Stroke occurs when blood supply to the brain is interrupted or reduced, causing brain cells to die. The most common type is ischemic stroke, which accounts for 80% of cases and occurs when a blood vessel is blocked. A stroke is a medical emergency and prompt treatment is important to minimize damage. Guidelines recommend administering thrombolysis within 3.5 hours, carefully controlling blood pressure, ordering diagnostic tests, and monitoring for potential complications. Lifestyle factors like controlling hypertension, cholesterol levels, diabetes, and use of anticoagulants can affect risk and outcomes of stroke.

1. http://crisbertcualteros.page.tl
STROKE

2. Stroke occurs when the supply of blood to the brain is either interrupted or reduced
Brain does not get enough oxygen or nutrients which causes brain cells to die.

3. Stroke Classification:
Ischemic
-Ischemic strokes are the most common ( 80%) of stokes
-occur when there is an occlusion of a blood vessel impairing the flow of blood to the brain
-Ischemic strokes are divided into:
a) thrombotic b) embolic c) systemic hypoperfusion.
Hemorrhagic

4. Red Flags
Pain in Acute Stroke Patient:
 AMI
Aortic Dissection
Pneumothorax
Limb Ischemia

5. Low BP in Acute Stroke Patient:
Silent MI
Infective Endocarditis

6. Mimics of Stroke:
Hypoglycemia
Neuropathies/plexopathies
Structural Brain Lesion(SDH)
Focal Epilepsy with Todd’s Paralysis
Migraine Aura
Transient Global Amnesia
Labyrithine D/O
Parkinsons Disease
Alcohol Intoxication

7. Golden Hour:
within 3.5 hours  thrombolysis
Apply ABC
HTN: treat only if BP >220/110

8. Labs:
FBC
Renal Panel
PT/ PTT
Fasting Glucose
HBA1C
CT brain

9. Emergencies in Stroke
Seizure: <2% of patients
-Large cortical stroke
-Bleeding
-CVT
Delirium
Intracranial Hemorrhage
-Inform Neurosurgery ASAP
-Target BP: <160/90
-? hemicraniectomy

10. Emergencies in Stroke
Large Cerebellar Stroke
-High risk for posterior fossa compression
-Hydrocephalus
Potentially Malignant MCA Infarcts
Sepsis/DVT/PE

11. Chronic Strokes
TACI
PACI
LACI
POCI

12. Total anterior circulation syndrome
Unilateral motor, sensory deficit, or both affecting at least two of face, arm, and leg
Higher cerebral dysfunction, e.g. dysphasia, dyspraxia, neglect, dyscalculia
Homonymous hemianopia

13. Partial anterior circulation syndrome
Two of the three components of TACS or pure higher cortical dysfunction or pure motor or sensory deficit not as extensive as for lacunar syndromes

14. Lacunar syndrome (LACS):
Pure motor or pure sensory deficit affecting at least two of face, arm, or leg
Sensorimotor deficit
Ataxic hemiparesis
Dysarthria, clumsy hand syndrome
Acute onset movement disorder

15. Posterior circulation syndrome
Isolated hemianopia
Brain stem signs
Cerebellar ataxia

16. Mechanism of Stroke
Atherosclerosis:
- AKA “hardening of the arteries,”
-calcified lipid or fatty deposits accumulate circumferentially along the innermost intimal layer of the vessel wall
-Atherosclerosis and the development of arterial plaques are the product of a host of independent biochemical processes (oxidation of LDL, formation of fatty streaks, and the proliferation of smooth muscle cells)
-As the plaques form, the walls become thick, fibrotic, and calcified
-lumen narrows, reducing the flow of blood to the tissues the artery supplies

17. Thrombus
A thrombus is a blood clot (aggregation of platelets and fibrin) formed in response to atherosclerotic lesion or to vessel injury
In response to vessel or tissue injury, the blood coagulation system is activated, which initiates the following cascade of processes transforming prothrombin and resulting in a fibrin clot: Prothrombin⇒Thrombin⇒Fibrinogen⇒ Fibrin⇒Fibrin Clot
Approximately 33% of all stroke cases are attributed to thrombi.

18. CVD
Cardiovascular diseases:
atrial fibrillation and myocardial infarction weaken the cardiac wall and introduce abnormalities in the physiological function of the heartbeat
result in reduced systemic pressure and conditions of ischemia.

19. HTN in Stroke (Ischemic)
Not to start anti-HTN in 24hours
To aim <140/90 in 2weeks post stroke
Lacunar Stroke: AIM: <130/90
With IHD: use bets blocker / ACEI
With DM: use ACEI
Severe Intracranial Disease: allow SBP 130- 150; to drop BP slowly

20. Statins in Stroke
<75 yo: use high intensity statins ( to drop LDL by 50%
-Use atorvastatin or rusovastatin
-Moderate intensity ( drop LDL by 30-50%)
-AIM: LDL <100 or < 2.6

21. DM in Stroke
AIM HBA1C: <7.0

22. Anticoagulation in AF
Target INR: 2-3
NOAC vs Warfarin
Pt with contraincation for warfarin: Aspirin + clopidogrel
Pt with Intracranial Stenosis: DAPT x 3/12 then back to single antiplate
CHANCE TRIAL: Aspirin + Plavix x 3/52 then LIFELONG Aspirin

23. Sources:
Medscape
Harrisons
Oxford
Google