Stroke, CVA, Cerebrovascular accident talk

Stroke is a type of cardiovascular disease.
It affects the arteries leading to and within the
brain. A stroke occurs when a blood vessel that
carries oxygen and nutrients to the brain is either
blocked by a clot or bursts. When that happens,
part of the brain cannot get the blood and oxygen it
needs, so it starts to die.
WHAT IS A STROKE?

Ischemic stroke is caused by a lack of blood reaching part of
the brain and is the most common type, accounting for over 80
percent of all strokes:
• Symptoms develop over a few minutes or worsen over hours.
• Ischemic strokes are typically preceded by symptoms or
warning signs that may include loss of strength or sensation on
one side of the body, problems with speech and language or
changes in vision or balance.
• Ischemic strokes usually occur at night or first thing in the
morning.
• Often a TIA (transient ischemic attack) or “mini stroke” may
give some warning of a major ischemic stroke.
TYPES OF STROKE

Fifteen to 20 percent of strokes happen when a blood vessel
ruptures in or near the brain. This is called a hemorrhagic or
bleeding stroke:
• In hemorrhagic strokes, the fatality rate is higher and overall
prognosis is poorer.
• People who have hemorrhagic strokes are younger.
• This kind of stroke is often associated with a very severe
headache, nausea and vomiting, and usually the symptoms appear
suddenly.
• A transient ischemic attack (TIA) or any other stroke warning
sign may not precede this type of stroke.
TYPES OF STROKE

What are the risk factors I can’t control?
Increasing age – stroke affects people of all ages, from young
children to elderly individuals. But the older you are, the greater
your stroke risk.
Gender – in most age groups, more men than women have stroke,
but more women die from stroke.
Heredity and race – people whose close blood relations have had a
stroke have a higher risk of stroke themselves. Certain races have a
higher risk of death and disability from stroke than others, because
they have high blood pressure more often.
Prior stroke – someone who has had a stroke is at a higher risk of
having another one.
RISK FACTORS FOR STROKE

Knowing your risk factors is the key to prevention - some can be
changed or treated, others can’t.
What risk factors can I change or treat?
High blood pressure – this is the single most important risk factor
for stroke. Know your blood pressure and have it checked at least
once every two years. If it’s 140/90 or about, it’s high. Talk to your
doctor about how to control it and take your medicine as directed;
Diet - improve your eating habits by avoiding foods which are high
in fat and cholesterol, cut down on saturated fat, sugar and salt. Eat
more fruit, vegetables, cereals, dried peas and beans, pasta, fish,
poultry and lean meats;

6
Tobacco use – don’t smoke cigarettes or use other forms of
tobacco;
Diabetes – while diabetes is treatable, having it increases your
risk of stroke. Work with your doctor to manage diabetes and
reduce other risk factors;

Carotid or other artery disease – the carotid arteries in your neck supply blood
to your brain. A carotid artery damaged by a fatty build-up of plaque inside the artery wall
may become blocked by a blood clot, causing a stroke;
TIAs – Transient ischemic attacks (TIAs) are “mini strokes” that produce stroke-like
symptoms but no lasting effects. Recognizing and treating TIAs can reduce the risk of a
major stroke. Know the warning signs of a TIA and seek emergency medical treatment
immediately;
Atrial fibrillation or other heart disease – in atrial fibrillation the heart’s upper chambers
quiver rather than beat effectively, causing the blood to pool and clot, increasing the risk of
stroke. People with other types of heart disease have a higher risk of stroke too;
Certain blood disorders – a high red blood cell count makes clots more likely, raising the
risk of stroke. Sickle cell anemia increases stroke risk because the “sickled” cells stick to
blood vessel walls and may block arteries;
High blood cholesterol – high blood cholesterol increases the risk of clogged arteries. If
an artery leading to the brain becomes blocked, a stroke results.

Physical inactivity and obesity - being inactive, obese or both
can increase your risk of cardiovascular disease. Exercise
regularly – check with your doctor before you start. Start slowly
and build up to at least 30 minutes a session at least three to four
times per week. Try to maintain a healthy weight;
Excessive alcohol intake – drinking an average of more than
one drink per day for women or more than two drinks a day for
men raises blood pressure. Binge drinking can lead to stroke, so
limit your alcohol intake.
Stress – decrease your stress level as much as possible and seek
emotional support when it’s needed.

HOW TO RECOGNIZE IF YOU ARE
HAVING A STROKE...
Call the Emergency Services immediately if you are experiencing:
• Sudden numbness or weakness of the face, arm or leg, especially
on one side of the body;
• Sudden confusion, trouble speaking or understanding;
• Sudden trouble seeing in one or both eyes;
• Sudden trouble walking, dizziness, loss of balance or co-ordination;
• Sudden severe headache with no known cause.

HOW TO RECOGNIZE IF SOMEONE
ELSE IS HAVING A STROKE...
At a recent American Stroke Association conference, a report was
presented that showed a bystander may be able to spot someone having a
stroke by giving a quick, simple test, as follows:
• Asking the individual to smile;
• Asking him or her to raise both arms and keep them up;
• Asking the person to speak a simple sentence coherently.
If the person has trouble with any of these tasks, contact the Emergency
Services immediately and describe the symptoms to the Dispatcher. Time
is crucial in treating a stroke.

History of Cerebrovascular Disease
Where have we been?
Where are we now?
Where should we go in the
future?
04/04/2017 11

400 BC-1700 AD
Emphasis on Prognosis and early
Exploration of Brain Anatomy and
Function
Hippocrates- circa 400 BC
Galen 130-200 AD
Andre Vesalius 1514-1564
Johann Wepfer 1620-1695
Sir Thomas Willis 1621-1675
The Past

Johann Jakob Wepfer 1620-1695
Observationes Anatomicae, ex Cadaveribus
Eorum, quos Sustulit Apoplexia (1658)
Performed necropsies and showed that bleeding
into the brain was an important cause of
apoplexy
Described the anatomy and presence of
hardening and occlusions within the intracranial
Carotid and Middle Cerebral Arteries
The Past-Pathology

Sir Thomas Willis 1621-1675
Dissections described and illustrated by Sir
Christopher Wrenn in Cerebri Anatomi (1664)
Clarified anatomy of the Brain and Cranial Nerves
Dissected cranial arteries and described
connections at the base of the Brain (Circle of
Willis)
Respected clinician who described TIAs and
Migraine
The Past- Anatomy and Clinical

Sir Thomas Willis
Sedleian
Professor of
Natural
Philosophy at
Oxford
University

Diagram of an Anastamosis - Willis 1664

Rudolph Ludwig Carl Virchow (1821-1902)
Clearly showed that vascular occlusion
caused infarction
Described the phenomenology of
arterial thrombosis
Recognized the important interaction
between the vascular wall and the blood
Described embolism
The Past-Pathology & pathophysiology

Vieusseux -1810
Dec 29, 1807 Vieusseux developed an unusual
and severe pain in the left gum and jaw. 5 days
later the pain recurred along with severe pain in
the left eye.
He then developed severe vertigo. “A peculiar and
inexpressible perturbation in all his sensations” a
giddiness that affected his vision and “occasioned
feelings similar to those produced by a ship
violently agitated.”
He then lost his voice, had difficulty swallowing,
and felt that his left side was weak.

Vieusseux -1810
He then examined himself and found that “the whole
of his right side was so insensible that he could be
scratched or pinched without experiencing any pain
and that this insensibility abruptly terminated at a
line dividing the whole body in a vertical direction”
The sensations of heat and cold were totally different
from normal on his right side but he was puzzled to
find that he had not lost the perception of touch on
his right side.
The left side of the head and face were also
insensible to pricking or scratching over the left
forehead, nose, lips, chin, and ear.

Vieusseux -1810
The whole of the left side of the body
preserved its usual degree of sensibility.”
He also noted that his left eye was partially
shut and the left corner of the mouth was
drawn downward.
His left leg dragged when he walked.
During the next weeks the dysarthria and
dysphagia improved but he developed
hiccups
“His intellectual faculties remained quite
unimpaired so that he could accurately
observe the whole succession of symptoms.”

Charles Miller Fisher
Pathology and Clinical Features of ICH (1961-71)
Clinical features (1951-4) and pathology (1986) of
Carotid Artery Disease
Clinical features of Vertebral artery disease (1971)
and Vascular lesions in Lateral Medullary Infarcts
(1961)
Clinical and pathological features of Lacunar
infarction (1965-present)

1951
Technology is rapidly improving and still
developing. CT and MRI allow delineation of the
location and type of lesion and CTA and CT
perfusion, MRA, and extracranial and
transcranial ultrasound (TCD) allow definition of
arterial lesions. Echocardiography, cardiac
rhythm monitoring, and blood analysis detect
cardiac, aortic, and hematological causes of
stroke. Neurologists of today can quickly and
safely define the cause and extent of
cerebrovascular disease.

Cerebrovascular
Accident
(Stroke)

I.Definition of Terms:
Cerebrovascular Accident
- Also know as stroke and brain attacks
-is a sudden loss of neurological
function caused by an interruption of the
blood flow to the brain

I. Definition of terms
-It is a non-traumatic brain injury caused
by occlusion or rupture of cerebral blood
vessel that results in sudden
neurological deficit characterized by
loss of motor control.

I. Definition of Terms
Aneurysm
-It is a localized dilatation or bulging of
the blood vessels especially arteries
- It promotes rupture of the vessel as it
continues to bulge.

APOPLEXY – sudden strike of paralysis,
dumbness or fainting, from which victim
is frequently failed to recover
o Atherosclerosis
-Formation of multiple plaques within
the blood vessels.

Embolus
- an object that migrates from one part
of the body to causes blockage or
occlusion to another part of the body.

I. Definition of terms
Hematocrit
-Also know as Packed Cell Volume
(PCV) or Erythrocyte Volume Fraction
(EVF)
-is the proportion of the blood volume,
which is occupied by red blood cell.

Hemorrhage
-Is the loss of blood at the circulatory system
or excessive presence of blood outside the
circulation
- Can be internally or externally.

Hypertension
 Also referred to as high blood pressure
(HTN or HPN.)
 It is a medical condition in which the blood
pressure is chronically elevated
Infarction
-A process of anoxic death of tissue due to loss of
blood supply because of occlusion or blockage of the
artery

Ischemic
-Insufficient blood flow to an organ
cause by the blockage of the artery.
Transient Ischemic Attack
-(Mini Stroke) Caused by changes in
blood supply in the brain produces
same manifestation as stroke within 24
hours.

Thrombus
- Is the final product of the blood
coagulation step in hemostasis It is
achieved via the aggregation of
platelets that form a platelet plug. It is
physiologic in injury but pathologic in
case of thrombosis

II. Epidemiology
Stroke is the third leading cause of
death.
The most common cause of disability
among adults at the United States
It is approximately 700,000 individuals
was affected each year.

II. Epidemiology
About 500,000 are new strokes and
200,000 are recurrent strokes (Usually
people older than 65 y/o).
In United States, in 1960’s 200 per
100,000 are affected by stroke and it
was decreased as it reached to late
1960’s –1970’s.

II. Epidemiology
In 1980’s the stroke is flattened
because of the improvement of cranial
computed tomography (CT) and
Magnetic Resonance imaging (MRI).
According to age, 28% higher
possibilities in people older than 65 y/o
than younger ones

II. Epidemiology
According to sex, having an incidence
of stroke, Men are 19% higher rather
than women.
According to race, Black Americans are
more prone rather that White
Americans.
Asian Countries are more prone having
stroke compared to United States.
(Cause by intracranial hemorrhage)

Causes Percentage
Large vessel
occlusion/infarction
32
Embolism 32
Small vessel occlusion/
lacunar
18
Intracerebral hemorrhage 11
Subarachnoid hemorrhage 7
II. Epidemiology
Table 77-2 Causes of stroke (Delisa)

II. Epidemiology
Most of the patients who die from acute
stroke succumb in the first 30 days.
Survival in the first 30 days of new
stroke reported to be 70- 85%
dependent on the stroke type.

II. Epidemiology
In Intracerebral Hemorrhage is only 20-
50% , cause death usually occur in first
3 days.
In Cerebral infraction is 85%.
After 30 days of survival, the death rate
declines.

III. Epidemiology
Stroke is most commonly cause of
chronic disability.

II. Etiology
A. Atherosclerosis
-Major contributory factor of Cerebrovascular
Accident.
-accumulation of lipids, fibrins, complex
carbohydrates and calcium deposit on the arterial
walls that leads to progressive narrowing of blood
vessels.
Found in the bifurcations of vessels.

II. Etiology
B. Ischemic Strokes
-Results from a thrombus, embolism or
conditions that produce low systemic
perfusions pressures.

II. Etiology
C. Cerebral Thrombosis
 Refers to the formation of development of
a blood clot within the arteries and their
branches.
 Moving thrombus is called embolus.

II. Etiology
Thrombosis  Ischemia  Infarction
IntraCerebral Hemorrhage
 Is cause by the ruptured of cerebral vessel
with subsequent bleeding to brain
Types of IntraCerebral Hemorrhage

II. Etiology
-Primary CEREBRAL Hemorrhage
-occurs in small blood vessels
weakened by atherosclerosis produces
aneurysm.
-SUBARACHNOID hemorrhage
-hemorrhage occurs at the sub arachnid
space typically from a saccular or berry
aneurysm affecting primary vessels.

II. Etiology
E. Artriovenous malformation
 Is a congenital defect that can cause
stroke.
-The arteries and veins are tortuous
tangled with interposing capillaries
system.

III. Risk Factors of Stroke
Hypertension- Is the most important
risk factors
 It is define as a blood pressure higher
than 160/95 mmHg.
 Among the survivors of stroke, 67% of
them have chronic hypertension
 It gives risk in cerebral infarction,
thrombotic, lacunars and hemorrhagic
stroke.

2. Heart disease
 Is an important risk factor for stroke
 Atrial fibrillation and valvular heart disease
increase the risk of cerebral infarction
because of presence of cerebral emboli.

3.Diabetes Mellitus
 Independent risk factor that doubles the
risk of stroke.
 It increases the risk of ischemic stroke
to three to six times.
 The prevalence of diabetes among
stroke survivors is 20%.

4. Hyperlipidemia
 Poses only small additional risk for strokes
mainly for individuals younger at age of 55.
 Increase in blood viscosity, hematocrit and
serum fibrinogen have been implied the
risk factor of stroke.

Risk Factors of stroke
Smoking
 It is an important factor for cardiovascular
disease but influence for stroke is not
cleared.
 The risk for heavy smokers (>40
cigarettes) is twice than light smokers (<10
cigarettes).

III. Risk Factors Of Stroke
- Some studies that smoking to an
increased risk of hemorrhagic stroke in
addition to ischemic cerebral infarction.

III. Risk factor of stroke
6. Transient Ischemic Attack
-Is another important risk factor.
- An About 10 % of individuals with TIA
will go on to have a major stroke within
90 days and 5 % will have a major
stroke within 2 days.

III. Risk Factors of stroke
7. Obesity
 Hypertension and diabetes mellitus are in
common in obese and strong influences
risk of stroke.
 Some studies says that weight loss has
positive influences on blood pressure and
diabetic control and also helps in reduction
of risk of strokes.

IV. Stroke Prevention
Active promotions of lifestyle changes
by physicians have the best potential to
decrease the annual rate of new stroke
occurrence.

To the individuals who have a stroke in
the past history additional intervention
and medication was given like:
-Antiplatelet therapy
- Anticoagulation
-Carotid Endarterectomy.

Antiplatelet Therapy
-Aspirin is the most frequently prescribe
antiplatelet agent.
-Aspirin achieves a significant anti
platelet effect at fairly low serum
concentrations.

Anticoagulation
-The use of Warfarin anticoagulation for
primary stroke prevention in non-
valvular atrial fibrillation.
-Warfarin reduces relative stroke risk by
58%to 86%over that in control subjects.

Carotid Endarterectomy
 Is a surgical procedure that use to correct
the carotid stenosis
 It is the removal of material inside the
artery.

CEREBRAL BLOOD FLOW
(CBF)
Controlled by auto-regulatory
mechanism that modulates a constant
rate of blood flow through the brain.
These mechanisms provide
homeostatic balance.

ISCHEMIC CASCADE
Within seconds to minutes of the loss
of perfusion to a portion of the brain, an
ischemic cascade is unleashed.

CLASSIFICATIONS OF
STROKE
• Ischemic
 Thrombus
 Embolism
 Lacunar
• Hemorrhagic
 Subarachnoid
 Intracerebral

ISCHEMIC STROKE
Thrombus
 Due to Atherosclerotic Plaque Formation
 Occurs frequently at major vascular branching
sites including COMMON CAROTID and
VERTEBROBASILAR ARTERIES.
 Occurs often in the presence of chronic
hypertension.

ISCHEMIC STROKE
Embolism
 Major Source of cerebral emboli is the
heart.
 Atrial fibrillation
 Most emboli lodge in the middle
cerebral artery distribution because
80% of the blood carried by the large
neck arteries flow through the middle
cerebral arteries.

ISCHEMIC STROKE
 Most Frequent Target:
 Superficial branches of cerebral and
cerebellar arteries.

ISCHEMIC STROKE
Lacunars Infarct
 Lacunar infarcts occur as a result of an
occlusion of small, deep penetrating arteries
known as Lenticulostriate Arteries branch from
the MCA.
 Occlusions of these vessels or penetrating
branches of the circle of Willis, including
vertebral or basilar arteries, are referred to as
lacunar strokes.

ISCHEMIC STROKE
Small arteriole becomes torturous and
develops subintimal dissection and
micro-aneuryms rendering the arteriole
susceptible to occlusion from micro-
thrombi.
 Fibrin Deposition

HEMORRHAGIC STROKE
Subarachnoid Hemorrhage
 Bleeding that occurs between the Dura
and Pia Mater.
 Commonly caused by:
1.ARTERIOVENOUS MALFORMATION
(AVM)
1. ANEURYSMS

HEMORRHAGIC STROKE
1. AVM
• Tangled, dilated blood vessels in which arteries flow
directly into veins.
• Occur most often at the junction of cerebral arteries,
usually within the parenchyma of the frontal-parietal
region, frontal lobe, lateral cerebellum, or overlying
occipital lobe.
• Results to seizures.

HEMORRHAGIC STROKE
2. Aneurysms
• Focal dilations in the artery
• Found in the anterior region of the Circle of Willis,
particularly near branches of the Anterior Communicating
Artery, ICA, MCA and junctions of almost any branch site.
• Contributing factors include atherosclerosis and
hypertension.

HEMORRHAGIC STROKE
Intracerebral Hemorrhage
 Originates from deep penetrating vessels and
causes injury to the brain tissue by disrupting
connecting pathways and causing localized
pressure injury.
 Bleeding in the surrounding brain tissue.
 Also caused by AVM and aneurysms.

OCCLUSIONS IN THE
ARTERIES
• ANTERIOR CEREBRAL ARTERY (ACA)
 First of the two terminal branches of the internal
carotid artery (ICA). It supplies the medial
aspect of the cerebral hemispheres (frontal and
parietal) and subcortical structures, including
basal ganglia.
 Proximal occlusion results to minimal defects
since the Anterior Communicating artery allows
perfusion of the proximal ant. cerebral artery.
 ACA occlusions are uncommon.
ACA

OCCLUSIONS IN THE
ARTERIES
• VERTEBROBASILAR ARTERY
 Arise from the subclavian arteries and travel
into the brain along the medulla where they
merge at the inferior border of the pons to form
the basilar artery. The basilar artery eventually
gives rise to two Posterior Communicating
Artery.

SIGN AND SYMPTOMS…
Symptoms of stroke depend on the
type and which area of the brain is
affected. Signs of ischemic stroke
usually occur suddenly, and signs of
hemorrhagic stroke usually develop
gradually. Symptoms include the
following:

Difficulty speaking or understanding
speech (aphasia)
Difficulty walking
Dizziness or lightheadedness (vertigo)
Numbness, paralysis, or weakness,
usually on one side of the body
Seizure (relatively rare)
Severe headache with no known cause
Sudden confusion

Sudden decrease in the level of
consciousness
Sudden loss of balance or coordination
Sudden vision problems (e.g., blurry
vision, blindness in one eye)
Vomiting

COMPLICATION…
Complications may result from ischemic
cascade or develop as a result of the
patient becoming immobile or
bedridden.

COMPLICATION…
Complications that may occur within 72
hours of stroke include the following:
Cerebral swelling (edema)
Increased intracranial pressure (ICP)
Intracerebral hemorrhage
Seizures

MUSCULOSKELETAL
loss of voluntary movement and
immobility result in loss of range of
movement and contractures.
UE: limitations in shoulder motions of
flexion, abduction, and external rotation
Contructure
Disuse atrophy and muscle weakness
Impairments in gait, balance, falls
Osteoporosis

NEUROLOGICAL
SEIZURES- common right after stroke
during the acute phase and late-onset
seizures can also occur several month
after stroke
Common in occlusive carotid disease
(17%)
HYDROCEPHALUS- may experience
headache, nausea, vomiting, ↑ lethargy,
and ataxia.

CARDIOVASCULAR/
PULMONARY
THROMBOPHLEBITIS/DVT
-complication for all immobilized
patients
DVT signs:
- rapid onset of unilateral leg
swelling with dependent edema
- tenderness, dull ache, or tight
feeling in calf; not severe pain

CARDIOVASCULAR/PULMONA
RY
CARDIAC FUNCTION
- impaired cardiac output
- cardiac decompensation
- serious rhythm disorders
- directly alter cerebral perfusion and produce
additional focal signs
- exhibit low work capacities result acute illness,
bedrest, and limited activities level.
- ↓ activity levels may also related to depression

CARDIOVASCULAR/PULMONA
RY
PULMONARY FUNCTION
- ↓lung volume
- ↓pulmonary perfusion
- ↓vital signs
- altered chest wall excursion
- ↑fatigue
- ↓endurance

CARDIOVASCULAR
PULMONARY
ASPIRATION- more common during
any phase of recovery and can occur
during any phase of swallowing
DYSPHAGIA- lead to dehydration and
compromised nutrition

INTEGUMENTARY
Ischemic damage and subsequent
necrosis of the skin results in skin
breakdown and decubitus ulcer
Skin breakdown typically over bony
prominence from pressure, friction,
shearing and/or maceration

Differential Diagnosis
Lethargy
Dizziness/Vertigo
Slurred speech
Loss of coordination
Uncontrollable eye movements
Behavioral changes

Disease
Hypoglycemia
Mass Lesions
History
Blood sugar is too
low
Cerebral Abscess
Subdural Hematoma
Metastatic Tumor
Distinguishing
Features
Hunger,
Nervousness, Cold
sweat, Convulsion
Progressive
syndrome, Rigorous
headache,
Stiff/aching at the
neck, shoulders and
back

Disease
Multiple
Sclerosis
Epilepsy
Encephalitis
History
Autoimmune disease
that affects the CNS
Abnormal electrical
activity in the brain
Inflammation in the
brain
Distinguishing
Features
Decrease attention
span, urinary
frequency, hearing
loss
Electric shock feeling,
drooling, twitching
movements
Fever, , delirium,
deafness, dementia

LABORATORY TEST AND
DIAGNOSTIC TOOLS

TEST AND MEASURES
1. Urinalysis
-Detects infection, diabetes, renal
failure, dehydration
-can reveal diseases that have gone
unnoticed because they do not
produce striking signs or symptoms.

TEST AND MEASURES
2. Blood analysis
-Provides complete blood count,
platelet count, prothrombin time,
partial thromboplastin time, and
erythrocyte sedimentation rate.

TEST AND MEASURES
3. Fasting blood glucose level
-Is used to screen for and diagnose
diabetes and pre-diabetes.
-Collected after an 8 to 10 hr fast
4. Blood chemistry profile
-Test measures the value of a different
substance in the blood. These values
provide information on the function of
different organ systems (kidney, liver,
etc.) or the risk for

TEST AND MEASURES
5. Blood cholesterol and lipid profile
-Is a group of simple blood tests that
reveal important information about the
types, amount and distribution of the
various types of fats (lipids) in the
bloodstream.
6. Thyroid function tests
-A collective term for blood tests
used to check the function of the thyroid

TEST AND MEASURES
7. Full cardiac evaluation
-Includes electrocardiograph to detect
arrhythmias as source of emboli or
coincidental heart disease.
8. Echocardiography
-Also known as a cardiac
ultrasound
-It uses standard ultrasound
techniques to image two-dimensional
slices of the heart. The latest ultrasound
systems now employ 3D real-time imaging.

TEST AND MEASURES
9. Lumbar puncture
-diagnostic and at times therapeutic
procedure that is performed in order to
collect a sample of cerebrospinal fluid
(CSF) for biochemical, microbiological,
and cytological analysis, or occasionally
as a treatment ("therapeutic lumbar
puncture") to relieve increased
intracranial pressure.

IMAGING
1. Computerized Tomography
-Commonly used imaging technique
-Allows identification of large arteries
and vein, and venous sinuses
-Used to rule out other brain lesions

Hemorrhagic stroke Ischemic stroke

2. Magnetic Resonance Imaging
-Measures nuclear particles as
they interact with powerful
magnetic field
IMAGING

IMAGING
3. Positron Emission Tomography
-Allows imaging of regional blood
flow and localized cerebral
metabolism
4. Transcranial and Carotid Doppler
-Used for noninvasive imaging of
the neck and chest level.

IMAGING
5. Cerebral Angiography
-Invasive and involves the
injection of radiopaque dye into
blood vessels with subsequent
radiography

Cerebral Angiogram showing a transverse projection of vertebrobasilar
and posterior cerebral circulation

Recovery begins as people get better from the
immediate effects of a stroke. Over months and even years,
other areas of the brain might learn to take over from the dead
areas.
Rehabilitation is the process of overcoming or
learning to cope with the damage the stroke has caused.
Stroke can cause weakness or paralysis in one side
of the body and problem with balance or coordination.

Helps regain as much mobility and muscle
control as possible.
Assess the stroke survivor’s strength,
endurance, ROM, gait abnormalities and
sensory deficits to design individualized
rehabilitation program.

Work at patient bedside assuring adequate
ROM and teaching bed mobilities, rolling and
sitting.
Helps survivors regain the use of stroke
impaired limbs, teach compensatory
strategies to reduce the effect of remaining
deficits and establish ongoing program to help
people retain their newly learned skills.

Positioning
The room should be arranged to maximize
patient awareness of the hemiplegic side. Affected
side should be towards the main part of the room.
Since patient spends significant time on bed, we
have to prevent undesirable posture which can lead to
contractures or pressure sores.

BE PATIENT. REHABILITATION IS A
SLOW AND OFTEN FRUSTRATING PROCESS.
DON’T WORRY IF THERE ARE DAYS WHEN
LITTLE PROGRESS SEEMS TO BE MADE.

BE POSITIVE. CONSTANT
ENCOURAGEMENT AND PRAISE ARE
NEEDED TO KEEP UP EVRYONE’S
SPIRITS.

NO PROGRAM CAN SUCCEED WITHOUT
A STRONG DESIRE BY THE PATIENT
TO BE INDEPENDENT.NEVERTHELESS;
FAMILY INVOLVEMENT IS ALSO A KEY
INGREDIENT IN A SUCCESSFUL
REHABILITATION PROGRAM.

134
Neuro-ophthalmology:
•Visual field abnormalities…primarily those
related to neuro-ophthalmic problems
•Case
•Field defect in relation to anatomical location
•Importance of the history and examination

04/04/2017 135
case
A 43y woman complains of a mild headache
(left forehead). The headache has been
present 2 months, and is not getting better.
As you listen she tells you the sight is dim in left
eye.
Examination confirms red colours in the left eye
are not as bright as when seen with the right
eye.
Further examination shows a pale optic disk
and afferent pupillary defect, and visual field
defect, but even without these findings a CT
scan is needed. CT scan details:

04/04/2017 137
Recall
…visual pathway

04/04/2017 138
Recall
…disease of the eye itself causes various visual
symptoms

04/04/2017 139
Recall
…disease of the eye itself causes various visual
symptoms
cataract
glaucoma
Retinitis pigmentosa or advanced glaucoma
Macular
degeneration
Retinal vascular
occlusion
Refractive
error

04/04/2017 141
Optic nerve
No symptoms
Loss of
colour vision
Central scotoma
(or greater)
Pain behind eye with eye
movements + visual symptoms
Headache and visual symptoms

04/04/2017 142
Pituitary (chiasmal) area

04/04/2017 143
Pituitary (chiasmal) area
right left

04/04/2017 145
Retrochisamal
Large lesion
anywhere
Smaller
lesions…specific
features…this is
temporal lobe

04/04/2017 146
Visual symptoms mini-quiz
Central vision
reduced ARMD
Superior retinal vein
occlusion
Tunnel vision…young
patient…RP
This field both
eyes…CVA/SOL
Loss of colour
vision…optic nerve
unilateral
This field both
eyes…CVA/SOL
Temporal lobe
Central vision reduced
optic nerve
Young patient
old patient

04/04/2017 148
Summary
•The history can give you a BIG clue
•CT/MRI helpful …
but experts will locate lesion without
•Horizontal border to defects….eye
•Vertical…..retro-chiasm
•Early disease…few if any symptoms
•Small pituitary tumours…no field defect
(microadenomas)
•Key symptoms can be very localising..eg
loss of colour vision in one eye, gradual
increase in headache over 2 months,

Cardioembolic
Stroke:
Diagnosis and
Management

Treatment
of Acute
Cardioembolic
Stroke

 Recent trial results
 Risk factors for early stroke recurrence
 Risk of hemorrhagic complications
 Risk factors for sympotomatic ICH
 Recommendations for therapy
Treatment of Acute
Cardioembolic Stroke

Risk of Early Stroke Recurrence
 Multiple recent emboli
 Mechanical heart valve
 Atrial fibrillation + high risk features
 Established intra-cardiac thrombus
Treatment of Acute

Acute Medical
Treatment of Stroke
Restore Blood Flow
 Thrombolytics
 Mechanical devices
 Stroke progression
or recurrent
thromboembolism
 Anticoagulants
 Antiplatelet agents

Stroke Code
Who is eligible for tPA?
What needs to be checked
before starting the tPA infusion?
Common errors to avoid

Guidelines for
Anticoagulant Therapy
Urgent administration of anticoagulants
has not yet been associated with
lessening the risk of early recurrent
stroke or improving outcomes. Because
it can increase the risk of brain
hemorrhage, routine use cannot be
recommended.
American Heart Association, 2003

Guidelines for
Anticoagulant Therapy
Anticoagulants are not recommended for
any subgroup of patients with acute stroke
based on any presumed mechanism or
location (e.g., cardioembolic, large vessel
atherosclerotic, vertebrobasilar, or
“progressing” stroke) because data are
insufficient.
American Academy of Neurology / AHA, 2003

Recurrent Stroke Within 14
Days
(N = 19,435)

Guidelines for
Aspirin Therapy
Early aspirin therapy (160-325 mg/day)
is recommended
Delay aspirin for at least 24 hours after
tPA
Aspirin can be used safely in
combination with low doses of
subcutaneous heparin
Acute Ischemic Stroke

Guidelines for
Acute Stroke Therapy
tPA is recommended for eligible patients
within 3 hours of stroke onset
Aspirin is recommended for non-tPA
eligible patients
Use of full-dose anticoagulation with
intravenous, subcutaneous, or low
molecular weight heparins should be
avoided
ACCP, 2004

Risk of Hemorrhagic Complications
 Anticoagulation increases the risk of
extracranial hemorrhage by about 2%
 Spontaneous hemorrhagic transformation is
common and usually asymptomatic
 Anticoagulation increases the risk of
symptomatic ICH by about 2%
Treatment of Acute

Risk Factors for Symptomatic ICH
 Infarct size
 Timing of reperfusion (12 - 48 hours)
 Excesssive anticoagulation / tPA
 Heparin bolus?
 Severe hypertension?
Treatment of Acute

Recommendations for Therapy
 Aspirin for acute therapy (t-PA if eligible)
 If low risk for early recurrence:
begin warfarin (days to weeks)
 If high risk of early recurrence:
consider early anticoagulation if low risk for
symptomatic hemorrhage
Treatment of Acute

 Diagnostic criteria for cardioembolism
 Clinical and neuroimaging features
 Aortic atheroma
 Patent foramen ovale
 Treatment of cardioembolic stroke
Cardioembolic Stroke:
Diagnosis and Management

Stroke, CVA, Cerebrovascular accident talk

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