1. A stroke occurs when blood flow to the brain is interrupted, either by a blood clot blocking a vessel (ischemic stroke) or a blood vessel rupturing (hemorrhagic stroke). 2. The main types of ischemic strokes are caused by blood clots forming in arteries (thrombosis) or traveling from another part of the body (embolism). Hemorrhagic strokes are either subarachnoid hemorrhages or intracerebral hemorrhages. 3. Treatment for ischemic strokes involves clot-busting drugs or surgery to remove clots, while hemorrhagic strokes focus on controlling bleeding, blood pressure, and complications. The goals are

1. STROKE
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2. Stroke
■ A stroke is the acute neurologic injury that occurs as a result of one of these pathologic
processes:
 The process may be intrinsic to the vessel, as in atherosclerosis, arterial dissection,
lipohyalinosis, developmental malformation, aneurysmal dilation, or venous
thrombosis, inflammation or amyloid deposition,.
 The process may originate remotely, as occurs when an embolus from the heart or
extracranial circulation lodges in an intracranial vessel.
 The process may result from inadequate cerebral blood flow due to decreased
perfusion pressure or increased blood viscosity.

3. ■ The first three processes can lead to transient ischemic attack
or ischemic stroke
PERIPHRA
L
CARDIAC CEREBRAL
Overlap of serious vascular
disease in the stroke patient

4. ■ The process may result from rupture of a vessel in the subarachnoid space or
intracerebral tissue.
■ The fourth results in either subarachnoid hemorrhage or an intracerebral hemorrhage
(primary hemorrhagic stroke).
■ Approximately 80 percent of strokes are due to ischemic cerebral infarction and 20
percent to brain hemorrhage.

5. CALSSIFICATION
Stroke
Ischemic
Thrombosis Embolism
Systemic
hypoprefusion
Hemorrhagic
Subarachnoid
hemorrhage
Intracerebral
hemorrhage

6. Strokeinevolution
Completedstroke
Reversibleischemicneurologicdeficit
a stroke that
resolves
within 1
week A stroke in
which
symptoms
are not
worsening
stroke
in which
symptoms
are
worsening

9. TIA
■ A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or
retinal ischemia, without acute infarction.
■ This tissue-based definition ofTIA relies on the absence of end-organ injury as
assessed by imaging or other techniques.

10. Ischemia
Thrombotic
Large vessel
disease
Small vessel
disease
Embolic
Cardiac source
Cardiac or
aortic source
Arterial source
Unknown
source
Systemic
hypoprefusion

13. Ischemic stroke risk factors
- Age older than 40 years - Heart disease
- High blood pressure - Smoking
- Recent childbirth - High blood cholesterol levels
- Illegal drug use - Inactive lifestyle and lack of exercise
- Previous history of transient ischemic attack - Obesity
- Diabetes - Current or past history of blood clots
- Family history of cardiac disease and/or stroke

14. HEMORRHAGIC STROKE

18. Intracerebral hemorrhage
 Bleeding in intracerebral hemorrhage is usually derived from arterioles or small
arteries.
 The bleeding is directly into the brain, forming a localized hematoma which spreads
along white matter pathways.
 Accumulation of blood occurs over minutes or hours; the hematoma gradually
enlarges by adding blood at its periphery like a snowball rolling downhill.
 The most common causes of ICH are hypertension, trauma, bleeding diatheses,
amyloid angiopathy, illicit drug use (mostly amphetamines and cocaine), and vascular
malformations. Less frequent causes include bleeding into tumors, aneurysmal
rupture, and vasculitis.
 Neurologic symptoms usually increase gradually over minutes or a few hours.

19. Subarachnoid hemorrhage
■ Rupture of arterial aneurysms is the major cause of subarachnoid hemorrhage.
■ Aneurysm rupture releases blood directly into the cerebrospinal fluid (CSF) under
arterial pressure.The blood spreads quickly within the CSF, rapidly increasing
intracranial pressure.
■ Death or deep coma ensues if the bleeding continues.The bleeding usually lasts only a
few seconds but rebleeding is common.
■ Other causes of SAH: vascular malformations, bleeding diatheses, trauma, amyloid
angiopathy, and illicit drug use, the bleeding is less abrupt and may continue over a
longer period of time.

20. ■ Symptoms of SAH begin abruptly, occurring at night in 30 percent of cases.The
primary symptom is a sudden, severe headache (97 percent of cases).
■ The headache is lateralized in 30 percent of patients, predominantly to the side of the
aneurysm.The onset of the headache may or may not be associated with a brief loss
of consciousness, seizure, nausea, vomiting, focal neurologic deficit, or stiff neck

22. Hemorrhagic stroke risk factors
- High blood pressure - Smoking
- Illegal drug use (especially cocaine and "crystal meth")
- Use of warfarin or other blood thinning medicines
In some cases, the stroke may be due to problems with the blood vessels in the brain or
the blood itself. For example:
■ A hemorrhagic stroke can occur if a person has an aneurysm (a weakness in a blood
vessel wall), even if this has never caused symptoms in the past.
■ An ischemic stroke may occur in a healthy person who takes certain medications (for
example, estrogen replacement therapy increases the risk of blood clots).

23. CLINICAL FEUTURES:

25. MANEGMENT
■ The goals in the initial evaluation include:
●Insuring medical stability
●Quickly reversing any conditions that are contributing to the patient's problem
●Moving toward uncovering the pathophysiologic basis of the patient's neurologic symptoms.
 It’s important to assess and optimize vital physiologic function before sending the patient
for an imaging study.
 Vital signs —concern in patients with stroke: blood pressure, breathing, and temperature.
 The history and physical examination should be used to distinguish between other
disorders in the differential diagnosis of stroke

27. INVESTIGATIONS:
■ Blood tests and brain imaging:
• The imaging is to see the area of the brain affected by the stroke, as well as to confirm
the type of stroke (ischemic or hemorrhagic).
• NoncontrastCT is typically the first diagnostic study in patients with suspected stroke.
• CT is highly sensitive for the diagnosis of hemorrhage in the acute setting.
• MRI is more sensitive than CT for the early diagnosis of brain infarction.

28. ■ Blood tests:
• Complete blood count
• Platelet count
• Prothrombin time and partial thromboplastin time
• Serum lipids
■ Heart testing:
• Electrocardiogram (ECG)
• Echocardiogram
 Because many people with ischemic strokes also have coronary artery disease, there may
be a lack of blood flow in the heart during the stroke.

29. TREATMENT
 Ischemic stroke:
■ Intravenous thrombolytic therapy with alteplase (recombinant tissue-type
plasminogen activator or rt-PA) improves outcomes in patients with acute ischemic
stroke who can be treated within 3 to 4.5 hours from stroke onset.
■ Early treatment with intra-arterial mechanical thrombectomy using a second-
generation stent retriever device improves outcomes for patients with ischemic stroke
caused by a large artery occlusion in the proximal anterior circulation.

31. ■ Guidelines from the American Heart Association/American Stroke Association
recommend that patients with ICH receive monitoring and management in an
intensive care unit.
■ Specific recommended interventions for patients with ICH:
• Sources of fever should be treated, and guidelines suggest the use of antipyretic
medications to lower body temperature
• Hyperglycemia in the first 24 hours after stroke is associated with adverse outcomes,
and current guidelines suggest insulin treatment to target serum glucose level
between 140 to 180 mg/dL. Hypoglycemia should be avoided.

32. • Intermittent pneumatic compression is the mainstay for prevention of venous
thromboembolism in acute ICH.
• Normal saline initially should be used for maintenance and replacement fluids;
hypotonic fluids are contraindicated as they may exacerbate cerebral edema and
intracranial pressure. Hypervolemia should be avoided as it may worsen cerebral
edema.
• Dysphagia is common and is a major risk factor for developing aspiration pneumonia.
Prevention of aspiration in patients with acute stroke includes initial NPO status until
swallowing function is evaluated. Some experts suggest that patients with a GCS <8
be intubated to decrease the risk of aspiration.

33. ■ For patients who develop an ICH, all anticoagulant and antiplatelet drugs should be
discontinued acutely after the onset of hemorrhage, and anticoagulant effect should
be reversed immediately with appropriate agents.
■ Aggressive use of intravenous vitamin K may be necessary in patients who suffer an
ICH while taking warfarin.

34. ■ Blood pressure:
■ Current guidelines for managing elevated blood pressure in acute ICH are:
• For patients with SBP >200 mmHg or MAP >150 mmHg, consider aggressive reduction of blood
pressure with continuous intravenous infusion of medication accompanied by frequent (every five
minutes) blood pressure monitoring
• For patients with SBP >180 mmHg or MAP >130 mmHg and evidence or suspicion of elevated ICP,
consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous
medication to keep cerebral perfusion pressure in the range of 61 to 80 mmHg
• For patients with SBP >180 mmHg or MAP >130 mmHg and no evidence or suspicion of elevated ICP,
consider a modest reduction of blood pressure (eg, target MAP of 110 mmHg or target blood pressure
of 160/90 mmHg) using intermittent or continuous intravenous medication, and clinically reexamine
the patient every 15 minutes

35. ■ Seizure treatment:
• The reported risk of seizures in patients with acute spontaneous ICH ranges from 4.2
to 29 percent.
• If a seizure occurs, appropriate intravenous antiepileptic drug (AED) treatment should
be administered to prevent recurrent seizures.
 Intracranial pressure:
Current guidelines recommend a graded approach to the management of elevated ICP:
• Elevate the head of the bed to 30 degrees, once hypovolemia is excluded.

36. • Analgesia and sedation, particularly in unstable, intubated patients. Sedation should be
titrated to control pain and minimize ICP elevation.
• Normal saline initially should be used for maintenance and replacement fluids; hypotonic
fluids are contraindicated.
• Glucocorticoids should NOT be used to lower the ICP in most patients with ICH.
Dexamethasone did not improve outcome but did increase complication rates, primarily
infection.
• Intravenous mannitol is the treatment of choice to lower increased intracranial pressure,
quickly and effectively lowering ICP. Barbiturate anesthesia can be used if mannitol fails to
lower ICP to an acceptable range.
• Cerebrospinal fluid drainage by intraventricular catheter placement (ventriculostomy) is an
effective means of lowering ICP.
• Surgery

37. ■ After completing the initial assessment, the goal of the subsequent evaluation is to
determine the underlying pathophysiology of the stroke in order to guide therapy.
■ In practice, then, this second stage of evaluation is focused upon distinguishing
between embolic and thrombotic strokes