Stroke of different types.Hemorrhagic,Ischemic

Stroke of different types.Hemorrhagic,Ischemic

1. Stroke
Department of Neurology and Neurosurgery
Odessa National Medical University
2020
Alina Ivaniuk
teaching assistant

2. Vascular supply
of the brain
0
Department of Neurology and Neurosurgery
Odessa National Medical University, 2020

3. Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
Stroke | Vascular supply of the brain
Image source: Bluemenfeld’s Neuroanatomy through clinical cases (2010)

4. Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
Stroke | Vascular supply of the brain
Image source: Wikimedia Commons

5. Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
Stroke | Vascular supply of the brain
Image source: Wikimedia Commons

6. Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
Stroke | Vascular supply of the brain
Image source: Radiopaedia.org

7. Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
Stroke | Vascular supply of the brain
Image source: Bluemenfeld’s Neuroanatomy through clinical cases (2010)

8. Department of Neurology and Neurosurgery
Odessa National Medical University, 2020
Stroke | Vascular supply of the brain
Image source: Bluemenfeld’s Neuroanatomy through clinical cases (2010)

9. Stroke | Definition and 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 of Neurology and Neurosurgery
Odessa National Medical University, 2020

11. Ischemic
stroke
Caplan LR, Kasner SE, 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, Kasner SE, 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
Image source: 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
Image source: 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 of other 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 Neurology and 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 Neurology and Neurosurgery
Odessa National Medical University, 2020

21. Stroke | Ischemic stroke: 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 | Ischemic stroke: 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 | Ischemic stroke: 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 | Ischemic stroke: 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 | 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]

26. Stroke | Ischemic stroke: 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 et al (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
Department of 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 of Neurology and Neurosurgery
Odessa National Medical University, 2020

30. Stroke | Definition of 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 Neurology and Neurosurgery
Odessa National Medical University, 2020

32. Stroke | Definition and 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 | Ischemic stroke: 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 | Ischemic stroke: 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