This document defines stroke as a focal brain dysfunction lasting over 24 hours caused by a non-traumatic vascular issue. It then classifies strokes as ischemic (85%) or hemorrhagic (15%) and discusses their risk factors like hypertension, smoking, atrial fibrillation, diabetes, and age. The diagnosis involves examining for weakness, speech issues, vision problems, and performing a CT or MRI scan. Investigations help identify the cause and rule out mimics. Treatment focuses on stabilizing the patient, controlling risk factors, and using thrombolysis, aspirin, or anticoagulants depending on the type of stroke. Lifestyle changes and secondary prevention aims to modify risk and prevent future strokes.

3. WHAT IS STROKE ?

4. DEFINITION OF STROKE
STROKE means-
Focal deficit of brain function
Due to
Non traumatic
vascular cause
Lasting more than 24 hours

5. • TIA
• STROKE
• STROKE IN EVALUTION
• COMPLETED STROKE

7. Pathological classification
• Ischemic Stroke (85%)
– Anterior( carotid ) circulation (65%)
– Posterior ( Vertibrobasilar) circulation (20%)
• Haemorrhagic stroke (15%)
– Intracerebral (10%)
– Subarachnoid (5%)

8. WHY ME, DOCTOR????

9. WHAT ARE THESE RISK FACTORS?
Modifiable :
 Hypertension
 Smoking
 Atrial fibrillation
 Infective endocarditis
 Mitral stenosis
 Recent large MI
 Oral Contraceptive pill, HRT
 Carotid stenosis
 Obesity
 Diabetes Mellitus
 Hyperhomocystinuria
 LVH

10. C. Non Modifiable :
 Age
- Risk doubles for each decade
after 55 years
 Sex ( M F, excepts at extreme age)
 Race /ethnicity Afro-carribbeanAsian  Europian )
 Hereditary/familial factors
 RR 2.4 for paternal history
 RR 1.4 for maternal history
 Geographic location

11. Cerebral infarct
Cardiac embolism
Premature atherosclerosis
Arterial dissection
Thrombophilia
Homocystinuria
Antiphospholipid antibody syndrome

12. Continued..
Systemic lupus erythematosus
Vasculitis
CADASIL (cerebral autosomal dominant
arteriopathy with subcortical infarcts and
leucoencephalopathy)
Mitochondrial cytopathy
Fabry’s disease
Neurovascular syphilis

13. Arteriovenous malformation(AVM)
Drug misuse(amphetamine,cocaine)
Coagulopathy

14. Saccular (‘berry’) aneurysm
AVM
Vertebral dissection

15. HOW CAN WE DIAGNOSE A
PATIENT WITH STROKE???

16. WEAKNESS

17. Speech Disturbance
• Dysphasia and dysarthria most common
presentations of disturbed speech in
stroke

18. Dysphasia
damage to the dominant frontal or parietal
lobe

19. Dysarthria
• dysarthria is a nonlocalising feature reflecting
weakness or incoordination
of the
– face
– pharynx
– Lips
– tongue or
– palate.

20. OTHER PRESENTATION
• Visual deficit
• Visuo-spatial dysfunction
• Ataxia, Diplopia, vertigo
• Headache
• Seizure
• Coma

21. SO, HOW TO APPROACH ????

22. Differential diagnosis of stroke
and TIA
‘Structural’ stroke mimics
Primary cerebral tumours
Metastatic cerebral tumours
Subdural haematoma
Cerebral abscess
Peripheral nerve lesions(vascular or compressive)
Demyelination

23. Differential diagnosis of stroke and
TIA
‘Functional’ stroke mimics
Todd’s paresis (after epileptic seizure)
 Hypoglycaemia
Migrainous aura (with or without headache)
Focal seizures
Ménière’s disease or other vestibular disorder
Conversion disorder
Encephalitis

24. How to Differentiate?????

25. Features stroke Stroke
mimics
Symptoms
onset
sudden slower
progression rapid slow
Pattern of
deficit
hemiplegic Non specific
Severity of
deficit
unequivocal Variable/uncer
tain
Loss of
consciousness
uncommon Most common

27. Differentiating Ischemic and
Haemorrhagic stroke
Haemorrhage Infarction

28. After Differentiating D/D
GO for Examination

29. General examination
–Temperature : Increased ( if pneumonia)
–Eye : xanthelasma,arcus senilis, Diabetic
changes, hypertensive changes
–pulse : irregularly irregular(AF), thickened
arterial wall ( atherosclerosis )

30. General examination
–Peripheral pulse : May be absent (IF PVD )
–BP: HTN ( C.hmg,C.thrombosis,SAH )
–JVP : raised ( if heart failure,hypovolemia )
–skin : Rash (vasculitic disorder),colour and
temp change over the lower limb
(DVT),injury sustained during collapse with
stroke

31. CVS
– Murmur (MDM in MS )
– features of RHD
Indicating Source of Embolism

32. OTHERS
– Respiratory : Signs of P.edema ,P.infection
– Abdomen : Palpable bladder (urinary retention )
– nervous system :
• Level of consciousness : by GCS
• Muscle power
• Muscle tone
• Jerks : exaggerated in contralateral side
• Clonus
• planter response : extensor in the contralateral side
• Hoffman sign
• Cerebellar sign

35. Unilateral Facial Weakness

36. Unilateral Grip Weakness

37. Unilateral arm weakness

38. Unilateral Leg Weakness

39. Speech Loss

40. Visual Field Defect

41. Others
• Loss of consciousness
• seizure

42. Roisiers Scale
• Unilateral facial weakness +1
• Unilateral grip weakness +1
• Unilateral arm weakness +1
• Unilateral leg weakness +1
• Speech loss +1
• Visual feld defect +1
• Seizure -1
• Loss of consciousness -1
SCORE  0 indicates stroke is a possible cause

43. Others Assessments
• Exclude Hypoglycemia
• Language deficit
• Motor deficit
• Sensory And Visual Inattention
• Truncal ataxia

45. Investigations
– CT scan of head ( To know whether the lesion is
vascular origin or ICSOL or anything else ;if
vascular whether it is ischemic or hemorrhagic ) :
If comes within 24 hours of onset
– MRI of brain : If comes after 7 days

46. Investigations
– CXR PA view : Cardiac chamber enlargement, to
Dx pneumonia
– Dx of risk factors :
• CBC with ESR
• Blood sugar
• serum lipid profile
• Blood urea,serum creatinine
• Serum electrolyte ( Stroke causing E.imbalance or stroke
to vomiting to E.imbalance )

47. Investigations
–If SAH is suspected : lumber puncture
–To know the source :
• Cardiac origin : ECG,Echo
• Vascular origin :
– Carotid Doppler,Doppler USG
– MRA,CTA of cerebral vessels
– DSA of cerebral vessels ( Gold standard to find AVM
and aneurism)

48. Investigations
– others test according to suspicion of cause
• collagen vascular disease : ANA,Anti-ds-DNA,Anti
phospholipid Ab
• vasculitis : pANCA,cANCA, ESR,CRP
• Thrombophilia : Protein C,protein S,serum AT-iii level
• neurosyphilis : VDRL,TPHA
• Homocysteinuria : serum and urinary level of
homocysteine and methionine

50. Treatment

51. • Airway : NPO ( if swallowing is difficult ), clear airway
,oropharyngeal suction
• Breathing : Check Respiratory rate, oxygen saturation &
give O2 ( if SpO2  95%)
• Circulation :Check peripheral perfusion,pulse,BP and give
IV fluid (NS ), anti arrythmatics and ionotropic drugs as
appropriate
• Maintenance of nutrition by NG feeding( if dysphagia 
48 hours)200 ml 2 hourly from 6 AM to 10 PM
• Maintenance of intake output chart
• If the patient is dysphagic consider alternative
route for medications

52. Continued…
• care of the mouth : Anti fungal gel
• care of the eye : antibiotic drop and ointment (
if necessary)
• care of bowel : Prevent constipation ,bed pan is
used to avoid soiling of bed
• care of bladder : catheterization in sterilized
way
• Care of the skin : change the posture 2
hourly,provide pressure relieving mattress, treat
any infection if present

53. • Raised BP at presentation should not be
lowered in the 1st week
• Usually within the first few days of Stroke
the BP returns to normal

54. Indication of reducing BP
• BP >185/110 mm of Hg
• Evidence of Hypertensive Encephalopathy
• Concomitant Myocardial Ischemia
• Heart Failure
• Renal Failure
• Evidence of Aortic Dissection

55. • Thiazide diuretics
• ACE inhibitors
OR
• Other agents

56. Continued…..
• Hyperglycemia – Give insulin
• Hypoglycemia- 25% glucose
• Fluid and electrolyte disturbances
• Control of Hyperlipidemia: statin
• Control of cardiac disease/AF : LMW
heparin followed by warfarin

57. Specific Management
Ischemic Stroke
• Thrombolysis by r-tPA
• Aspirin
• Clopidogrel
• Heparin
• Carotid Endarterectomy and
Angioplasty

58. Thrombolysis by r-tPA
• If given within 4.5 hours of symptom onset,
improvement in overall outcome is
observed
• Problem with thrombolysis : Haemorrhagic
transformation of cerebral infarct which is potentially
fatal

59. Aspirin
• Start immediately (300 mg at once then
75mg daily )after ischemic stroke
• If rt-PA has been given to the patient then
witheld for at least 24 hours
• If aspirin tolerant  Clopidogrel (75 mg
Daily )

60. Heparin
• Patient with recent MI
• Arterial dissection
• Progressing stroke
Exclude ICH on brain imaging before
considering it

61. Carotid endarterectomy
• Carotid stenosis more than 50% on the side of
the brain lesion
• Most effective when-
– Severe stenosis ( 70-90%)
– Performed within first couple of weeks

62. Specific Management of
Haemorrhagic stroke
• Immediate withdrawal of anti-coagulant drug
like warfarin (if any)
• If massive hematoma causing mass effect :
hematoma evacuation
• Nimodipine ( If ventricular extension OR SAH )

63. Secendory Prevention
Treatment Target group
Antiplatelet drugs
(clopidogrel,
aspirin/dipyridamole)
Ischaemic stroke or TIA (in
sinus rhythm)
Statins Ischaemic stroke or TIA
Blood pressure-lowering All stroke (ischaemic or
haemorrhagic)
with blood pressure >
130/80 mmHg

64. CONTINUED…..
Treatment Target group
Anticoagulation with
warfarin
(or newer oral
anticoagulant)
Ischaemic stroke patients
in atrial fbrillation
Carotid endarterectomy Ischaemic stroke or TIA
Recently symptomatic
severe carotid
stenosis

65. Life Style Modification
Smoking cessation
Lower salt intake
Lower fat intake
Lower excess alcohol intake
Increase exercise
Lose excess weight

67. Stroke or atypical or multiple
cerebral TIAs
CT brain scan within24 hours of onset;
MRI if later than 7 days
Ischemic Haemorrhagic

68. Ischemic
ECG
Carotid
duplex

69. ECG
Sinus
Rhythm
Antiplatelet
drugs
Atrial fibrillation
Thyroid function tests and
echocardiogram
Consider Cardioversion
& Anti Arrythmic Drugs
Anti palatelet
drugs IWC
Warfarin if no
Contraindications

70. Carotid Duplex
Refer if > 70% stenosis on symptomatic
side
Carotid endarterectomy
Antiplatelet drugs

71. Along with Previous protocol
• Control BP
• Lower Cholesterol
• Modify life style

72. Haemorrhagic stroke
Lower BP
if BP > 130/70 mmHg 1–2 weeks after onset
Lifestyl
e