Stroke occurs when blood flow to the brain is interrupted, causing brain cells to die. It is a leading cause of death and disability worldwide. In Bangladesh, around 10% of emergency medical admissions are due to stroke. Presenting symptoms can include weakness, speech problems, visual issues, ataxia, headache, and seizures. Risk factors include hypertension, diabetes, smoking, obesity, and high cholesterol. Rapid diagnosis and treatment is important to reduce long-term effects through thrombolysis, aspirin, carotid surgery, and rehabilitation.

1. Ischaemic Stroke
Dr. Imdadul Magfur
MD Resident, phase –A
Department of Psychiatry, SOMC

2. What is stroke ?
According to WHO - 'rapidly developing clinical signs of focal (at times global)
disturbance of cerebral function, lasting more than 24 h or leading to death with no
apparent cause other than that of vascular origin'.
A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that
resolve within 24 hours.

3. Stroke a Global Burden…..
• Stroke has is now the third most common cause of death globally and the
major cause of disability. About 20% of stroke patients die within a month
of the event and at least half of those who survive are left with physical
disability.
• Up to 20 million stroke events occur yearly, Worldwide
• Accounts for 5.7 million deaths each year
• The incidence is expected to increase by another 30 percent by 2020

4. BANGLADESH Scenario….
• Not known (10% of all emergency admission in medical wards)
• SOMCH-13% of all medical admission

5. What to see in a stroke pt

6. classification

11. The concept of ischaemic penumbra
The term penumbra was coined in analogy to the half- shaded zone around the
center of a complete lunar eclipse in order to describe the ring-like area of reduced
flow around the more densely ischemic center of an infarct. In pathophysiological
terms it is the blood flow range between the thresholds of transmitters release and
cell membranes failure. So functional activity of the neurons is suppressed
although the metabolic acitivity for maintenance of structural integrity of the cell is
still preserved - neurons are injured but still viable. Penumbra should be defined as
a flow range between 0.10 - 0.23 ml/g/min

12. A penumbral lunar eclipse………….

13. Within the penumbra zone:
- auto regulation of blood flow is disturbed
- CO2 reactivity of blood vessels is partially preserved
- ATP is almost normal
- slight decrease of tissue glucose content
(beginning insufficiency of substrate availability)

15. Presenting complain
 Weakness
 Unilateral weakness is the classical presentation of stroke
 The weakness is sudden, progresses rapidly and follows a hemiplegic pattern
There is rarely any associated abnormal movement. Reflexes are initially reduced but
then become increased with a spastic pattern of increased tone. Upper motor neuron
weakness of the face (7th cranial nerve) is often present

16. (Contd.)
• Speech disturbance
 Dysphasia and dysarthria are the most common presentations of disturbed
speech in stroke .
 Dysphasia indicates damage to the dominant frontal or parietal lobe, while
dysarthria is a non-localising feature that reflects weakness or incoordination of
the face, pharynx, lips, tongue or palate.

17. (Contd.)
 Visual loss
Visual loss can be, caused by disturbance of blood flow in the internal carotid
artery and ophthalmic artery, leading to monocular blindness. due to unilateral
optic ischaemia (called amaurosis fugax if transient)
Ischaemia of the occipital cortex or post-chiasmic nerve tracts results in a
contralateral hemianopia

18. (Contd.)
• Visuo-spatial dysfunction
Damage to the non-dominant cortex often results in contralateral visuo-spatial
dysfunction, e.g. sensory or visual neglect and apraxia (inability to perform
complex tasks despite normal motor, sensory and cerebellar function),
sometimes misdiagnosed as delirium.

19. (Contd.)
 Ataxia
Stroke causing damage to the cerebellum and its connections can present as an acute
ataxia and there may be associated brainstem features such as diplopia and vertigo
• Headache
Sudden severe headache is the cardinal symptom of SAH but also occurs in
intracerebral haemorrhage, acute ischaemic stroke,in cerebral venous disease.

20. (Contd.)
• Seizure
Seizure is unusual in acute stroke but may be generalised or focal (especially in
cerebral venous disease)
• Coma
Coma is uncommon, though it may occur with a brainstem event. If present in the
first 24 hours, it usually indicates a subarachnoid or intracerebral haemorrhage

24. Risk factors

32. Differential diagnosis of acute ischemic stroke
Diagnosis Findings supportive of
alternative diagnosis
Intracerebral
hemorrhage
Prominent headache. Nausea and vomiting
Early decreased consciousness
Very sudden and severe onset
Hypertensive
encephalopath
y
Headache. Decreased consciousness
Delirium
Elevated blood pressure
Visual loss. Seizures
Migraine History of prior events
Positive phenomena (aura)
Prominent headache
Nausea and vomiting
Younger age (especially women)

33. (Contd.)
Seizure (with post-ictal
signs)
History of seizures,Witnessed seizure activity
Confusion, Lateral tongue bites
March of symptoms, Onset/resolution
Mass lesion (subdural
hematoma/tumor)
Evolution of signs, Headache
Personality changes
History of trauma
Encephalitis Evolution of signs, Decreased consciousness
Seizures. Fever
Malaise and other constitutional symptom
Hypoglycemia
Hyperglycemia
History of diabetes/insulin use
Decreased consciousness, Confusion/delirium
Autonomic signs – clammy
Conversion disorder Lack of cranial nerve findings
Findings – nonvascular pattern
Inconsistent examination
Unusual emotional reaction for the
situation

36. Rapid recognition of symptoms and diagnosis
• In people with sudden onset of neurological symptoms a validated tool, such as
FAST (Face Arm Speech Test), should be used outside hospital to screen for a
diagnosis of stroke or TIA.
• People who have had a suspected TIA who are at high risk of stroke (that is, with
an ABCD score of 4 or above) should have aspirin (300 mg daily) started
immediately
• specialist assessment and investigation within 24 hours of onset of symptoms

45. Insular ribbon sign hypoattenuation in the lentiform nucleus

46. ACUTE STROKE MANAGEMENT
• Five mainstays
Treatment of general condition that need to be stabilized
Specific therapy directed against particular aspects of stroke
pathogenesis
Prophylaxis & treatment of complications which may be either
neurological or medical
Early secondary prevention
Early rehabilitation

48. (Contd.)
• Reperfusion (thrombolysis & thrombectomy)
Intravenous thrombolysis with recombinant tissue plasminogen activator
(rt-PA)
mechanical clot retrieval (thrombectomy) in patients with a large-vessel
occlusion
• Aspirin

49. (Contd.)
• Carotid endarterectomy and angioplasty
 patients with a carotid territory ischaemic stroke or TIA will have more
than 50% stenosis of the carotid artery on the side of the brain lesion.
Surgery is most effective in patients with more severe stenoses (70–99%).
Carotid angioplasty and stenting are technically feasible but have not been
shown to be as effective as endarterectomy for the majority of eligible
patients.

52. Secondary prevention