Stroke (Ischemic and Hemorrhagic)

In this presentation, I have described stroke and its subtypes, the ischemic stroke and the hemorrhagic stroke, their diagnosis, clinical manifestations and treatments.

1. Stroke ILKIN BAKIRLI

2. Introduction A stroke occurs when blood flow to the brain is interrupted by a blocked or burst blood vessel It is defined by 3 features 1. Abrupt onset of neurological deficit 2. Persists >24h 3. With no other apparent cause other than that of vascular origin Oxygen supply is limited and this causes the symptoms Clinically classified into evolving (focal deficits worsen with time), completed (persistent deficits that do not worsen) or TIA (deficits that resolve in 24h) 4 th leading cause of death in USA

3. Risk factors Modifiable Non-modifiable Hypertension Age Heart disease (AF, HF) Male gender Diabetes mellitus Asian race Hyperlipidemia Family history of CVD Smoking Previous vascular event Excess alcohol consumption Oral contraceptives Obesity Physical inactivity

4. Classification (types)

5. Etiology Large vessel disease- atherosclerosis, thrombosis, embolus, Small vessel disease- arteriosclerosis, microatheroma Cardioembolic disease- seen in AF and infective endocarditis Severe hypotension Vasculitis Arterio -venous malformations (AVM)

6. Pathophysiology of Hemorrhagic Stroke Entry of blood into the brain parenchyma which structurally disrupts the neurons Immediate cessation of neuronal function Expanding hemmorhage has a mass effect and further worsens the neurological deficits Large hemmorhages can cause transtentorial coning and rapid brain death Intracerebral hemmorhage is a result of small arteries’ damage due to chronic HTN Subarachnoid hemmorhage occurs as a result of saccular or Berry aneurysms rupture, AVM or angiomas

7. Pathophysiology of Ischemic stroke Thrombotic Stroke Atherosclerosis is the most common pathology Lacunar stroke results from occlusion of small deep penetrating arteries of the brain. Thrombosis leads to small infarcts called lacunes Embolic Stroke Cardioembolic stroke most commonly affects the MCA. Causes include AF, MI, prosthetic valves Artery to artery embolism is when a thrombus formed on an atherosclerotic plaque is embolized to intracranial vessels, most commonly from the carotid bifurcation

8. Stroke warning signs Sudden numbness or weakness of the face, arms or legs, especially unilateral Sudden confusion, trouble speaking or understanding Sudden visual disturbances Sudden trouble walking, dizziness Sudden severe headache with no known cause

9. Clinical manifestations Left hemisphere stroke Right hemisphere stroke Brainstem stroke Aphasia Neglect of left visual field Ataxia Right hemiparesis Left hemiparesis Bilateral weakness Right-sided sensory loss Left-sided sensory loss Vertigo Right visual field defect Left visual field defect Diplopia Dysarthria Dysarthria Difficulty reading, writing, calculating Spatial disorientation Extinction of left-sided stimuli

10. Localization of stroke syndromes Large vessel stroke within the anterior circulation Large vessel stroke within the posterior circulation Small vessel disease of anterior or posterior vascular bed Anterior circulation: internal carotid artery, MCA, ACA ,anterior choroidal artery Posterior circulation: Vertebral artery, basilar artery, PCA

11. Diagnosis History: onset and progression of symptoms, previous TIAs, DM, HTN, anticoagulant therapy, oral contraceptive use, polycythemia vera , cocaine use Examination: neurological Skin: xanthelesma , rashes, petechiae Eyes: diabetic changes, emboli, hypertensive changes CVS: BP, arrhythmia, murmurs, raised JVP CBC, glucose, lipids, blood culture, HIV, clotting screen, lumbar puncture (SAH) ECG to rule out cardiac causes

12. Imaging Non-invasive Invasive CT scan Lumbar puncture MRI scan Contrast angiography (cerebral arteriography) MRA CT angiography Doppler USG EEG PET SPECT

13. Differential diagnosis Craniocerebral trauma Meningitis/ encephalitis Intracranial mass (tumour, subdural hematoma) Seizure with persistent neurological signs Migraine with persistent neurological signs Metabolic- hyperglycaemia, hypoglycaemia, post-cardiac arrest, drug overdose

14. Management of an acute stroke Airway (open airway) Breathing (check O2 saturation) Circulation (BP, pulse) Hydration (I.V or NGT) N utrition (NGT) M edication (NPO) Control BP (ischemic 180/110mmHg, hemmorhagic <115mmHg MAP) Maintain glycemia and temperature

15. Treatment Ischemic stroke Thrombolytics (recombinant tissue plasminogen activator- alteplase ) Aspirin 300mg, clopidogrel , heparin/warfarin 20%mannitol I.V, pentoxyphylline , neuroprotective agents Carotid endarterectomy and angioplasty Hemmorhagic stroke Control of HTN Control coagulation problems Surgical decompressive craniectomy and surgery for aneurysms or AVM

16. Secondary prevention A- anticoagulant and anti-platelet B- blood pressure control C- cessation of smoking, cholesterol-lowering drugs, carotid endarterectomy D- diet E- exercise