Medical Radiological and Surgical Management of Stroke

Basic overview of stroke and its management.

1. Radiological Medical & Surgical Management of stroke Dr G Malleswara Rao M.S. Mch Prof. & HOD Neurosurgery Mamata Superspecialty Hospital

2. Stroke  is  defined  by the World Health Organization as 'a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin .‘ If <24 Hrs = TIA

3. Burden of Stroke  Morbidity ( 12 country WHO study ) Incidence : 0.2 -2.5/1000/yr. Mortality: leading cause of death & disability through out world  33% cases die within 3 weeks, 48% die within 1yr

4. Dr Thomas Willis

5. Stroke Brain attack Term increasingly being used to describe stroke and communicate urgency of recognizing stroke symptoms and treating their onset as a medical emergency

6. Risk Factors Nonmodifiable Age Gender (women more likely to die) Race (African Americans) Heredity

7. Risk Factors Modifiable Asymptomatic carotid stenosis Diabetes mellitus Heart disease, atrial fibrillation Heavy alcohol consumption Hypercoagulability Hyperlipidemia

8. Risk Factors Modifiable Hypertension Obesity Oral contraceptive use Physical inactivity Sickle cell disease Smoking

9. Etiology and Pathophysiology Brain requires continuous supply of O 2 and glucose for neurons to function If blood flow is interrupted Neurologic metabolism is altered in 30 seconds Metabolism stops in 2 minutes Cell death occurs in 5 minutes

10. Etiology and Pathophysiology Atherosclerosis is a major cause of stroke Can lead to thrombus formation and contribute to emboli

11. Sites for Atherosclerosis Fig. 56-2

12. Etiology and Pathophysiology Around the core area of ischemia is a border zone of reduced blood flow where ischemia is potentially reversible If adequate blood flow can be restored early (<3 hours) and the ischemic cascade can be interrupted less brain damage and less neurologic function lost

13. Transient Ischemic Attacks (TIA) Temporary focal loss of neurologic function caused by ischemia (analogous to angina in CAD) Most resolve within 3 hours May be due to micro-emboli that temporarily block blood flow A warning sign of progressive cerebrovascular disease

14. Types of Stroke Classification based on underlying pathophysiologic findings Ischemic Thrombotic Embolic Hemorrhagic

15. Major Types of Stroke Fig. 56-3

16. Ischemic Stroke Result of inadequate blood flow to brain due to partial or complete occlusion of an artery Constitute 85% of all strokes Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24 hours Symptoms often worsen during first 72 hours d/t cerebral edema

17. Ischemic Stroke Thrombotic stroke Thrombosis occurs in relation to injury to a blood vessel wall → blood clot Result of thrombosis or narrowing of the blood vessel Most common cause of stroke

18. Ischemic Stroke Thrombotic stroke Two-thirds are associated with HTN and diabetes Often preceded by a TIA

19. Ischemic Stroke Embolic stroke Embolus lodges in and occludes a cerebral artery Results in infarction and edema of the area supplied by the vessel Second most common cause of stroke

20. Ischemic Stroke Embolic stroke Majority of emboli originate in heart, with plaque breaking off from the endocardium and entering circulation Associated with sudden, rapid occurrence of severe clinical symptoms

21. Ischemic Stroke Embolic stroke Patient usually remains conscious although may have a headache Recurrence is common unless the underlying cause is aggressively treated

22. Hemorrhagic Stroke Account for approximately 15% of all strokes Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles

23. Hemorrhagic Stroke Intracerebral hemorrhage Bleeding within the brain caused by a rupture of a vessel Hypertension is the most important cause Commonly occurs during activity

24. Hemorrhagic Stroke Intracerebral hemorrhage Often a sudden onset of symptoms that progress over minutes to hours b ecause of ongoing bleeding Manifestations include neurologic deficits, headache, Nausea & Vomiting decreased levels of consciousness, and HTN

25. Hemorrhagic Stroke Subarachnoid hemorrhage Bleeding into cerebrospinal space between the arachnoid and pia mater Commonly caused by rupture of a cerebral aneurysm

26. Manifestations of Right-Brain and Left-Brain Stroke Fig. 56-6

27. Assessment findings Altered level of consciousness GCS Weakness, numbness, or paralysis Speech or visual disturbances Severe headache ↑ or ↓ heart rate Respiratory distress Unequal pupils

28. Assessment findings Hypertension Facial drooping on affected side Difficulty swallowing Seizures Bladder or bowel incontinence Nausea and vomiting Vertigo

29. Imageology

30. Overview - Imaging modalities Unenhanced CT • Can be performed quickly. • Can help identify early signs of stroke, and can help rule out hemorrhage. CT angiography can depict intravascular thrombi. CT perfusion imaging can demonstrate salvageable tissue which is indicated by a penumbra.

31. MRI Acute infarcts may be seen early on conventional MR images. Diffusion weighted MR imaging is more sensitive for detection of hyperacute ischemia . Becomes abnormal within 30 minutes Distinguish b/w old and new stroke New stroke: bright on DWI Old stroke: Low SI on DWI It detects irreversible infarcted tissue Gradient-echo MR sequences can be helpful for detecting a hemorrhage.

32. Ischemic Stroke Massive Rt MCA territory Infarct Midline Shift

33. Ischemic Stroke Massive Left MCA territory Infarct 52 year old Male , Smoker , Alcoholic, DM+ , HTN +. Initial GCS 12 - E3V3M6 Left Hemiplegia Worsened Symptomatically

34. Acute Intra Cerebral Hemmorhage 18/f admitted with GCS 9/15 BP 230/150 Capsulo Ganglionic Region Causing Mass Effect Effaced Ventricles Diffuse Cerebral Edema

35. Left Capsulo Ganglionic Hemorrhage in a 69/f , H/o Hypertension.

36. 45/ f , H/o Headache , Vomitings . Acute Severe SAH Note : - Inter Hemispheric Hematoma Sub Arachnoid Hemorrhage in B/l Sylvian Fissure

37. Interventions – Initial: ABC Ensure patient airway Remove dentures Perform pulse oximetry Maintain adequate oxygenation IV access Maintain BP according to guidelines (treat if SBP > 220 or MAP > 130) Management Acute Care

38. Interventions – Initial Immediate CT scan to determine cause (ischemic vs hemorrhagic) Measures to control ICP Head & neck in alignment (avoid flexion) Elevate HOB 30 ° if no symptoms of shock or injury Avoid hip, knee flexion Pain management, euvolemia , diuretics if needed Management Acute Care

39. Interventions – Initial Institute seizure precautions Avoid hyperthermia ( ↑s cerebral metabolism) Anticipate thrombolytic/fibrinolytic therapy for ischemic stroke Management Acute Care

40. Management Acute Care Thrombolytic/fibrinolytic therapy with recombinant tissue plasminogen activator ( tPA ) is used to Reestablish blood flow and prevent cell death in patients of ischemic stroke

41. Collaborative Care Acute Care Thrombolytic/fibrinolytic therapy given within 4 hours of the onset of symptoms ↓ disability But at the expense of ↑ in deaths within the first 7 to 10 days and ↑ in intracranial hemorrhage

42. Collaborative Care Acute Care For ischemic strokes (24 hr after tPA): Antiplatelets Anticoagulants (Heparin, coumadin) Must maintain therapeutic levels PTT, INR

43. Management Acute Care Interventions – Ongoing Monitor vital signs and neurologic status Level of consciousness Motor and sensory function Pupil size and reactivity O 2 saturation Cardiac rhythm

44. Management Approximately 10-15% of patients who experience a stroke will have seizures, usually within 24 hours

45. Surgical interventions: To Combat Life threatening raised ICP. – Decompressive Hemicraniectomy To Divert Intraventricular Contents (blood / CSF) – External Ventricular Drainage Endoscopic / Craniotomy for evacuation of Intra cerebral Hematoma Clip , wrap or coil aneurysm to prevent rebleed Excision of AV - Malformations

46. Surgery in Ischemic Stroke Large cortical infarcts (strokes) are invariably associated with brain swelling The brain shrinks with age and in older people there is usually enough space in the skull for the brain to swell In young patients there is no spare space in the skull and therefore the brain swelling causes compression of vital centres in the brain stem Young patients with very large strokes are therefore at high risk of rapid deterioration and death within the first 48 hours. Surgery may be required. This may be life saving, but will not reverse the damage the of the initial stroke.

47. Indications for Surgery Age < 60 years*** Severe MCA infarct (NIHSS>15) Fall of conscious level to drowsy (e.g. a score of 1 or greater on NIHSS 1a or GCS E+M <=9) Signs on CT of an infarct of at least 50% of MCA territory or infarct volume >145 cm3 Referral within 24 h of stroke onset, surgery no later than 48 h after stroke onset

48. Age < 60 years*** • Severe MCA infarct (NIHSS>15) • Fall of conscious level to drowsy (e.g. a score of 1 or greater on NIHSS 1a or GCS E+M <=9) • Signs on CT of an infarct of at least 50% of MCA territory or infarct volume >145 cm3 • Referral within 24 h of stroke onset, surgery no later than 48 h after stroke onset

49. Ischemic Stroke: Surgery Massive Left MCA territory Infarct Dasu - 52 year old Male , Smoker , Alcoholic, DM+ , HTN +. Initial GCS 12 - E3V3M6 Left Hemiplegia Worsened Symptomatically

50. Underwent Decompressive Craniotomy Post OP CT shows, residual edema Brain Bulging out of the calvarial defect 4 days on ventilator support , pneumonia , tracheostomy . Discharged day 25.

51. Surgery : Hemorhagic stroke Massive hemorrhage leads to Mass effect Raised ICP Brain Herniation Death DECOMPRESSIVE HEMICRANECTOMY WITHOUT HEMATOMA EVACUATION

52. Hemorrhagic stroke Decompressive Craniectomy Hematoma evacuated via neuroendoscope

53. Intraventricular Hemorrhage : Obstructive hydrocephalus Intraventricular Extension External Ventricular Drainage Temporary divert Blood and CSF. Followed by shunt .

54. Decompressive Hemicraniectomy

55. INFILTRATION WITH XYLOCAINE ADR

56. INCISION

57. HEMOSTASIS AND FLAP REFLECTION

58. BONE FLAP ELEVATION

59. DURAL LAYER SEPARATION

60. Duroplasty Autologous Fascia Lata harvested for repair of dural defect Large dural defect depicts the magnitude of cerebral edema Biosynthetic grafts also available.

61. WOUND CLOSURE

62. ABC of Stroke Prevention A- antiplatelet and anti coagulants B- blood pressure lowering medication C- cholesterol lowering, cessation of smoking D- diet E- exercise

63. Thank You