This document provides information about strokes, including: - The anatomy of the brain and its blood supply from arteries. - The definition of a stroke as a neurological dysfunction lasting over 24 hours due to cerebrovascular disease. - The types, causes, risk factors, signs and symptoms, and management of ischemic and hemorrhagic strokes. - Myths and facts about strokes, including that up to 80% are preventable but they can affect anyone at any time. It then discusses the case of a 77-year-old woman who suffered paralysis on her right side and an inability to speak after a stroke, indicating a left middle cerebral artery blockage.

1. STROKE
Prepared By : MS. Nechirvan M Arif
MS. Sabah Salim Majeed

2. • Anatomy ,Blood Supply ,Function Areas
• Introducion ,Definiton ,infos
• Pathophysiology ,Risk Factors ,Causes
• Types ,Syndromes ,S&S ,Differentation
• Managment ,DDx ,Prognosis
• Facts and Myths
• Case Discussion (Problem Solving)

3. A 77-year-old woman was cooking in the kitchen when she collapsed
onto the floor. Her daughter called an ambulance and the woman
was taken to the emergency room. She had suffered a stroke, and
slowly regained consciousness over the next two days. However,
when she woke up, she had the following signs and symptoms:
- paralysis of the right face and arm
- loss of sensation to touch on the skin of the right face and arm
- inability to answer questions but ability to understand what was
said to her
- ability to write down her thoughts more easily than to speak them
Disscussion would be on the LAST SLIDES

4. Anatomy of brain and it’s blood supply
• The brain receives its arterial supply from two pairs of vessels, the vertebral and
internal carotid arteries which are interconnected in the cranial cavity to produce
an arterial circle (of Willis).
• Vertebral Artery Branch of first part of subclavian A Passes – foramen
transvesarium C6 – C1 Enters through foramen magnum – perforates dura &
arachnoid mater – enters subarachnoid space Turns upward, forward, medially –
medulla oblongata Lower border of pons – joins opposite side to form BASILAR
artery.
• The two internal carotid arteries enter the cranial cavity through the carotid
canals on either side.

9. Functional areas of brain

10. Blood Supply

11. What’s Stroke ?
• an episode of neurological dysfunction due to a
cerebrovasculare diseases which last for more than 24hr. &
reach it's peak of defecit in less than 6hr

12. Top 10 causes of death worldwide
• Of the 56.4 million deaths worldwide in 2015,
more than half (54%) were due to the top 10
causes. Ischaemic heart disease and stroke are
the world’s biggest killers, accounting for a
combined 15 million deaths in 2015. These
diseases have remained the leading causes of
death globally in the last 15 years

13. Stroke By The Numbers
•Each year nearly 800,000 people experience a new or
recurrent stroke.
•A stroke happens every 40 seconds.
•Stroke is the fifth leading cause of death in the U.S.
•Every 4 minutes someone dies from stroke.
•Up to 80 percent of strokes can be prevented.
•Stroke is the leading cause of adult disability in the U.

14. Types of stroke
• Ischemic stroke It accounts for 80% of all stroke cases.
• Hemorrhagic stroke : aneurysms and arteriovenous
malformations(AVMs). But uncontrolled hypertension (high
blood pressure).
• TIA (transient ischemic attack) : “mini stroke”symptoms
resolve within 24 hours due to a temporary clot

16. Types of Stroke
80% ischemic 20% hemorrhagic
50%
Thromboti
c
30%
embolic
13%
Intracerebral
7%
SAH
Mortality
40%
Mortality
80%

17. Causes of stroke
Atherosclerosis Hypertension
Embolization
Intravascular coagulation
Vasculitis

18. Pathophysiology of ischemic stroke
• Insufficiency of blood supply
• causes cell hypoxia
• 6-8 minutes ---> Infarction
• neurons & other cells die.
• Ischemic Penumbra : area of stunned parenchyma
surrounding the ischemic core.
• Has the potential for recovery ONLY if reperfusion is rapidly
established.

19. Ischemic penumbra

20. (A) Non modifiable:
–age
–Race/ethnicity
–Gender : Male>Female
–Family history
Risk factors

21. Risk factors
(B) Modifiable:
• Hypertension
• DM
• Heart disease (AF)
• Hyperlipidemia
• Cigarette Smoking
• Excessive alcohol consumption
• Estrogen –containing drugs e.g OCP
• Sickle cell diseases ,polycythemia
• Malignancy

22. 1- Hemorrhagic & Ischemic.
2- Anterior & Posterior cerebral circulation.
How To Diffrentiate ???
(clinical)
Stroke syndromes

23. ***About 80 out of 100 strokes are ischemic strokes.

24. Ischemic Stroke
• Sudden numbness or weakness of the face, arm or leg,
especially involving one side of the body
• Sudden confusion, trouble speaking or understanding
• Loss of vision in one or both eyes
• Trouble walking, dizziness, loss of balance or coordination

25. Hemorrhagic Stroke
(A) Intracerebral hemorrhage
(B) Subarachnoid hemorrhage

26. (A) Intracerebral hemorrhage — Symptoms almost always occur when the
person is awake.
it appeara without warning, and develop gradually.
Symptoms worsen over a period of 30 to 90 minutes include:
– Sudden weakness
– Paralysis or numbness in any part of the body
– Inability to speak
– Inability to control eye movements correctly
– Vomiting
– Difficulty walking
– Irregular breathing
– Stupor
– Coma

27. (B) Subarachnoid hemorrhage — When caused by a ruptured
aneurysm, symptoms can include:
– A very severe headache that starts suddenly (Some people describe it like
a "thunderclap.")
– Loss of consciousness
– Nausea and vomiting
– Inability to look at bright light
– Stiff neck
– Dizziness
– Confusion
– Seizure
– Loss of consciousness

29. Posterior
Patients usually have crossed findings (cranial nerve findings
ipsilateral, with motor and sensory findings contralateral) and
include some of the
5 Ds (dizziness, diplopia, dysarthria, dysphagia, and dystaxia)

31. Mangement

32. Investigation
• CT scan (Computerised Tomography) : to rule out a possible bleed in
the brain.
• Blood tests : TF, cholesterol levels and glucose levels.
• Carotid Duplex (atherosclerosis).
• ECG
• MRI scan

33. Management Of Ischemic Stroke
• ABC: Airway - secure? Breathing - O2 Sat, CHF? Circulation - BP too high
or too low ?
• BP,BS,Hydration,Infection
• Thrombolysis : Less than three hr. rTPA (recombinant tissue
plasminogen activator )
• Antiplatelete : Aspirin Clopidogril
• Anticoagulant : Warfarin
• Statin

34. Saving penumbra area
•Keep BP high
•Good oxygenation
•hypothermia
•Euglycemia
•Keeping the brain dry

35. Management Of Hemorrhagic
• O2
• Manitol
• Head elevation 30 degree
• Hyperventilation
• High-dose 20% mannitol (1.4 g/kg) results in better ICP control and outcome
than lower doses
• –STANDARD: No Steroids!
• BP Reduction
• Prophylactic phenytoin for 7 days for patients at risk for increased ICP
• Surgical Management

36. Differential diagnosis
Functional
Hypoglycemia
Todd's paresis
Conversional disorders
Encephalitis
Demyelination
Migraine with aura
Structural
Primary brain tumor
Metastatic brain
tumor
SDH
Cerebral abscess

37. ***ICH – Worse Outcomes Than Ischemic Stroke
***Stroke Effect depends on Site , Duration and
amount of dead brain tissue
Prognosis

38. MYTH FACT
MYTH: Stroke cannot be prevented. FACT: Up to 80 percent of strokes are preventable.
MYTH: There is no treatment for stroke.
FACT: At any sign of stroke call 9-1-1- immediately. Treatment may be
available.
MYTH: Stroke only affects the elderly. FACT: Stroke can happen to anyone at any time.
MYTH: Stroke happens in the heart. FACT: Stroke is a "brain attack".
MYTH: Stroke recovery only happens for the first few months after a
stroke.
FACT: Stroke recovery is a lifelong process.
MYTH: Strokes are rare.
FACT: There are nearly 7 million stroke survivors in the U.S. Stroke is the
5th leading cause of death in the U.S.
MYTH: Strokes are not hereditary. FACT: Family history of stroke increases your chance for stroke.
MYTH: If stroke symptoms go away, you don’t have to see a
doctor.
FACT: Temporary stroke symptoms are called transient ischemic
attacks (TIA). They are warning signs prior to actual stroke and
need to be taken seriously.

39. A 77-year-old woman was cooking in the kitchen when she collapsed
onto the floor. Her daughter called an ambulance and the woman
was taken to the emergency room. She had suffered a stroke, and
slowly regained consciousness over the next two days. However,
when she woke up, she had the following signs and symptoms:
- paralysis of the right face and arm
- loss of sensation to touch on the skin of the right face and arm
- inability to answer questions but ability to understand what was
said to her
- ability to write down her thoughts more easily than to speak them

40. Questions:
1. Based upon the patient's symptoms, which cerebral artery was blocked?
(Be Specific)
2. Why was she paralyzed in the right face and arm?
3. What is the name of her language disorder, and what caused it?
4. Was this woman's dominant or nondominant hemisphere damaged?

41. THANK YOU.