Download as PDF, PPTX
![Stroke | Ischemic stroke: Treatment
Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
What to do if
the time has
passed?
Source: Powers et al (2019) Guidelines for Management of AIS
Intra-arterial thrombolysis
(<6 hours)
[only MCA stroke]
Mechanical
thrombectomy (up to 24
hours)
[only large-artery stroke]](https://image.slidesharecdn.com/stroke-240714125350-c14dae8d/75/Stroke-of-different-types-Hemorrhagic-Ischemic-25-2048.jpg)
![DUAL AND TRIPLE ANTITHROMBOTIC THERAPY FOR SECONDARY STROKE [Autosaved].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/dualandtripleantithrombotictherapyforsecondarystrokeautosaved-230904113552-c3502b37-thumbnail.jpg?width=640&height=640&fit=bounds)
Stroke of different types.Hemorrhagic,Ischemic
- 1. Stroke Department of Neurologyand Neurosurgery Odessa National Medical University 2020 Alina Ivaniuk teaching assistant
- 2. Vascular supply of thebrain 0 Department of Neurology and Neurosurgery Odessa National Medical University, 2020
- 3. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 Stroke | Vascular supply of the brain Image source: Bluemenfeld’s Neuroanatomy through clinical cases (2010)
- 4. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 Stroke | Vascular supply of the brain Image source: Wikimedia Commons
- 5. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 Stroke | Vascular supply of the brain Image source: Wikimedia Commons
- 6. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 Stroke | Vascular supply of the brain Image source: Radiopaedia.org
- 7. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 Stroke | Vascular supply of the brain Image source: Bluemenfeld’s Neuroanatomy through clinical cases (2010)
- 8. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 Stroke | Vascular supply of the brain Image source: Bluemenfeld’s Neuroanatomy through clinical cases (2010)
- 9. Stroke | Definitionand classification of stroke Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Stroke - a disorder of the brain resulting from the disrupted cerebral perfusion Ischemic Hemorrhagic due to blockage of an artery due to bleeding from an artery 85% 15%
- 10. Ischemic stroke 1 Department ofNeurology and Neurosurgery Odessa National Medical University, 2020
- 11. Ischemic stroke Caplan LR, KasnerSE, Dashe JF. Etiology, Classification, and Epidemiology of Stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate https://www.uptodate.com/contents/etiology-classification-and-epidemiology-of-stroke Stroke | Ischemic stroke: Risk factors Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Nonmodifiable risk factors Age ≥ 65 years Sex (males > females) Ethnicity (black > white) Family hx of cardiovascular or cerebrovascular disease Genetic disorders (e.g., sickle cell anemia) History of TIA
- 12. Ischemic stroke Caplan LR, KasnerSE, Dashe JF. Etiology, Classification, and Epidemiology of Stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate https://www.uptodate.com/contents/etiology-classification-and-epidemiology-of-stroke Stroke | Ischemic stroke: Risk factors Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Modifiable risk factors Hypertension Hyperlipidemia & atherosclerosis Diabetes mellitus Carotid artery stenosis Atrial fibrillation Obesity Hypercoagulation disorders Alcohol and tobacco overuse Recreational drug use (e.g., cocaine)
- 13. Ischemic stroke |TOAST classification Large-artery atherosclerosis Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke | Ischemic stroke: TOAST classification Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Cardioembolic Small-vessel occlusion Stroke of other determined etiology Stroke of undetermined etiology 1 2 3 4 5
- 14. Ischemic stroke Large-vessel atherosclerosis Stroke| Ischemic stroke: Etiology Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Can be atherothrombotic or atheroembolic - Thrombi most frequently form at the branches of the vessels Image source: Wikimedia Commons (Public Domain)
- 15. Ischemic stroke Cardioembolic stroke Imagesource: Wikimedia Commons (Public Domain) Stroke | Ischemic stroke: Etiology Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Most commonly affects the middle cerebral artery (MCA) Sources: ● Atrial fibrillation > atrial thrombi ● Rheumatic heart disease > valve thrombi ● Ventricular aneurysms > ventricular thrombi ● Infectious emboli (bacterial endocarditis) > valve thrombi Paradoxical embolism occurs in patients with right-to-left cardiac shunt (e.g., patent foramen ovale) !
- 16. Ischemic stroke Small-vessel stroke Imagesource: Mustapha M, Nassir CMNCM, Aminuddin N, Safri AA and Ghazali MM (2019) Cerebral Small Vessel Disease (CSVD) – Lessons From the Animal Models. Front. Physiol. 10:1317. doi: 10.3389/fphys.2019.01317 (CC-BY)) Stroke | Ischemic stroke: Etiology Department of Neurology and Neurosurgery Odessa National Medical University, 2020 a.k.a. lacunar stroke - occurs in subcortical structures w/o involvement of cortex HTN is the major risk factor ● HTN → vasculopathy → lipohyalinosis of the small vessels → occlusion of small arteries (e.g., lenticulostriate artery) → lacunar stroke
- 17. Ischemic stroke Stroke ofother determined etiology Image source: Radiopaedia.org (CC-BY-SA 3.0) Stroke | Ischemic stroke: Etiology Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Hypercoagulability (e.g., thrombophilia, polycythemia, hormonal contraceptives) Vasculitis (e.g., giant-cell arteritis) Arterial dissection Hypotension >> watershed infarct
- 18. Image source: Radiopaedia.org(CC-BY-SA 3.0) Stroke | Ischemic stroke: Etiology Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Core: - irreversible damage (death) - flow <10/100g/min Ischemic penumbra: - reversible damage - electric silence - spreading depression - blood flow < 10-17/100g/min - may become either healthy tissue or core Healthy tissue: - blood flow > 17/100g/min - may become penumbra
- 19. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020 time is BRAIN In stroke, 2 million neurons die each minute get the patient to the hospital, perform CT and initiate treatment ASAP
- 20. Department of Neurologyand Neurosurgery Odessa National Medical University, 2020
- 21. Stroke | Ischemicstroke: Diagnostics Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Initial evaluation Check ABCs and vitals, get IV line Stabilize the vitals if needed Fingerstick glucose Draw blood for tests (do not wait for the results) - glucose - CBC - coagulation Noncontrast CT** Check Hx - time last known well - concurrent conditions (esp. CV) and drug intake Perform NIHSS exam ** + MRI with DWI and ADC seq. for patients with wake-up stroke or presenting > 4.5 hours after onset; CTA or MRA for patients with large-stroke occlusion presenting 6 to 24 hours after onset
- 22. Stroke | Ischemicstroke: Diagnostics Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Imaging Hyperdense MCA sign Hypodensity of brain parenchyma Image source: Radiopaedia.org (CC-BY-SA 3.0)
- 23. Stroke | Ischemicstroke: Diagnostics Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Imaging ??? absence of hemorrhage - most important finding Image source: Radiopaedia.org (CC-BY-SA 3.0)
- 24. Stroke | Ischemicstroke: Treatment Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Thrombolysis indications Confirmed stroke with initial onset of symptoms ≤ 4.5 hours Source: Powers et al (2019) Guidelines for Management of AIS
- 25. Stroke | Ischemicstroke: Treatment Department of Neurology and Neurosurgery Odessa National Medical University, 2020 What to do if the time has passed? Source: Powers et al (2019) Guidelines for Management of AIS Intra-arterial thrombolysis (<6 hours) [only MCA stroke] Mechanical thrombectomy (up to 24 hours) [only large-artery stroke]
- 26. Stroke | Ischemicstroke: Treatment Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Thrombolysis contraindications Any Hx of or present hemorrhagic stroke Ischemic stroke within 3 months Active bleeding or coagulopathy Hypertension > 185/110 mm Hg (decrease 1st) Hypoglycemia < 50 mg/dL or hyperglycemia > 400 mg/dL (correct 1st) Anticoagulation (revert 1st) Minor nondisabling stroke (NIHSS <5) or TIA Source: Powers et al (2019) Guidelines for Management of AIS
- 27. Source: Powers etal (2019) Guidelines for Management of AIS Stroke | Ischemic stroke: Blood pressure management Department of Neurology and Neurosurgery Odessa National Medical University, 2020
- 28. Stroke | Prevention Departmentof Neurology and Neurosurgery Odessa National Medical University, 2020 Stroke prevention Primary Secondary decrease risk of 1st ever stroke decrease risk of next stroke - Healthy diet - Physical activity - Weight loss - Smoking cessation - Medical management of risk factors (e.g., antihypertensives, antiplatelets) - Antiplatelet therapy with aspirin or clopidogrel (started after 24 hours after recanalization) - Management of risk factors
- 29. Transient ischemic attack (TIA) 2 Department ofNeurology and Neurosurgery Odessa National Medical University, 2020
- 30. Stroke | Definitionof TIA Department of Neurology and Neurosurgery Odessa National Medical University, 2020 TIA - temporary, focal cerebral ischemia that results in neurologic deficits without acute infarction or permanent loss of function - Same risk factors as for stroke - TIA increases the risk of further stroke - Features: Manifests with transient focal neurological symptoms (typically last <1 hour) - symptoms depend on the affected vascular territory (e.g., hemianopsia in posterior cerebral artery stroke) - Dx: MRI (to rule out infarction) + carotid ultrasound - Tx: Medical management of risk factors (e.g., antihypertensives, antiplatelets)
- 31. Hemorrhagic stroke 3 Department of Neurologyand Neurosurgery Odessa National Medical University, 2020
- 32. Stroke | Definitionand classification of hemorrhagic stroke Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Hemorrhagic stroke - disrupted cerebral perfusion due to hemorrhage Subarachnoid hemorrhage mostly due to rupture of saccular aneurysms Intraparenchymal hemorrhage mostly due to hypertension and amyloid angiopathy - nontraumatic -
- 33. Stroke | Ischemicstroke: Treatment Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Subarachnoid hemorrhage Most commonly result from ruptured intracranial aneurysms (saccular!) Characterized by thunderclap headache (sudden, severe, worst-in-life) + meningeal signs Best initial test - brain CT - if negative, perform lumbar puncture - if negative, do angiography Treatment - keep SBP under 160 mm Hg - CCB (nimodipine) to prevent vasospasm - maintain euvolemia and electrolyte balance - surgery - endovascular coiling or clipping
- 34. Stroke | Ischemicstroke: Treatment Department of Neurology and Neurosurgery Odessa National Medical University, 2020 Intraparenchymal hemorrhage Most commonly result from chronic arterial hypertension or cerebral amyloid angiopathy Characterized by - focal neurological signs that progress (worsen) over minutes to a few hours - late manifestation: elevated ICP (Cushing triad, decreased mental status, papilledema) Best initial test - brain CT Treatment - SBP > 220 mm Hg: rapidly lower to 140–160 mm Hg - maintain euvolemia and electrolyte balance - if elevated ICP: intubation with hyperventillation, head elevation, mannitol bolus