moderately to severely disabled, 20-30% have mild to moderate
disability, and 20-30% are without deficits.

41. THANK YOU!