Topic: Stroke/CVA Faculty: Medicine Course: BSc ATOT - 2nd year - Definition, classification, risk factors, causes, pathophysiology, clinical features, investigations and treatment of stroke - Subarachnoid hemorrhage(SAH) - Transient ischemic attack(TIA)

1. Stroke/CVA
Dr. Salman Ahmad Ansari
Kanachur Institute of Medical Sciences

2. Contents
● Definition of stroke
● Classification
● Risk factors
● Causes
● Pathophysiology
● Clinical features
● Investigations
● Treatment
● SAH
● TIA

3. Stroke/Cerebrovascular accident(CVA)
Defined as sudden onset of neurologic deficit from a vascular
mechanism
- Leading cause of neurological disability in adults
- More common in males and mainly affects elderly people

4. Classification of stroke
Ischemic(85%)
Hemorrhagic(15%):
● Subarachnoid hemorrhage
● Intracerebral hemorrhage

5. Risk factors for stroke
• Hypertension
• Diabetes
• Smoking
• Alcohol consumption
• Family history of stroke
• Obesity
• Hyperlipidemia
• Trauma (hemorrhagic
stroke)
• Drug use(like cocaine)
• Male sex
• Older age
• Race(e.g. blacks)

6. Ischemic stroke
● due to sudden occlusion of an intracranial vessel, with
reduction in blood flow to the brain area supplied by that vessel
● Block can be due to thrombosis in that vessel itself(in situ
thrombosis) or embolism from a distant site

7. ● In situ thrombosis: in previously diseased vessel such as
atherosclerotic vessels - rupture of plaque
● Emboli: from distant sites, such as from the heart and other
arteries

9. Causes of ischemic stroke
Thrombosis
• Small vessel thrombosis
(lacunar stroke)
• Large vessel thrombosis
• Dehydration
Embolic occlusion
• Artery-to-artery
– Carotid disease
– Aortic disease
• Cardio-embolic
– Atrial fibrillation
– Myocardial infarction
– Infective endocarditis

10. Uncommon causes
● Hypercoagulable disorders
● Vasculitis
● Drugs: cocaine

11. Pathophysiology of ischemic stroke
● Block of the vessel leads to reduction in blood flow to the
brain region it supplies
● Which leads to ischemia or infarction depending upon
severity of blood flow
● If blood flow is restored early, patient experiences
transient symptoms, which is called a Transient Ischemic
Attack(TIA)

12. ● Infarcted area is surrounded by an ischemic area, called
ischemic penumbra, the function of which can be restored
within a certain time, but will infarct if not restored
● Revascularisation therapy aims to save the ischemic
penumbra

14. Clinical features of ischemic stroke
● Symptoms occur suddenly - numbness, weakness or paralysis
of the contralateral limbs or face, inability to speak(aphasia),
confusion, visual disturbances in one or both eyes, dizziness,
loss of balance, headache
● History of sudden, severe headache, vomiting, impaired
consciousness or coma
● Neurologic deficits depend upon the vessel blocked and area of
brain involved

16. 108

17. Investigations
Plain CT head:
- Investigation of choice
- Can be done quickly
- Infarct appears as hypointense area(but it can take 24-48 hours
to become visible)
- Helps to exclude hemorrhage, abscesses
- Contrast CT - useful in subacute infarcts

19. MRI brain:
- More expensive and time consuming
- Not preferred in acute situation
- It is more sensitive than CT in picking up early infarction
ECG, echocardiogram
Blood tests: blood sugar, RFT, electrolytes, Hb, coagulation, lipid
profile

20. Treatment of ischemic stroke
Initial management:
- Airway, Breathing, Circulation
- Secure airway
- Oxygen
- Ventilatory support if needed
Antithrombotic treatment:
- Antiplatelet agent(aspirin) should be given as soon as the
diagnosis of ischemic stroke is confirmed
- Loading dose of aspirin 325 mg, followed by 150 mg daily lifelong

21. - Aspirin prevents extension of clot and chances of recurrent stroke,
called secondary prevention
- In case of minor stroke or TIA: clopidogrel plus aspirin(dual
antiplatelet therapy) within 24 hours of symptom onset and
continued for 21 days
Anticoagulation: in atrial fibrillation - heparin or low molecular weight
heparin given subcutaneously
Intravenous thrombolysis: recombinant tPA(tissue plasminogen
activator) within 3 hours of onset of stroke

22. Mechanical thrombectomy: intra-arterial thrombolysis,
endovascular thrombectomy
Statins: high-intensity statins - atorvastatin 80 mg daily lifelong
Supportive measures:
- Antipyretics to reduce temperature
- Monitor blood glucose
- Prevent DVT, infections
- Cerebral edema on 2nd/3rd day - reduced by IV mannitol and
head end elevation

23. SAH

24. Subarachnoid hemorrhage
Bleeding into subarachnoid space

26. Etiology
● Rupture of saccular aneurysm
● Trauma
● Illicit drug use: cocaine
● AV malformation

27. Risk factors
● Cigarette smoking
● Hypertension
● Alcohol
● Family history
● Use of anticoagulants

28. Clinical features
● Sudden, severe headache - thunderclap headache -
described as worst headache of their lives
● Seizure, nausea, vomiting

29. Investigations
● Plain CT head - clot in subarachnoid space
● Lumbar puncture: elevated opening pressure and blood stained
CSF - xanthochromia(yellowish colour)
● CT angiography

32. Xanthochromia

33. Treatment
● ICU admission
● Bedrest, stool softeners, analgesia
● DVT prophylaxis: compression stockings
● Stop all anticoagulants and antiplatelet agents
● Reduce Intracranial pressure(ICP):
- head end elevation
- Mannitol 20% 100 ml i.v every 6th hourly

34. ● Reduce BP: labetalol infusion
● Prevent vasospasm: nimodipine 60 mg every 4th hour
● Seizure prophylaxis

35. Complications
● Rebleeding - usually within first 24 hours
● Vasospasm - leading to infarction
● Hydrocephalus

36. TIA

37. Transient ischemic attack(TIA)
Focal brain ischemia leading to sudden, transient
neurologic deficit without permanent brain infarction
- Usually resolve within 24 hours
- Deficit lasting more than 24 hours ->CVA
- TIA increases the risk of subsequent stroke

38. Etiology
Modifiable risk factors:
● Hypertension
● Cigarette smoking
● Dyslipidemia
● Diabetes
● Obesity
● Lack of physical activity
● High saturated fat diet

39. ● Heart disorders such as MI, IE. AF
● Alcoholism
● Drugs: cocaine use
Non-modifiable risk factors:
● Previous stroke
● Old age
● Family history of stroke
● Male sex

40. Clinical features
● Neurological deficit, similar to stroke but lasts for a
short duration
● Features of anterior circulation TIA: Amaurosis
fugax(transient monocular blindness)
● Features of posterior circulation TIA: Diplopia,
vertigo, transient amnesia, dysarthria, loss of
consciousness

41. Investigations
● MRI or CT head
● Carotid and vertebral artery doppler
● ECG, echocardiogram
● Routine blood tests

42. Treatment of TIA
● Main aim of treatment is to decrease the risk of subsequent
stroke
● Antiplatelet agents: loading dose of aspirin 300 mg followed by
75 mg daily lifelong
● Statins: atorvastatin
● Anticoagulants: heparin
● Surgery: carotid endarterectomy
● Treat risk factors like diabetes, hyperlipidemia, hypertension
● Stop smoking

43. Carotid endarterectomy

44. References:
● Manipal Prep Manual of Medicine
Questions:
salman.s.ansari92@gmail.com
For PPT, scan: