Stroke: Incidence, Mortality, and Phenomenology

• A stroke affects one side of the brain, resulting in damage to the opposite side of the body.

Stroke Incidence and Mortality: Income-Based Disparities

• There's a 42% decrease in stroke incidence in high-income countries.
• Mid- and low-income countries experienced a 100% increase in stroke incidence from 1970 to 2008.
• Early stroke morbidity and mortality is generally decreasing, but at a slower rate in low- and middle-income countries compared to high-income countries.
• Mortality in low-income countries is 3.5 times higher than in high-income countries.

Recognizing Vascular Events: Key Phenomenology

• Recognizing a vascular event requires a sudden onset history.
• Clinical signs reveal which vessel is occluded and the lesion site.
• Most occlusive events involve the anterior circulation, with the MCA territory being the most frequent.
• The clinical context provides clues to determining the cause.
• Suspect thrombosis in cases with a progressive or stuttering course, especially in posterior circulation strokes.

MCA Strokes: Impact Areas

• Somatic motor/sensory area strokes cause contralateral paralysis (face, arm, leg) with sensory loss, impairing cortical sensory functions, two-point discrimination, unilateral sensory extinction, astereognosis, position sense, and dermatographia.
• Dominant hemisphere strokes affect speech, causing Broca's or Wernicke's dysphasia, or global aphasia, acalculia, finger agnosia, agraphia, and right-left confusion.
• Non-dominant parietal lobe strokes result in paralysis, spatial disorientation, neglect, and construction apraxia.
• Frontal visual field strokes lead to paralysis of conjugate gaze to the contralateral side.

ACA Strokes: Impact Areas

• Motor leg area strokes induce contralateral leg paralysis.
• Sensory leg area strokes induce contralateral cortical sensory loss.
• Medial frontal lobe strokes result in paratonia, grasp reflex, and sucking reflex.
• Paracentral lobule strokes cause social urinary incontinence.
• Bilateral medial frontal lobe strokes cause abulia and lack of spontaneity.
• Deep frontal white matter strokes cause gait apraxia.

Posterior Cerebral Artery Strokes

Peripheral Territory

• Visual field defect (calcarine cortex or optic radiation).
• Cortical blindness (bilateral calcarine cortex).
• Alexia without agraphia (dominant calcarine cortex and posterior corpus callosum).
• Memory defects (temporal lobe).
• Colour anomia, visual illusions and hallucinations.

Central Territory

• Chorea, tremor, hemisensory loss or pain, mild hemiparesis (Thalamus).
• Cerebellar ataxia/pyramidal signs with 3rd nerve (ventral brainstem, midbrain level).
• Contralateral hemiplegia (cerebral peduncle).
• Upgaze weakness, loss of vertical eye movements, bilateral ptosis, depressed consciousness (dorsal midbrain).

Brainstem Stroke- Medial Medullary Syndrome

• Clinical signs include ipsilateral tongue paresis, atrophy, and fibrillation, contralateral hemiplegia (face spared), contralateral loss of joint position sense (JPS) and vibration, and impaired upward gaze.
• It can be caused by vertebral artery, anterior spinal artery or lower segment of basilar artery.
• Potential risk factors are atherosclerosis, vertebrobasilar dissection, dolichoectasia of VBA, embolism and meningovascular syphilis.

Lateral Medullary Syndrome

• Occlusion of intracranial vertebral artery or PICA is a major cause.
• Other possible causes are vertebral artery dissection trauma, and radionecrosis

Ipsilateral Effects

• Cerebellar symptoms and signs
• Horner's syndrome occurs
• Facial sensation loss
• Palatal, pharyngeal, vocal cord paralysis with dysarthria and dysphagia.

Contralateral Effects

• Trunk sensation loss.

Other Effects

• Vertigo.
• Hiccups
• Dysphagia, facial paresis, abnormal gait

Millard-Gubler Syndrome

• Ventrocaudal pons is affected unilaterally.
• Contralateral hemiplegia (sparing face) occurs.
• Ipsilateral VI & VII nerve palsy is present.

Weber's Syndrome

• It affects the medial cerebral peduncle.
• Contralateral hemiplegia occurs.
• Ipsilateral pupil has III nerve palsy.

Benedikt Syndrome

• Involves the ventral tegmentum, including the red nucleus, brachium conjunctivum, and III nerve fascicle.
• Ipsilateral pupil exhibits III nerve palsy.
• Results in contralateral involuntary movements.
• Symptoms include tremor, hemichorea, and hemiathetosis.

Claude Syndrome

• Dorsal Tegmentum is affected
• Symptoms include Red nucleus abnormalities, Brachium conjunctivum issues, cerebellar signs and no hemiballismus

Parinaud's Syndrome

• Paralysis of conjugate upgaze (+/- downgaze).
• Pupillary abnormalities (usually mid-dilated, light-near dissociation).
• Convergence retraction nystagmus.
• Lid retraction (Collier's sign).
• Lid lag.
• Pseudo-abducens palsy due to excess convergence tone.

Recognizing Cerebrovascular Deficit: The F.A.S.T. Test

• Face: Ask for a smile to check for drooping.
• Arms: Check for drifting when arms are raised.
• Speech: Repeat a simple sentence to detect trouble or slurring.
• Time: Critical for intervention.

Transient Ischemic Attack (TIA)

• Brief neurological dysfunction from focal brain or retinal ischemia, with symptoms lasting less than 1 hour and without acute infarction evidence.
• 23% of strokes are preceded by TIA.
• Average stroke risk post-TIA: 3.1% (2 days), 5.2% (7 days), 10-14% (3 months).
• Risk factors include large artery disease, symptom duration over 1 hour, and atrial fibrillation.

ABCD2 Score

• Used to predict stroke risk after TIA.

Scoring

• Age ≥60 years = 1 point.
• Systolic BP >140 mmHg or diastolic BP >90 mmHg = 1 point.
• Unilateral weakness = 2 points, isolated speech disturbance = 1 point.
• Duration of TIA: >60 minutes = 2 points, 10-59 minutes = 1 point, <10 minutes = 0 points.
• Diabetes (present) = 1 point.

Risk Assessment Based on Score

• Score 6-7: High two-day stroke risk (8.1%).
• Score 4-5: Moderate two-day stroke risk (4.1%).
• Score 0-3: Low two-day stroke risk (1.0%).
• Score <2: No risk of stroke.

TIA Management: Insights from the EXPRESS Trial

• A recent trial showed that the second period had more urgent assessment.
• Treatment delay went from 3 days to 1 day.
• Time to prescription decreased from 20 days to 1 day.
• Stroke risk at 90 days reduced from 10% to 2%.
• The ABCD² score helps determine urgency of management, guiding decisions on hospital admission and outpatient investigation.

General Rx Goals

• Focus on ABC's (Airway, Breathing, Circulation).
• Take patient history, do examination, and order investigations then, admit to stroke unit.

Monitoring

• Blood pressure.
• ECG for arrhythmias.
• CVP for rehydration.
• Oxygen saturation.
• Respiratory rate.
• Blood sugar.
• Temperature.
• Fluid and electrolytes.

Respiratory Care Protocols

• Administer supplementary O2 via nasal cannula to maintain saturation above 92%.
• Intubate when GCS is below 8 to protect the airway.
• Use assisted ventilation only if the cause of respiratory failure is reversible and do not ventilate if the prognosis is poor.

Fluid and Electrolyte Management

• Maintain euvolemia, avoid both over and underhydration.
• Maintain CVP between 8-10 cm.
• Correct any electrolyte abnormalities.
• Avoid 1/2 normal saline, 5% Dextrose water and 10% Dextrose water.

Blood Glucose and Tempurature Management

• Both hyperglycemia and hypoglycemia will increase infarct size & worsens outcome
• Treat > 10 GR with Insulin and < 2.7 GR with Glucose
• Pyrexia increases infarct size and worsens outcome
• Treat patients > 37.5 C with paracetemol and sponging etc

NIH Stroke Scale (NIHSS)

• Used to assess the level of consciousness, orientation, and ability to respond to commands.
• Assesses gaze, visual fields, and facial movement.
• Evaluates motor function in arms and legs, ataxia, sensory loss, and language abilities.
• Assesses articulation, extinction, and inattention.

Major Stroke Complications

• Raised Intracranial Pressure (ICP).
• Pneumonia.
• Urinary Tract Infection (UTI).
• Bedsores.
• Deep Vein Thrombosis (DVT) with Pulmonary Embolism (PE).
• Seizures.

Raised ICP Management

• Elevate the head to 30 degrees.
• Maintain euvolemia.
• Control pain.
• Administer phenobarbital and mannitol (20%, 1g/kg every 6 hours).
• Use hypertonic saline.
• Intubate and hyperventilate to maintain pCO2 at 30-35 mmHg.
• Induce hypothermia (33-35°C) only in specialized centers.
• Consider surgical decompression.

Common Cause for Pneumonia

• Most common complication, due to Aspiration, Postural an Impaired cough mechanism

Management

• Protect airway and prevent aspiration
• NG tube, TPN, ET tube
• Facilitate with chest physio

DVT Management

• Only 5% of stroke patients develop deep vein thrombosis (DVT), but 25% of those with DVT die from pulmonary embolism (PE).
• Use compression stockings for treatment.
• Administer heparin with caution due to increased bleeding risk.

Seizures After a CVA

• They're commonly found after CVA
• Prophylactic AED's are not recommended
• Preventing recurrent seizure is recommended.

Cerebral Autoregulation and Blood Pressure Treatment

• Maintaining optimal blood pressure is critical for cerebral perfusion.
• Cerebral blood flow is affected by arterial blood pressure and intracranial pressure (ICP).
• Lowering blood pressure may reduce cerebral perfusion, impacting the ischemic penumbra.
• CPP = MAP - ICP.
  • CPP = Cerebral perfusion pressure
  • MAP = Mean arterial pressure
  • ICP = Intracranial pressure

Blood Pressure in Acute Stroke

• Increased blood pressure is common in acute stroke.
• Blood pressure usually declines back to prestroke levels within 1 week spontaneously.
• A significant decline may be seen in the first few hours (30%).
• Some studies note association between poor outcome with high admission BP.
• IST shows that a U-shaped curve, or high admission can result in poor mortality

Blood Pressure Therapy

• Consider reducing blood pressure in acute stroke if systolic is >220 mmHg and diastolic is >120 mmHg, or in hypertensive emergencies such as aortic dissection, LVF, acute MI, and eclampsia.
• Labetalol 10mg IV or Nicardipine 5mg/hr is recommended.
• For a diastolic of >140, use Sodium nitroprusside 0.5mcg/Kg/Min infusion.

Goals

• Lower systolic BP (SBP) by 10-25% in the first 24 hours, with a target BP of 140/90 within 7 days.

Restoring Bloodflow

• IV Tpa
• Endovascular treatments with IA thrombolytics or combined IV+IA or Mechanical devices

Thrombolysis

• TPa is the standard treatment for acute ischemic stroke
• Age older than 80 years and recent myocardial infarction are contraindications.

Factors to Consider: rtPA

• There's a risk of significant intracranial hemorrhage (ICH), which is 6-10%.
• Only a limited portion of patients (10-20%) will meet rtPA criteria.
• Limited patients (10%) have access to rtPA.

Time Window for tPA Administration

• tPA IV administration is beneficial up to 4.5 hours
• There is an increased in mortality beyond 4.5 hours
• The ECASS III trial verified that tPa administration is beneficial administered within 3.0 to 4.5 hours from symptoms Onset

ASPECT Score

• Used to identify a patient with high risk of ICH following rtPA
• A 10 point quantitative topographic CT Scan score
• Subtract 1 point for each abnormal area. Score of < 7 indicates a poor prognosis.

Rapid Stroke Evaluation

• Door to physician evaluation should happen in 10mins.
• Door to Stroke team notification in 15mins.
• Door to CT Scan Initiation in 25mins.
• Door to CT Scan interpretation in 45mins.
• Door to Drug (Needle) in 60mins.
• Door to Monitored Bed in 180 mins

Medical Recanalization Rx

• rt-Pa 0.9mg/kg IVI, max 90mg, 10% bolus and the rest
• Administered within 3- 4.5 hours of onset

Considerations

• The patient has to be awake.
• Given in ICU setting.
• Aspirin withheld for 24 hours.

Important

• Must meet inclusion and exclusion criteria stated in Checklist.
• Suspect ICH, if you see sudden increase in BP, decline in MSE or neurological examination, or if severe headache is experienced.

Endovascular Treatment Options

• Intra-arterial Thrombolytics.
• Bridging with intravenous-intra-arterial approaches.
• Mechanical Devices.

Secondary Preventitive Measures

• Modify Vascular rish factors
• Anti-platelet Agents
• Anti-Coagulation
• Surgery (CEA or Stent)

Modifiable Risk Factors for Stroke

• Hypertension and a goal of established BP of >/= 140/90mmHg
• Dyslipidaemia and a goal of LDL < 100mg/dl
• DM
• Sleep Apnea
• Carotid Dx
  • CAS , CEA
• Intracranial Atherosclerosis
  • Treat with Stroke within 30 days or Major vessel treatments

Secondary Stroke Prevention: Antiplatelet Therapy

• Single Agents - Aspirin, Clopidogrel, Dypiridamole (ER) and Cilostazol
• Newer Agents - Ticargrelor, Ticlodipine and Trifusal

Aspirin Use for Stroke Prevention

• Usage has a 23% increase in preventing strokes.
• Has small likelihood of intracranial hemorrages

Stroke Prevention Treatment.

• For patients, A combination of aspirin and clopidogrel may be superior to a single antiplatelet agent in the first 3 months
• Has to be in combination with a ischemic stroke

Therapeutic Agents

• Patients can be given agents that can help prevent the risk of a heart attacks.
• These agents can also help prevent the risk of blood clotting

Rehabilitation Team

• Doctor
• Nurse
• Physiotherapist
• Occupational Therapist
• Speech & Language Therapist
• Swallow Team
• Dietition
• Social Worker
• Patient, Family and Community
• Time is Brain

Stroke Team Members

• Neurologist
• Paramedics
• Stroke Co-ordinator
• ER Physicians
• Highly trained nurses
• Therapists
• Neurosurgeon
• Interventionalist
• Anaesthetist
• and most important Patient
• Time is Brain

Four Key Steps in Stroke Management

• General Principles.
• Restoration of Blood Flow.
• Prevention of Another Stroke.
• Rehabilitation.
• Time is Brain