This document provides information about strokes, including: - Strokes occur when the blood supply to the brain is interrupted, causing neurological deficits. The two main types are ischemic (85%) and hemorrhagic (15%). - Risk factors include hypertension, diabetes, high cholesterol, smoking, obesity, and prior cardiovascular disease. - Diagnosis involves history, physical exam, blood tests, CT/MRI scans. CT scans are used to distinguish between ischemic and hemorrhagic strokes. - Treatment depends on the type of stroke. Ischemic strokes may be treated with fibrinolytic drugs like rtPA within 3 hours to break up clots. Hemorrhagic strokes focus on controlling

1. STROKE
RAZIL K. R

2. INTRODUCTION
 When the blood supply to the brain is seriously
disturbed spontaneously is called stroke
 If the blood supply to the brain is interrupted even for
few seconds damage to neurons occurs

3. DEFINITION
 FOCAL NEUROLOGICAL DEFICIT DUE TO LOCAL
DISTURBANCE OF BLOOD SUPPLY TO THE BRAIN ,
IT ONSET IS USUALLY ABRUPT BUT MAY EXTEND
OVER FEW HOURS OR EVEN LONGER

4. EPIDEMIOLOGY
 Stroke is frequent cause of death
 The incidence incresed with age, mainly people b/w
40-60 yrs also effected more
 Stroke occurs 30% more frequently in men than
women

5. TYPES
ISCHEMIC STROKE
Where the blood supply to the part of brain suddently
become inadequate for a brain to fn it occurs 85%
HAEMORRHAGIC STROKE
Where the blood vessel rupture and blood rushes with
through the brain tissues .destroying / outside the
brain it self in to the SA space , it accounts for 15%
TIA: if symptom less than 1-2 hrs

6. ETIOLOGY
 ISHEMIC : cerebral thrombosis, cerebral
embolism(clot may responsible for embolism),
cerebral ishemia
 HAEMORRHAGIC: weakness of vessel wall, high BP,
cerebral aneurysm, AV malformation,

7. RISK FACTORS
 HTN
 DM
 Cholestrerol
 Smoking
 Obesity
 CV diseases
 Use of OCP
 Genetic

8. PATHOPHYSIOLOGY
Stroke is an devastating event because of brain
circulatory and metabolic need for survival , the brain
uses 15% cardiac output & consume 20% oxygen supply
available for entire body
 ISCHEMIC
Blood vessel occuldes ( > 6 mtr)
Necrosis

9. Still viable but non functional (is called ischemic
penumbra) with cerebral infarction
Edema resulting incresed ICP & herniation

10. HAEMORRHAGIC
Blood fread in to surrounding cerebral
parenchyma
Create haematoma
It displace and compress adjacent cerebral tissues
Cerebral edema occurs resulting increased ICP

11.  Majot initial cerebral haemorrahage laeds to mid line
shift and herniation , its has high mortality rate about
50%

12. SIGNS & SYMPTOMS
 facial deviation
 Arm drift
 Slurred speech
 Head ache , numbness , visual field deficit ,
incordinate gait, hemiplegia, weakness

13. DIAGNOSTIC EVALUATION
 H/O , P/E
 Routine blood tests
 Cerebral angiography
 CT , MRI
 LP ( during recovery phase to r/o chronic meningitis)

14. CT

15. MRI

16. CINCINNATI PRE HOSPITAL
STROKE SCALE
 FACIAL DROOP
One side of face does not move as well as the other side
 ARM DRIFT
One arm does not move or one arm drift down
compared with the other(one sided motor weakness)
 ABNORMAL SPEECH
Pt slurs words , uses the wrong words, or its unable to
speak

17. AMBULANCE VICTORIA STROKE
SCALE
 1. facial droop
 2. speech
 3. hand grip
 4. blood glucose level : hypoglycemia

18. THE LOS ANGELES PRE HOSPITAL
STROKE SCALE
 Scrrening criteria all should be YES or can be
UNKNOWN
Age > 45 yrs
h/o seizure / epilepsy
Symptom began < 24 hrs ago
Pt not wheel chair – bound or bed ridden at base line
Blood glucose level b/w 60- 100 mg/dl

19.  Interpretation : if any 1 of these 3 signs is abnormal ,
the probability of a stroke is 72%. The presence of all 3
findings indicates that the probability of stroke is
greater than 85%

20. RX
 Time to arrival to hospital to the CT being in run in 25
mnts, with the CT being run and interpreted in 45
mnts of arrival at the hospital
 CT ----- heamorrhagic
 YES NO
 Neuro cx , admit ICU fibrolytic therapy
 (< 3 hrs in ischemic )

21. MANAGEMENT - general
 Mgt of incresed ICP due to cerebral edema ,
inj. Mannitol 100mg
 Anticoagulant therapy except haemorrahgic stroke
Inj. Heparin 5000 iu , sc
 Anti convalsants therapy to reduce seizure occurrence
 Anti hypertensives to reduce BP and cardio vascular
disease

22. Surgical mgt
 Carotid endarterectomy is a surgical procedure
performed by vascular surgeons used to reduce the risk
of stroke by correcting stenosis in the common carotid
artery or internal carotid artery. Endarterectomy is the
removal of material on the inside of an arteryd
endarterectomy

23. FIBROLYSIS IN STROKE
 Pt who could be treated with rtPA with in 3 hrs from
symptom onset
 INDICATION
Diagnostic of iscemic stroke causing measurable
neurological deficit
Onset of symptom < 3 hrs before beginning Tx
Age > 18 yrs

24. Contra indication
 Significant head truma or prior stroke in prevuios 3 mnths
 Symptom suggest SAH
 Arterial puncture at non compressible site in previous 7
days
 h/o previous ICH
 Elevated BP > 185 /110 mmhg
 Active internal bleeding
 Blood glucose < 50 mg /dl
 Acute bleeding diathesis – current use of anti coagulants
INR > 1.7 or PT > 15 sec

25. Relative contra indication
 Seizure at onset with postictal residual neuro deficit
 Pregnancy
 Major surgery or serious trauma with in previous 14
days
 Recent GI /UT bleeding
 Recent AMI

26. MX – hemorrhagic stroke
 Reduce progression of bleeding
 Correcting coagulopathy or giving procoagulant
 Blood pressure control
 Reduce mass effect
 Hematoma removal
 Decompressive hemicraniectomy
 External Ventricular Drain

27. STROKE ALGORITHM
 Identify signs and symptoms of possible stroke
Activate EMS
CRITICAL EMS ASESSMENTS AND ACTIONS
 supports ABCs give o2 if needed
 Perform pre hospital stroke asessment
 establish the time of symptom onset
 Triage to stroke centre
 Alert hospital : consider direct transfer to CT
 check blood glucose as possible

28.  IMMEDIATE GEN. ASSESSMENT & STABILIZATION
 asess ABC s vitals
 Provide oxygen if hypoxemic
 Obtain IV acess & perform lab asessessments
 Check gluecose
 Perform neuro assessments
 Activate stroke team
 Order emergent CT or MRI of brain
 obtain 12 lead ECG

29. IMMEDIATE NEURO ASSESSMENT BY STROKE
TEAM
 Review pt h/o
 Establish time of symptom onset or last known
normal
 perform neurological assessment (NIH scale or
canadian neurological scale )

30.  does CT scan show hemorrhage
no hemorrhage hemorrhage

probable acute IS consult neurologist
consider fibrolytic therapy or neuro sx ,
 consider fibrolytic exclusion
 rpt neuro exam : are deficit rapidly admit ICU
improving to normal

31.  Patient remains candidate for fibrinolytic therapy
 (if candidate )
 Review risks / beneficts with pt and family if
acceptable
 Give rtPA
 No anticoagulan ts tx for 24 hrs

32.  Begin post rtPA stroke pathway
 Aggressively monitor
 Emergent admission to stroke unit or ICU

(if not a candidate )
administer ASPIRIN
admit to stroke unit or ICU