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Neurology: STROKE

Neurology: STROKE. superKAT :). Stroke. Condition characterized by rapidly developing signs and symptoms of a focal brain legion with symptoms lasting for more than 24 hours or leading to death no apparent reason

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Neurology: STROKE

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  1. Neurology: STROKE superKAT :)

  2. Stroke • Condition characterized by rapidly developing signs and symptoms of a focal brain legion with symptoms lasting for more than 24 hours or leading to death no apparent reason • Sudden neurologic syndrome, cerebrovascular disease – pathologic process of blood vessels • Occlusion of lumen by embolus/thrombus • Dissection • Permeability of blood vessel wall

  3. Primary disorder • Atherosclerosis • Hypertensive

  4. Epidemiology • 2nd most common cause of death around the world, next to heart disease • Out of 2 million, 2% will have a stroke • If you will have stroke, 30% will die, 30% permanently disabled, 30% recover • 10,000/1 mil (Philippines) = 1% • Cerebrovascular disease (stroke) = highest percentage of disability computed in life years

  5. Morbidity and mortality • 700,000 strokes per year in US • 22% men and 25% of women, higher among 65 years old • 1st leading cause of long-term disability • 2.7 million related stroke death in Asia, leading cause of death in China • Intracranial atherosclerosis, common in Asians 31%

  6. Risk factors (non-modifiable) • Age: Elderly • Gender : Males more susceptible • Genetic predisposition • Race/ethnicity: Non white groups have greater disk • Prior stroke or MI: Higher risk • Existing heart disease: increase risk for stroke

  7. Modifiable • Lifestyle • Smoking • Low physical exercise • Obesity • Alcohol consumption • Dietary restrictions • Pharmacotherapy • Hypertension • Arterial disease • Heart disease • Thrombotic phenomenon or embolic • Diabetes mellitus

  8. Diagnosis • Clinical • Based on history • Characteristic signs

  9. Subtypes • Ischemic • Thrombotic • Embolic • Hyperfusion • Hemorrhagic • Intracranial haemorrhage • Subarachnoid hemorrhagic

  10. Mechanism • Borderzone – 5% • Lacunar – 20% • Cryptogenic/rare cases – 20% • Artery to artery – 20% • Aortic arch -20%

  11. Stroke sub classifications according to clinical presentation • TACI – total anterior circulation infarct • Higher dysfunction • Homonymous hemianopsia • Motor/sensory deficit • 2/3 face arm/arm/leg

  12. PACI – partial anterior circulation (1/3 to ¼ of the brain) • 2 of 3 of TACI • Higher dysfunction alone • Limited motor/sensory deficit

  13. LACI - lacunar anterior circulation infarct • Pure motor stroke (2/3 parts) • Pure sensory • Sensorimotor • Ataxic hemiparesis • New dysphagis • New visuosptial problem • Proprioceptie sensory loss only • Vertebrobasilar features

  14. POCI – posterior • Crossed motor sensory deficit • Bilateral motor or sensory deficit • Conjugate eye movements problems • Cerebellar dysfunction • Isolated homonymous hemianopsia

  15. The brain 15% of cardiac output 20% of all O2 25% of all glucose 2-3% body weight *50ml/100gms/min *500mlof O2/min *75-100ml of glucose/min

  16. Oligemia – diminished blood flow(increased O2 extraction • Mild ischemia – increase in glycolysis, below 20cc – threshold for electrical failure • 10-20 cc per 100 grams per brain tissue per min = PENUMBRA – moderate ischemia • Severe ischemia – anoxic depolarization

  17. If perfusion of the cerebrum is suspended or critically reduced there are limited capacities for compensation and minimal energy reserves *auto regulation

  18. Vascular anatomy • Anterior circulation – from carotid system (80% supply of brain) • Posterior circulation – from vertebral system (20% supply of brain)

  19. Atherosclerosis and Thrombus foundation • Main pathology that can bring about stroke • Site of endothelial injury • Thrombus formation = ischemia • Formation of a plaque (atherosclerotic) • Atherosclerotic develops in time

  20. Thrombus formation and embolism • Leads to infract in brain • Thrombus = impedes laminar flow of blood, time characteristic • Embolism = small piece of clot, thrown off that can block, smaller than thrombus

  21. Extant and size of ischemia • Rate of occlusion – paulit-ulit ba? • Adequacy of collateral circulation • Resistance of brain structures to ischemia – dependent on function of cerebral autoregulation (ability of the blood vessel to respond, elasticity of blood vessels)

  22. Sites of atherosclerosis • Common area where it forms the junction • Junction between MCA and ACA • Mas malakas ang laminar flow sa junctions = increased pressure

  23. Types of stroke • Ischemic stroke (infarct) • Hemorrhagic stroke = intracerebral haemorrhages, compression, herniation and shifting of structure

  24. Ischemic stroke • 85% of stroke • Thrombotic or embolic • One month mortality: 15%

  25. Middle cerebral artery • Most common intracranially involved in ischemic stroke • Supply almost all parts of the convex surface of brain • Supply deep tissue: basal ganglia, putamen, parts of globus pallidus... • Usually hypodense lesion – left MCA stroke • Contralateral paresis – pyramidal decussation, unilateral lesion

  26. Left hemisphere = dominant • Right motor deficits • Face • Upper and lower extremities Right sensory loss All modalities Decreased stereognosis Agraphesthesia Language deficits Right homonymous hemianopsia Agraphia, acalculia, apraxia of left limbs

  27. Right hemisphere • Left hemiparesis • Left weakness of upper and lower extremities • Left hemineglect • Asomatognosia • Flat affect • Loss of prosody of speech

  28. Anterior cerebral artery • Supply medial and basal aspects of cerebral hemisphere • Extends to anterior two thirds • Caudate nucleus, parts if internal capsule, putamen and hypothalamus

  29. ACA stroke • Weakness of leg • +/- proximal muscle weakness in upper ex • Affect frontal lobe: impaired judgement and insight, change in affect • Presence of primitive grasp and suck reflex

  30. Vertebrobasilar system • Supplies: • Brainstem • Cerebellum • Thalamus • Visual occipital cortex

  31. Vertebrobasilar • Level of consciousness • Ranges from alert to coma • No cognitive impairments • Confusion or agitation uncommon • Motor impairments • Contralateral paresis of upper and lower ex • Quadriparesis – buong basilar artery involved • Crossed paresis • Dysarthria, hoarseness, dysphagia, ipisilateral ataxia, gait or truncal instability (cerebellar vermis involvement)

  32. Sensory impairments • Abnormalities of extraocular movement • Vertigo, nasuea, vomitting • Horner’s syndrome

  33. Hemorrhagic stroke • 15% of all total strokes • Intracerebaral > subarachnoid haemorrhage • Occur during stress or exertion • Focal deficits rapidly evolve • Confusion, coma, immediate death

  34. Intracerebral • Classic: sudden onset • Vomiting, elevated BP • Focal neurologic deficits that progress over minutes • Larger the deficits, the poorer the prognosis will be • Hypertensive damage to small penetrating vessels and has the same vascular distribution as lipophyalinosis • Charcot and Bouchard – mcircoaneurysm which ruptured, causing ICH • Other causes: trauma, ruptured aneurysm, AV malformation, anticoagulant intake, thrombolytic agents, cerebrovascular amyloidosis, bleeding disorders (leukemia)

  35. ICH • Most common site: putamen and adjacebt structures • Rupture of small penetrating branches of thalamus, pons, cerbellum

  36. Subarachnoid hemorrhage • Rupture of an aneurysm (usually located in the circle of Willis)

  37. Subarachnoid hemorrhage • Headache • Severe • Sudden or cataclysmic onset • Described as worst headache of life • Transient loss of consciousness, seizure, syncope, prolonged unresponsiveness, confusion, agitation • Nausea and vomitting • Photophobia and phonophobia • Hypertension and abnormal vital signs • Nuchal rigidity • Retinal haemorrhage

  38. May be secondary to ruptured aneurysm or arteriovenous malformation • 3 major risks affect subsequent events • Rebleeding • Vasoconstriction (delayed ischemic deficit) • Hydrocephalus (blood impedes normal flow)

  39. Management goals • Goals immediate diagnosis and evaluation: • Determine symptoms due to stroke • Advisability for acute treatment with thrombolytic therapy

  40. Management goals • History of physical examination • Note vital signs • Cardiac examination • Check for Carotid bruit • Validated scoring systems e.g. NIHSS to determine stroke severity • Immediate diagnostic studies • Cranial CT scan • ECG • Bloof glucose level • Serum electrolyte • Renal function test • CBC including platelet count

  41. General supportive care • ABC – airway, breathing, circulation • Control of fever • Cardiac rhythm • Hypoglycemia/hyperglycemia

  42. General supportive care • Hypertension • No clinically proven benefit for lowwering BP among patients with acute ischemic stroke • Antihypertensive agents should be withheld unless • DBP>120 or SBP>220 • Hypertensive encephalopathy • Aortic dissection • Acute renal failure • Acute pulmonary edema • Acute myocardial infarction

  43. Neuroimaging • Non-contrast enhanced CT scan of the brain • Early signs of infarction • Hyperdense MCA sign • Loss of gray-white differentiation in the cortical ribbon (particularly the lateral margins of the insula) or the lentiformnuclues • Sulcal effacement

  44. Neuroimaging • Multimodal MRI • DWI (diffusionweighted image) • Perfusion-diffusion mismatch (PWI: Perfusion weighted image) • Potential difficulty in reliably identifying acute intracranial hemorrhage - GRE

  45. Interventions • Primary prevention • Acute phase • Secondary prevention

  46. Treatment options – Acute phase • Stroke units • Thrombolysis • Neuroprotection • Aspirin and heparin • Surgery and intra-cerebral hemorrhage • Early secondary prevention

  47. Risk factor • Neuroprotectants • Thrombolytics • Stroke unit Stroke Event • Hematoma evacuation 3 hours • Revascularization Hospital • Recanalization

  48. Treatment options –Secondary prevention • Antiplatelet (thrombotic) and anticoagulant (embolic) therapy • Antihypertensive treatment post stroke • Statin therapy • Carotid artery disease

  49. Storokeunit team • Medical doctor • Pyshiotherapist • Nurses • OT • Social worker • Speech pathologist • Home care case manager • Nutritionist

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