Stroke/Cerebrovascular accident - Medicine - ATOT

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

8. 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

9. Uncommon causes Hypercoagulable disorders Vasculitis Drugs: cocaine

10. 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)

11. 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

12. 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

13. 108

14. 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

15. 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

16. 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

17. 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

18. 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

19. SAH

20. Subarachnoid hemorrhage Bleeding into subarachnoid space

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

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

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

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

25. Xanthochromia

26. 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

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

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

29. TIA

30. 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

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

32. 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

33. 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

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

35. 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

36. Carotid endarterectomy

37. References: Manipal Prep Manual of Medicine Questions: [email protected] For PPT, scan: