Stroke & its Management ( Medicine)
•Download as PPTX, PDF•
0 likes•105 views
This document discusses stroke, its types, symptoms, risk factors, investigations, management, and prevention. It defines stroke as a medical emergency caused by interrupted or reduced blood flow to the brain. The main types are ischemic (cerebral infarction) and hemorrhagic strokes (intracerebral hemorrhage and subarachnoid hemorrhage). Symptoms vary depending on the affected brain region but can include paralysis, confusion, vision changes, and severe headaches. Risk factors include high blood pressure, smoking, heart disease, and age. Investigations may include CT/MRI scans and angiography. General management focuses on treating underlying causes, while prevention emphasizes controlling hypertension and stopping smoking.
More Related Content
What's hot
What's hot (20)
Similar to Stroke & its Management ( Medicine)
Similar to Stroke & its Management ( Medicine) (20)
Recently uploaded
Recently uploaded (20)
Stroke & its Management ( Medicine)
- 1. Stroke & Its Types Dr, Syed Altaf Assistant Professor SBB Dewan University
- 2. • Definition of stroke • Types of stroke? • Pathophysiology • Clinical features • Investigations • Management • Risk Factors • Prevention Objectives Dr Syed Altaf Assistant Professor
- 3. Blood Supply of the Brain Dr Syed Altaf Assistant Professor
- 4. Dr Syed Altaf Assistant Professor
- 5. 2 Stroke • A stroke is a Medical Emergency in which the blood supply to any portion of the brain is interrupted or reduced. Definitions Stroke is defined as rapid onset of neurological deficit (usually focal) which is the result of a vascular lesion and associated with infarction of central nervous tissue. Dr Syed Altaf Assistant Professor
- 6. PathoPhysiology • Of the 180–300 patients per 100 000 population presenting annually with a stroke. • 85% sustain a cerebral infarction due to inadequate blood flow to part of the brain & most of the remainder have an intracerebral hemorrhage. Dr Syed Altaf Assistant Professor
- 7. S Y M P T O M S • Paralysis or weakness in the face, arms and/or legs. • Confusion. • Personality changes. • Sudden change in eyesight. • Decreased motor skills. • Severe headaches A sudden development of one or more of the following symptoms usually Indicates a Stroke. Dr Syed Altaf Assistant
- 8. 8 Cerebral infarction (Ischemic stroke) • Most Thrombo-Embolic cerebral infarctions cause an obvious stroke. • Following vessel occlusion brain ischemia occurs, followed by infarction. •Cerebral infarction is mostly caused by thromboembolic disease secondary to atherosclerosis in the major extra cranial arteries. (carotid artery and aortic arch). Dr Syed Altaf Assistant Professor
- 9. Cerebral hemisphere infarcts • The most common stroke is the hemiplegia caused by infarction of the internal capsule. • The signs are contralateral to the lesion: • Hemiplegia (arm > leg) • Hemi sensory loss. • UMN facial weakness. • Hemianopia. Dr Syed Altaf Assistant
- 10. • Brainstem infarction causes complex patterns of dysfunction depending on the sites involved: Brainstem infarction Dr Syed Altaf Assistant Professor
- 11. Lateral medullary Syndrome (Wallenberg Syndrome) Dr Syed Altaf Assistant
- 12. Dr Syed Altaf Assistant Professor
- 13. Intra-cerebral Hemorrhage Dr Syed Altaf Assistant
- 14. Intracerebral hemorrhage (ICB) • Intracerebral hemorrhage causes about 10% of acute stroke events but is more common in low-income countries. • It usually results from rupture of a blood vessel within the brain parenchyma but may also occur in a patient with an SAH. Dr Syed Altaf Assistant
- 15. Intracerebral hemorrhage (ICB) • If big enough, this can cause shift of the intracranial contents, producing transtentorial coning and sometimes rapid Death. Dr Syed Altaf Assistant Professor
- 16. Major risk factors for intracerebral hemorrhage Smoking Excess alcohol consumption HTN Dr Syed Altaf Assistant
- 17. Intracerebral Hemorrhage Diagnosis •CT scan •MRI General Management • Stop Anticoagulant • Maintain BP Surgical Management (Hydrocephalus) Dr Syed Altaf Assistant Professor
- 18. Subarachnoid hemorrhage (SAH) • SAH is a Neurological Emergency. • Incidence: (5% of stroke) • 1 /100000 • Age 50 Dr Syed Altaf Assistant
- 19. Clinical features SAH • Most intracranial aneurysms remain asymptomatic until they rupture and cause a SAH. Thunder Headache • The typical presentation of SAH is the sudden onset of severe headache. • Nausea/Vomiting • LOC Dr Syed Altaf Assistant
- 20. On Examination • On examination there may be signs of meningeal irritation (neck stiffness and a positive Kernig’s sign) Subhyaloid Hemorrhage 3rd Nerve palsy Dr Syed Altaf Assistant
- 21. Investigation • CT scan is the investigation of choice and should be undertaken as soon as possible. • Lumbar puncture is indicated if there is a strong clinical suspicion of a SAH but the CT scan is normal. • MR angiography Source of Bleeding fit for surgery. Dr Syed Altaf Assistant Professor
- 22. Management • Anti-HTN Drugs • 60mg 4hrsly P/O • 1-2mg I/V central line to reduce cerebral artery spasm, a cause of ischemia and further neurological deterioration. • Surviving patients should be advised on secondary prevention, especially on treatment of hypertension & the need to stop smoking. Dr Syed Altaf Assistant
- 23. RISKSFactors • High Blood Pressure • High Cholesterol • Smoking • Heart Disease • Diabetes • Obesity • Excessive alcohol consumption • Family History • Age • Sex • Race Modifiable Non-Modifiable Dr Syed Altaf Assistant Professor
- 24. Investigations • Blood Tests: (CBC,ESR,HbAIC,Lipid profile) • CT. Scan • MRI • Electrocardiogram (ECG): underlying heart conditions • Echocardiogram: blood clot from heart • Carotid Duplex: carotid artery stenosis. • Cerebral Angiography: identify responsible blood vessel Dr Syed Altaf Assistant Professor
- 25. General Management Stroke Treat Underline causes • Aspirin (300 mg Once 75mg daily for Ischemic Stroke. • Thrombolysis (rt-PA) I/V 0.05-0.1 mg/kg/hr • Statins (lipid-lowering Drugs) • Anti-HTN (Drugs) Dr Syed Altaf Assistant Professor
- 26. Prevention Dr Syed Altaf Assistant Professor
- 27. References Dr Syed Altaf Assistant Professor
Editor's Notes
- Blood supply of the brain : Two pairs of arteries, the carotid and vertebral. ■ The internal carotid system, 80% of the brain’s blood supply (anterior circulation) ■ The vertebral basilar system from subclavian artery(20%) (posterior circulation) Anastomose in the arterial circle of Willis.
- The arterial supply to the brain. (A) The area above the dotted line is supplied by the internal carotid artery and the area below the line is supplied by the vertebral artery. (B) A coronal section through the brain. The anterior cerebral artery supplies the medial surface of the hemisphere and the middle cerebral artery supplies the lateral surface of the hemisphere, including the internal capsule.
- Stroke is the second most common cause of death and a major cause of disability world-wide. About one-fifth of patients with an acute stroke die within a month of the event and at least half of those who survive are left with physical disability. Alternative names: Cerebrovascular accident/ disease (CVA), Cerebral infarction, Cerebral hemorrhage.
- Most strokes (85%) are caused by cerebral infarction due to arterial embolism or thrombosis. Thrombosis occurs at the site of an atheromatous plaque in carotid, vertebral or cerebral arteries. Emboli arise from atheromatous plaques in the carotid/vertebrobasilar arteries, or from cardiac mural thrombi (e.g. following myocardial infarction), or from the left atrium in atrial fibrillation. In about 15% of cases stroke is caused by intracranial or subarachnoid haemorrhage. Less commonly the clinical picture of stroke may be caused by intracranial venous thrombosis, multiple sclerosis relapse
- Ataxia Stroke causing damage to the cerebellum and its connections can present as an acute Ataxia. Coma first 24 hrs (SAH,ICB) Seizure is unusual in acute stroke but may be generalized or focal in cerebral venous disease.
- About 20% of infarctions are due to embolism from the heart, and a further 20% are due to thrombosis in situ caused by intrinsic disease of small perforating vessels (lenticulostriate arteries), producing so-called lacunar infarctions. About 5% are due to rare causes, including vasculitis,endocarditis & cerebral venous disease.
- internal capsule (the narrow zone of motor and sensory fibres that converges on the brainstem from the cerebral cortex; following occlusion of a branch of the MCA. Initially the patient has a hypotonic hemiplegia with decreased reflexes; within days this develops into a spastic hemiplegia with increased reflexes and an extensor plantar response, i.e. an upper motor neurone lesion.
- The arterial supply to the brain. (A) The area above the dotted line is supplied by the internal carotid artery and the area below the line is supplied by the vertebral artery. (B) A coronal section through the brain. The anterior cerebral artery supplies the medial surface of the hemisphere and the middle cerebral artery supplies the lateral surface of the hemisphere, including the internal capsule.
- It presents with sudden vomiting and vertigo, ipsilateral Horner’s syndrome, facial numbness, cerebellar signs and palatal paralysis with a diminished gag reflex. On the side opposite the lesion there is loss of pain and temperature sensation.
- The locked-in syndrome in which all voluntary muscles are paralysed except for those that control eye movement is caused by upper brainstem Infarction. Consciousness is preserved because the reticular formation is not damaged. The patient has intact vertical eye movements and blinking because the supranuclear ocular motor pathways that run dorsally are spared. The patient is able to communicate by movement of the eyelids but otherwise is completely immobile.
- The explosive entry of blood into the brain parenchyma causes immediate cessation of function in that area as neurons are structurally disrupted and white-matter fiber tracts are split apart. The haemorrhage itself may expand over the first minutes or hours, or it may be associated with a rim of cerebral oedema, which, along with the haematoma, acts like a mass lesion to cause progression of the neurological deficit.
- A transtentorial herniation is the movement of brain tissue from one intracranial compartment to another. This includes uncal, central, and upward herniation. These are life-threatening and time-critical pathologies that may be reversible with emergent surgical intervention and medical management Tonsillar herniation : specifically the movement of the cerebellar tonsils through the foramen magnum. The cerebellar tonsils are ovoid structures on the inferomedial surface of each cerebellar hemisphere. They are attached to the underlying cerebellum by the tonsillar peduncle.
- These risk factors lead to secondary vascular changes such as small vessel disease and arterial aneurysms which may eventually rupture and bleed. Presentation is with sudden loss of consciousness and stroke often accompanied by a severe headache..
- decision to restart anticoagulants (usually stopped for 7–10 days after an intracerebral haemorrhage) is made on case by case basis. Surgical Management Patients with a large intracerebral haematoma causing deepening coma or brainstem compression or patients with a cerebellar bleed causing hydrocephalus as a result of obstruction of the drainage pathways for CSF fluid should be referred for immediate neurosurgical evaluation.
- Subarachnoid hemorrhage means spontaneous rather than traumatic arterial bleeding into the subarachnoid space. Saccular (‘berry’) aneurysms in 70% of cases. These are acquired lesions that are most commonly located at the branching points. Congenital arteriovenous malformations in 10%.
- The typical presentation of SAH is the sudden onset of severe headache, often occipital, that reaches maximum intensity immediately or within minutes. The headache is typically described as the ‘worst ever’ and there is absence of similar headaches in the past. It is often accompanied by nausea and vomiting, and sometimes loss of consciousness.
- One of the physically demonstrable symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. A SUBHYALOID hemorrhage is an intraocular collection of blood that remains contained in a self-created, previously nonexistent space, usually between the posterior limiting layer of the vitreous and the retina. 3rd nerve Palsy : Symptoms and signs include diplopia, ptosis, and paresis of eye adduction and of upward and downward gaze. If the pupil is affected, it is dilated, and light reflexes are impaired.
- CT scan is the investigation of choice and should be undertaken as soon as possible. It shows subarachnoid or intraventricular blood in 95% of cases undergoing scanning within 24 hours of the haemorrhage; the sensitivity decreases after that time. Lumbar puncture : LP must be performed at least 12 hours. after symptom onset to allow sufficient time for haemoglobin to degrade into oxyhaemoglobin and Bilirubin.An increase in pigments (bilirubin and/or oxyhaemoglobin released from lysis and phagocytosis of red blood cells) is the key finding which supports the diagnosis of SAH. Detection of oxyhaemoglobin without bilirubin makes SAH less likely. Pigments in the CSF are detected by spectrophotometry of the supernatant after centrifugation of the last fraction of CSF taken at lumbar puncture. The specimen should be protected from light. Bilirubin can be detected in the CSF for up to 2 weeks after SAH.
- TIA CAD
- These help identify underlying causes of cerebrovascular disease: for example, blood glucose (diabetes mellitus), triglycerides and cholesterol (hyperlipidaemia) or full blood count (polycythaemia) in stroke. Erythrocyte sedimentation rate (ESR) and immunological tests, such as measurement of antineutrophil cytoplasmic antibodies (ANCA) (p. 1068), may be required when vasculitis is suspected. Genetic testing for rarer inherited conditions, such as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy), may be indicated.
- Aspirin 300mg daily) should be started immediately after an ischaemic stroke unless rt-PA has been given, in which case it should be withheld for at least 24 hours.Aspirin it may be given by rectal suppository or by nasogastric tube in dysphagic patients. Antiplatelet drugs • Aspirin 300 mg at once then 75 mg daily • Clopidogrel 75 mg daily if aspirin-intolerant • Dipyridamole MR 200 mg twice daily if event whilst on aspirin Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) increases the risk of haemorrhagic transformation of the cerebral infarct with potentially fatal results. However, if it is given within 4.5 hours of symptom onset to carefully selected patients, the haemorrhagic risk is offset by an improvement in overall outcome.The earlier treatment is given, the greater the benefit.