Stroke

1. Stroke

2. Stroke • Sudden in onset • Focal neurologic deficit • Involvement of the blood vessels

3. Temporal profiles of neurologic deficits that point to the underlying pathologic cause. -Mayo Clinic

4. Types of Stroke

5. DIFFERENTIAL DIAGNOSIS • Clinical Types of Stroke in the PHILIPPINES • 61.39% Ischemic • 38.6% Hemorrhagic

6. Hemorrhagic Stroke • Primary Intracerebral hemorrhage • Inside the brain • defective artery in the brain bursts • Bleed in the substance of the brain --. Basal ganglia (60% recurrence) 10 % recurrence at the different lobes, 10% at the cerebellum, 10% recurrence a • Secondary to hypertension • Subarchanoid Hemorrhage – • Outside the brain • a blood vessel on the brain's surface ruptures and bleeds • annuerysm, AVM

7. Hemorrhagic Stroke • intracerebral > subarachnoid hemorrhage • Occur during stress or exertion • Focal deficits rapidly evolve • Confusion, coma or immediate death

8. Hemorrhagic Stroke • Classic: sudden onset headache, vomiting, elevated BP • Focal neurologic deficits that progress over minutes • May present with agitation and lethargy but progresses to stupor or coma

9. Ischemic Stroke • Thrombus forms and blocks blood flow in an artery bringing blood to part of the brain

10. Sudden onset of a non-convulsive, FND due to CVD Embolic strokes Deficit reaches its peak almost at once Reverses itself within a few hours or days Thrombotic strokes Evolve more slowly over a period of several min/hrs and occasionally days Improve gradually over weeks or months Cerebral Hemorrhage There is severe deficit of rapid but not necessarily instantaneous onset Ischemic Stroke

11. Ischemic Stroke: Thrombotic • Local Origin of Clot • Usually develops at night during sleep • Symptoms perceived in the morning • Suspect in history of atherosclerosis, hypercoaguable states and collagen vascular disorders

12. Thrombotic • 1/3 of ischemic strokes, occlude large cerebral arteries (lCA, MCA, basilar), small penetrating arteries (lacunar strokes), cerebral veins, and venous sinuses. • Symptoms evolve over minutes to hrs. • Often preceded by TIA in same territory causing similar deficits.

13. Ischemic Stroke: Embolic • Proximal origin of clot • Occurs at any time • Frequently during periods of vigorous activity • History of AF, valvular vegetations, thromboembolism from MI, ulcerated plaques in carotid system • Seizures in 20% of cases

14. Embolic • 2/3 of ischemic strokes, from thrombus in heart, aortic arch, large cerebral artery or medium sized branches of brain a. • In anterior circulation usually effect MCA , in posterior circulation usually effect branch point of basilar or PCA. • Produce maximal neurological deficit at onset. • When TIAs precede, symptoms vary because emboli lodges in different places.

15. Ischemic Stroke • Classic: sudden onset of headache, vomiting,  BP • Focal neurological deficits progress over minutes • May present with agitation & lethargy but progresses to stupor & coma • Lacunar—small vessel disease

16. Diagnosis

17. Diagnose • Clinical Presentation • Neuroimaging/neurosonology • Establish mechanism/s

18. Clinical Presentation • WILL BE DISCUSSED BY ANOTHER TRIO

19. Neuroimaging/Neurosonology • NeuroImaging • Cranial CT Scan – to differentiate infarct vs hemorrhage • Timing of the test  important when to do the imaging • Cerebral Infarction  1st 6 hour normal • Bleeds  abnormal at the start • Cranial MRI  transmission weighted imaging • Infarct  early changes (DW1) • Diffusion-perfusion mismatch

21. Neurosonology • Carotid Duplex Examination • Carotid Artery, Vertebral Artery, IMT (thickening) • Stenosis • Obstruction • Transcranial Doppler Examination • Blood vessels inside the brain • Intracranial stenosis or occlusion • non-invasive, can be repeated, accurate

22. Mechanism of stroke • DISCUSSED ABOVE • HEMORRGAHIC, ISCHEMIC ETC

23. NIH Stroke Scale • The National Institute of Health (NIH) stroke scale (NIHSS) is a standardized method used by physicians and other health care professionals to measure the level of impairment caused by a stroke. • Assessment of whether or not the degree of disability caused by a given stroke merits treatment with tPA

24. NIH Stroke Scale • The NIH stroke scale measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. • A certain number of points are given for each impairment uncovered during a focused neurological examination.

25. NIH Stroke Scale • A maximal score of 42 represents the most severe and devastating stroke. Current guidelines as of 2008 allow strokes with scores greater than 4 points to be treated with tPA. • 0= no stroke • 1-4= minor stroke • 5-15= moderate stroke • 15-20= moderate/severe stroke • 21-42= severe stroke

26. NIH Stroke Scale • Level of Consciousness (LOC) • 0-Alert • 1-Drowsy • 2-Stuporous • 3-Coma • Best Gaze • 0-Normal • 1-Partial gaze palsy • 2-Forced deviation • Best Motor Arm • 0-No drift • 1-Drift • 2-Can't resist gravity • 3-No effort against gravity • LOC Answers Two Questions • (Pt. asked two questions) • 0-Answers correctly • 1-Answers one correctly • 2-Answers none • LOC Commands • (Patient given two commands) • 0-Obeys both correctly • 1-One correctly • 2-Incorrect • Pupillary response • 0-Both react • 1-One reactive • 2-Neither reactive • Best Visual • 0-No loss • 1-Partial hemianopia • 2-Complete hemianopia • Facial Palsy • 0-Normal • 1-Minor • 2-Partial • 3-Complete • Best Motor Leg • 0-No drift • 1-Drift • 2-Can't resist gravity • 3-No effort against gravity • Plantar Reflex • 0-Normal • 1-Equivocal • 2-Extensor • 3-Bilaterally extensor • Limb Ataxia • 0-None • 1-Lower or upper • 2Both • Sensory • 0-Normal • 1-Partial loss • 2-Dense loss • Neglect • 0-None • 1-Partial • 2-Complete • Dysarthria • 0-Normal articulation • 1-Mild/moderate • 2-Near unintelligible • Best Language • 0-No aphasia • 1-Mild/moderate • 2-Severe • 3-Mute • Change From Previous Exam • same/better/worse • Change From Baseline • same/better/worse