Stroke: Epidemiology, Pathophysiology, and Treatment PDF

Stroke Epidemiology 11% of deaths 110,000 people/year have a first stroke 40,000 people/year have a recurrence 24% die within one month of stroke ¼ of people over the age of 45 will have a stroke before they reach 85 years of age Approximately half of all stroke patients have an auton...

Stroke Epidemiology 11% of deaths 110,000 people/year have a first stroke 40,000 people/year have a recurrence 24% die within one month of stroke ¼ of people over the age of 45 will have a stroke before they reach 85 years of age Approximately half of all stroke patients have an autonomy deficit. The cost of treating a stroke patient is £5,000 over 5 years if intensive treatment is not required, which doubles the costs. Stroke can occur at any time in life ¼ of cases occur before the age of 65 Definition Acute focal neurological deficit resulting from vascular disease Ischaemic Transient ischaemic attack Cerebral infarct Venous thrombosis Haemorrhagic Intracerebral haematoma Typical site (thalamus-capsular) Atypical site Subarachnoid haemorrhage Clinical approach- pathophysiology ISCHAEMIC STROKE THROMBOSIS HEMBOLIA HAEMORRHAGIC STROKE INTRACEREBRAL HAEMATOMA SUBARACHNOID HAEMORRHAGE Cerebral arteries Cerebral vascular territories CEREBRAL VEINS Pathophysiology of cerebral ischemia Risk factors Gender Age Life habits smoking Concomitant diseases Hypertension Diabetes ATHEROSCLEROSIS Hypercholesterolaemia Heart diseases Atrial fibrillation Valvulopathies Myocardial infarction Cardiac malformations (Patent foramen ovale) Atherosclerosis Two ways to cause stroke 1. Embolic stroke Embolic stroke from atherosclerosis Atherosclerosis Two ways to cause stroke 1. Artery-to-artery embolism 2. Hemodynamic stroke Hemodynamic stroke Cardiac disorders causing embolic stroke Cerebral embolism Cerebral embolism No Embolus Embolus spontaneo spontaneo us lysis us lysis Minor Cerebral TIA stroke infarct Thrombotic ischemia Arterial thrombosis Thrombus Vessel occlusion fragmentation Non effective Effective collateral collateral circulation Embolic stroke circulation or recanalization No recnalalization Asymptomatic or Brain infarct TIA Symptoms of stroke Focal Are caused by the abnormal functioning of a brain area Specific Are related to the cerebral area involved (side, level, function) Severity of symptoms related to Functional extension of involved DObrain areas NOT recover Properly necrotic area MAY recover Perilesional area hypoperfusion oedema Cerebral infarct TIA/MINOR STROKE Diagnostic examinations in a patient with stroke – CT SCAN Brain CT Distinguish cerebral ischemia from cerebral hemorrage It is NORMAL in the first hours after symptom onset Brain CT angiogram Shows arterial vessel occlusion since the onset  Diagnostic examinations in a patient with stroke – MRI Brain MRI (DWI and T2 Flair sequences) < 4.5-5 hours from onset MISMATCH Hyperintense lesion in DWI Normal T2 FLAIR > 5 Hours after time onset NO MISMATCH Hyperintense lesion in DWI Hyperintense T2 FLAIR lesion Treatment Reperfusion Therapeutic time window Medical assistance Cardiovascular monitoring Respiratory function Prevention and treatment of adverse events Infections Deep venous thrombosis Prevention and treatment of neurological deficits Positioning Neuroriabilitation Speech therapy OVERVIEW OF REPERFUSION THERAPY Intravenous thrombolytic therapy (alteplase or tenecteplase) is first-line therapy, within 4.5 hours since the time the patient was last known to be well; Benefit is time dependent, so it is critical to treat patients as quickly as possible; Eligible patients should receive intravenous thrombolytic therapy without delay even if mechanical thrombectomy (MT) is being considered; Mechanical trombectomy (MT) is indicated for patients with acute ischemic stroke due to a large artery occlusion in the anterior circulation who can be treated within 24 hours of the time last known to be well (ie, at neurologic baseline), regardless of whether they receive intravenous thrombolytic therapy for the same ischemic stroke event MT within 24 hours of the time last known to be well may be a reasonable treatment option for patients with acute ischemic stroke caused by occlusion of the basilar artery Hyperacute Management of Ischemic Strokes Non traumatic brain haemorrhages Classification Intracerebral hematoma Typical Atypical Subarachnoid hemorrage Clinical symptoms of intracerebral hematoma Caused by the direct effect of the lesion Function of cerebral area compressed by the hematoma Perilesional edema Caused by the indirect effect of the lesion Volume of the hematoma INTRACRANIAL HYPERTENSION Effect on CSF circulation Headache Cerebral herniation Vomit Papilledema Stupor Coma Cerebral herniation Symptoms and signs of cerebral herniation Disturbance of consciousness Drowsiness Coma Signs of diencephalic and/or truncal distress with rostro-caudal deterioration Disturbance of breathing Abnormal responses to painful stimulus Decortication Decerebration Non-responsiveness Alterations in ocular motility Alteration of pupillary reflexes Cranial nerve compression signs Anisocoria Non traumatic subarachnoid hemorrage Epidemiology 7% of all stroke types Incidence 10/100,000 yr. Mortality related to clinical severity Mortality rate within 30 days adjusted for sex, age and clinical severity: 40-50%. Non traumatic subarachnoid hemorrage Causes Rupture of an intracranial aneurysm (85%) Non-aneurysmal perimesencephalic haemorrhage (10%) ESA from AVMs, tumours, AV dural fistulas, venous thrombosis, coagulopathies, drugs, vertebral or carotid dissection (5%) Cerebral aneurysm Risk factors for aneurysm rupture Asymptomatic aneurysms: prevalence 6% ISUIA: cumulative rate of rupture of asymptomatic aneurysms over 5 years with respect to size and site. Dimension Anterior circulation Posterior circulation mm escluded and posterior communicant posterior communicant artery artery % % 25 40 50 Other risk factors Collagen diseases Acid maltase deficiency Familiarity: 1/3 Smoking Hypertension Substance abuse Symptoms of the SAH Headache Isolated Associated with other neurological symptoms and signs Meningeal signs Rigor nucalis Kernig and Brudzinski signs Signs caused by brain suffering associated with ESA Disturbances of consciousness Convulsive seizures Cranial nerve palsies Diagnosis of SAH Clinical Instrumental Brain CT scan CSF examination Hemorrhagic Xantocromic Diagnosis of cerebral aneurysm or malformation Cerebral Angiography Brain CT angiogram Treatment of cerebral aneurysm Exclusion of the aneurysm from circulation Clipping Coiling Complications of SAH Early complications Rebleeding Acute hydrocephalus Cerebral vasospasm Brain ischemia Paroxysmal orthosympathetic hyperactivity Tachycardia, hypertension, hyperthermia, diaphoresis, hypertonia, hyperemia Late complications Normotensive hydrocephalus