Stroke

Sudden neurologic event of vascular origin

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 Stroke Advances
Stroke Units
Full work up < 3 4 hours
Early recognition
Neuroimaging
Early Treatment
Thrombolysis
Prevention
Risk factor management
Neurorehabilitation
Intensive

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 Stroke
Sudden neurologic event of vascular origin
Infarction
Embolus
Thrombus
Haemorrrhage
Intracerebral
Subarachnoid

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 Stroke Incidence & Mortality
53% decline in stroke mortality 1972 - 2000
incidence declining as BP control improves
Risk factor management
Case fatality rate declining
improved acute stroke care
stroke events less severe and different
increased ascertainement of mild cases

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Frequency of Stroke by Type
Infarction [Thrombo-embolic] 65% +

Haemorrhage 12%
subarachnoid Haemorrhage 6.6%
intracerebral haemorrhage 5.1%

Transient Ischaemic Attack 21%]

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 Stroke Risk factors
Vessel Wall Vessel Lumen
Hypertension Embolism
Heart Disease & Impaired cardiac
Smoking function CHD;AFib; LVH by
Atherosclerosis ECG; Valvular disease
Thrombosis
Hyperlipidaemia Haematocrit
Diabetes Fibrinogen
Other
Race + Family History
Oral Contraceptives
Obesity

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 Young Stroke <50
All of the above plus
Vessel Wall Disease
Large vessel
Fibromuscular dysplasia
Dissection
Migraine
Small vessel
Vasculitis
Drug induced
Sickle cell anaemia
Anti-phospholipid syndrome
Heart
Congenital Heart disease & complications
Valve prolapse
Patent Foramen Ovale

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 Cerebral Autoregulation
Thresholds of Ischaemia
Cerebral Blood Flow Ischaemia Thresholds
mls / 100 gms/ min

50

40
Electrical Function
30
affected
Electrical failure
20 complete
K+ release
10 Failure to clear ECF
50 100 150 Cell death
0
mean arterial blood pressure
mms Hg Stroke IC 110509
Lacunar Infarction

Perforating vessels
End arteries
No collateral
No pressure reduction
system
Supply critical areas
Present brain stem
Design fault
Charcot -Bouchard aneurysm
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 Intracerebral Haemorrhage
Important causes
Hypertension
Small vascular malformation [AVM etc]
Sympathomimetic drugs [cocaine / amphetamines]
Cerebral amyloid angiopathy [see Lecture on Alzheimer disease]
Anticoagulants + other bleeding disorders

NB Intracerebral implies that haemorrhage is into substance of brain

and differs from intracranial [which includes ALL haemorrhages]
and subarachnoid which usually refers to berry aneurysm rupture
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 Acute Stroke Like Event

Coag Screen
Normal CT -/+ Contrast
Drugs

Inconsistent
with clinical Infarct Haemorrhage
Findings
Consistent
with clinical Intraparenchymal SAH
Findings
BP BP N
Hx;Physical;
MRI Infarct Phase 1 tests
Vascular
FBC; ECG;ESR;CXR;
Imaging

?TIA Embolus - Large Vessel Small vessel

Holter; Vascular
Vasculitis
PFO Imaging
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Haemorrhage - Subarachnoid
Association
with
Polycystic
kidneys

Berry [saccular] aneurysm

Congenital defect
Progressive enlargement in life
Risk Factors - Cigarettes / Hypertension
Rupture usually spontaneous but .
Motels 3am unfamiliar partners
C.Drake London Ontario Canada 1982
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 Spontaneous Subarachnoid
Haemorrhage
The worst headache in my life - like an axe !
Outcome
Death
Coma or Alert
Survive - rebleed - 4 - 8 days
Death

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The worst headache in Neuro-exam
my life Neck stiffness
No Yes
Other intracranial
CT Scan pathology
Subarachnoid
Blood Yes

No
Vessel imaging
Lumbar puncture Angiography
To locate cause

Admit & observe Xanthochromia Yes

Repeat CT
Consider Angio
Or non-invasive No
Surgery Interventional
vessel maging
radiology
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 What you must know for Path.
Definition of stroke
Stroke Classification
Causes of different stroke types
Natural History of different strokes
Stroke Prevention
Stroke Investigation & Management

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 Current Issues in Stroke
Brain Protection
Thrombolytic therapy
Cerebrovascular stenting
Non-surgical treatment of aneurysms
Stroke Units
Neurorehabilitation - evaluation

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 Main Message for Final Med
All patients suspected of having a
stroke must be assessed and
diagnosed [including non-
contrast CT brain scan] within 3
hours of onset of
symptoms!!!!!!!!!!!!
Next slides are mainly clinical

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 General Management Measures
Early mobilization (prevent aspiration,
malnutrition, pneumonia, deep vein thrombosis,
pulmonary embolism, decubitus ulcers,
contractures)
Intermittent external compression stockings
Antibiotics to treat infectious complications of
stroke
Concurrent medical conditions should be treated

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 Stroke - Anticoagulants
Antiplatelet Therapy
Acute Stroke
Commence as soon as possible after ischaemic stroke
Secondary Prevention
Prior ischaemic stroke or TIA [aspirin / clopidogrel /
dipyramidole]
Anticoagulants
Acute Stroke
No indication - physical methods for DVT
Secondary Prevention
Prior TIA or Ischaemic Stroke + A - Fib - Warfarin
When?- 2 weeks plus

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 Thrombolytic Therapy
Ischaemic stroke within 6 hours - preferably 3
Benefits - increased proportion of patients
making good recovery at 6 months
Risks - Hemorrhage within 2 weeks
Need for further trials
Carotid Surgery
Stroke prevention [within 6 months]
Ipsilateral disease - severe stenosis
high risk
Ulcerated plaques
Specialist centres
Angioplasty
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 Carotid Endarterectomy
70% + stenosis occlusion
Most Beneficial
Healthy elderly; hemispheric TIA; Tandem
lesions;absent collaterals
50-69% occlusion
?????
<50% occlusion
No benefit

83 patients require to be treated to prevent one stroke in 2 years

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 Acute Ischemic Stroke Clinical Presentations

Altered consciousness Incoordination, weakness,

Stupor or coma
Confusion or agitation
Seizures Aphasia or other
higher cognitive disturbances
Dysarthria
Facial weakness or asymmetry
(ipsilateral or contralateral to
limb weakness)
paralysis, or sensory loss of one or
more limbs (usually one half of the
body)
Ataxia, poor balance, or clumsiness
or difficulty walking
Visual loss Monocular or binocular
May be partial loss of the field
Vertigo, double vision, unilateral
hearing loss, nausea, vomiting,
headache, photophobia

Usually all SUDDEN IN ONSET !!!!!!!!!!!!!!!!!

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 Ischaemic Stroke Classification
Total Anterior Circulation Infarction [TACI]
motor & sensory deficit, hemianopia,disturbed higher
cerebral funtion
Partial Anterior Circulation Infarction [PACI]
any two of above or isolated disturbed cerebral
function
Posterior Circulation Infarction [POCI]
brain stem dysfunction or isolated hemianopia or
ataxia
Lacunar Infarction [LACI]
pure motor stroke or pure sensory or mixed sensory -
motor or ataxic hemiparesis
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