Ischemic & Hemorrhagic Strokes PDF

The doctor mostly read the slides MM Br tafreegh 19 e tafreegh 18 e ‫ﺑﺴﻢ ﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﯿﻢ‬ Ischemic & hemorrhagic Strokes Dr. Amr Qoora Consultant Neurologist Done by: Aisha Al-Mutairi Dana Alasousi The dr was LITERALLY reading the slides💀 There are some slides that the doctor skipped but it d...

The doctor mostly read the slides MM Br tafreegh 19 e tafreegh 18 e ‫ﺑﺴﻢ ﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﯿﻢ‬ Ischemic & hemorrhagic Strokes Dr. Amr Qoora Consultant Neurologist Done by: Aisha Al-Mutairi Dana Alasousi The dr was LITERALLY reading the slides💀 There are some slides that the doctor skipped but it doesn’t mean that it’s not part of our curriculum Objectives • Define and differentiate the types of stroke • Recognize the urgency involved in the evaluation and management of patients having a stroke • Be knowledgeable of the acute and chronic management of stroke • Be aware of the prevention strategies for patients with or at risk of stroke Epidemiology of stroke - a global problem • Annually 15 million people worldwide suffer a stroke • About 5 million die, and about 5 million are left permanently disabled • These numbers increasing as populations age • 3rd commonest cause of death worldwide after ischaemic heart disease and cancer ex: myocardial infarction • 2/3 of stroke deaths and much stroke disability occurs in developing countries a bcuz some treatments may not be available for those countries Definition • Stroke – A sudden focal neurological deficit or acute neurological impairment caused by the interruption of blood flow to a specific region of the brain or spinal cord – “BRAIN ATTACK” 2 types of stroke: – Ischemic or Hemorrhagic occlusionI of BV ruptureI of BV Definitions • Transient Ischemic Attack (TIA) – Any focal deficit that resolves completely and or symptom spontaneously within 24 hours depends on duration, can’t exceed:g • 60% of patients with TIA have definite evidence of brain infarction Definitions According to new TIA definition, the difference btwn stroke & TIA is the duration AND absence of infarction • Newer definition of TIA depends on MRI (No evidence of infarction on MRI ) This is signi cant • Up to 8% risk of stroke in the next 48 hours following TIA. important to know 20% = hemorrhages Pathology of stroke 5% - subarachnoid haemorrhage 15% - intracerebral haemorrhage Lobar and deep haemorrhages with various different pathologies #3 cause most common type: 80% - ischaemic stroke Cardiac source of embolism 20% #2 cause Intracranial small vessel disease 25% #4 cause Rare causes 5% #1 most common cause: Atherothromboembolism 50% so most common cause Ischemic Stroke • 85% of all strokes • Caused by occlusion of an artery to a specific region of the brain – Thrombotic – Embolic – i occurs over time sudden & more acute than thrombotic Hypoperfusion watershed stroke • Global pattern • Low blood flow or intermittent periods of no flow ex: cardiac arrest; carotid artery stenosis Ischemic Stroke • Thrombotic – Acute occluding clot – Superimposed on chronic narrowing • Develops over time in patients w/ uncontrolled risk factors (diabetes, hypertension, etc…) • Stationary (unlike emboli) Ischemic Stroke • Embolic – Intravascular material, from heart/ most often a clot, another artery separates proximally – Flows through arterial system until it occludes distally – Atrial fibrillation Etiology ofEmbolism l Cardioembolism lAtrial fibrillation so most common cause lMitral stenosis lAnterior wall myocardial infarction lDilated cardiomyopathy lProsthetic valve lPatent foramen ovale lEndocarditis Another type of embolism is "artery to artery" e.g. a thrombus from internal carotid to middle cerebral artery when one area of the heart is infarcted there will be reduced blood movement in that area which leads to clot formation Multiple bilateral emboli from heart Lobar lesion Risk Factors for Stroke • • • • • • • • • • • • • Hypertension Smoking Diabetes mellitus Dyslipidemia Previous history of TIAs Heart Disease Hypercoagulopathy Increased RBC count/Sickle Cell Obesity Carotid Bruit Atrial fibrillation Snoring in obstructive sleep apnea (OSA) Cocaine 7x 5 2 5 3 2 3-7 3 Signs/Symptoms • Paralysis The most common cause • Numbness • Language Disturbance t ex: aphasia • Monocular Blindness Or Binocular blindness • Visual disturbance t ex: blurry vision or diplopia • Ataxia • Vertigo t ex: spinning sensation (not dizziness) Any symptom in the CNS can be a presenting symptom of stroke Symptoms + signs depend on artery (part of the brain) affected For example: if the parietal lobe was affected the patient will have aphasia Reminder: Cerebral Arterial Blood Supply lAnterior circulation (internal carotid arteries) lPosterior circulation (vertebral arteries) lCollaterals (anastomoses) lCircle of Willis (via anterior communicating and posterior communicating arteries) lBorderzone anastomoses between peripheral branches of the anterior, middle and posterior cerebral arteries. Middle Cerebral Artery (MCA) it’s impt. to know bcuz it’s the most common artery affected/involved Stroke Syndromes collection of sign & symptoms lInternal cerebral artery lIpsilateral retinal ischemia lSensorimotor dysfunction similar to MCA/ACA lMiddle cerebral artery (MCA) most impt. lContralateral face, arm>leg lAphasia (dominant hemisphere) the left in most people lContralateral sensory loss lCortical sensory loss (non-dominant hemisphere) lContralateral visual field defect ex: hemianopia lGaze deviation ipsilateral to the lesion if frontal lobe is affected Eyes deviated to the left (ipsilateral) (If brain stem was affected, the eyes will deviate AWAY from the lesion (contralateral) Infarction in left MCA causing edema & compression to surrounding areas r Left hemisphere lesion: • right side weakness (contralateral) • language involvement Eyes deviated to the left (ipsilateral) (If brain stem was affected, the eyes will deviate AWAY from the lesion (contralateral) Infarction in left MCA causing edema & compression to surrounding areas r Left hemisphere lesion: • right side weakness (contralateral) • language involvement Stroke Syndromes l Anterior cerebral artery (ACA) l Contralateral leg weakness l Contralateral leg sensory loss l Apraxia BBlunting of emotions depression); l Abulia (bilateral) (ex: frontal lobe affected l Posterior cerebral artery (PCA) l Contralateral homonymous hemianopia l Visual agnosia, cognitive dufunction • If it’s large, it could cause bilateral visual loss MCA ACA Stroke DD ex: a patient w/previous stroke history comes with infection & presenting w/symptoms on the side of the lesion, but MRI scan shows no new infarction & the patient has actually recovered from the previous stroke. presents w/ similar motor symptoms & signs Acute stroke treatment dead tissue; can’t be recovered (irreversible) Asusceptible to die; reversible by reperfusion F Penumbra is larger than the infarction itself 1.Pharmacologically (medications) 2. Mechanical • Time window of 4-4.5 hours from beginning of symptoms • Time window of 6 hours 4 & half hours = tPA 6 hours = mechanical gives an overview of the deficiency to determine the management plan Determine the degree of injury If total score is: 1. more than 4 it is an indication to give the patient thromboembolic therapy 2. more than 25 = severe stroke, which is contraindicated w/thromboembolic therapy FROM GOOGLE: aim of CT: to give therapy (Sulci not clear) Specific signs to stroke include: 1. widened MCA; reperfusion must be performed bcuz this is a large vessel disease 2. blood in CT is white most common Must be observed must be controlled a the first 48 hrs after reperfusion is considered high risk for complications Craniectomy performed (bone flap is removed to allow pressure to leave to relief patient) Large Right infarction Severe edema Left ventricular shifting most common Stroke Management • Patient with a suspected stroke – Admit patient to Acute Stroke Unit – Always ABCs first with vital signs Airway – Oxygen delivery if hypoxemic Breathing Circulation – IV access/Labs/Glucose – Start IV fluids with normal saline, avoid hypotonic fluids – Neurological screening assessment after you stabilize the patient – CT scan of brain /CT angiogram – 12 lead ECG Avoid glucose in the first 48 hrs bcuz it will increase the ischemic area / increase the amount of damage done Stroke Management Plain CT (without contrast) • CT scan (in the ideal world) bcuz the time limit of thrombus is limited – Complete scan within 25 minutes of arrival – Have scan read within 45 minutes of arrival Stroke Management Is hemorrhage present? Intracerebral hemorrhage Subarachnoid hemorrhage Stroke Management • Hemorrhage seen on CT – Consult neurology/neurosurgery – Mannitol to lower ICP CCB – Nimodipine for SAH to prevent vasospasm – BP management • May need higher than normal systemic BP to maintain cerebral perfusion – Supportive measures Stroke Management • No Hemorrhage on CT – Probable acute ischemic stroke – Consider fibrinolytic therapy – Inclusions—need all YES answers • Age18 or older AND • Clinical diagnosis of ischaemic stroke with a measurable neurologic deficit AND • Time of symptom onset well established as less than 3-6 hours before infusion would begin Indications of TPA • Acute ischemic stroke with significant deficit • Stroke onset is clear and initiation of treatment can occur within 4.5 hours • CT scan shows no well established acute infarct, no hemorrhage, brain tumor. not very important to know, just have an idea Stroke Management can worsen the stroke if NOT monitored • Fibrinolytic contraindications. Need to assure all “NOs” checked • NO haemorrhage on pretreatment non-con CT AND presents w/severe • NO suggestion of SAH even with normal CT AND headache • NO multilobar infarction on CT AND could show as normal in the first 24 hours • NO h/o intracranial haemorrhage AND • NO uncontrolled htn (185/110) AND • NO known avm, neoplasm, aneurysm AND • NO witnessed seizure AND • NO active internal bleeding or acute trauma AND • NO acute bleeding diathesis including plt < 100K; heparin within 48 hours with elevated aptt; inr > 1.7; PT > 15sec AND • NO intracranial or intraspinal surgery, serious head trauma, or I previous stroke within 3 months AND • NO noncompressible arterial puncture within 7 days Stroke Management • Relative Contraindications/Precautions to fibrinolysis – Only minor or rapidly improving stroke calculate – Within 14 days of major surgery/trauma must risk over benefit – Recent GI/GU hemorrhage—21 days – Recent AMI—3 months – Post MI pericarditis – Abnormal blood glucose level ex: melena if I have MRI available Stroke Management • All Stroke Patients – Admit to monitored bed – Monitor and treat BP if indicated – Monitor neurological status and CT if deterioration – Monitor blood glucose and treat if needed – Hydrate and initiate supportive therapy and treat comorbidities Stroke Management • Blood Pressure Management • If severe hypertension not eligible for fibrinolytic therapy – SBP < 220 OR DBP < 120 • Observe unless other end organ involvement, treat other stroke symptoms/complications – SBP > 220 OR DBP 121-140 • If swallowing then oral medication • GTN infusion, • Aim for 10-15% BP reduction 2-7 days post stroke • Hydration and NG feeding • If mild-moderate hypertension – Oral hypertensives by mouth or NG tube • Statins • No antiocoagulation even in AF for 2-4 weeks risk of embolism + infarction could transfer to a hemorrhage 3-4 weeks • If immobile active DVT prevention • If not swallowing NG tube • Ensure physiotherapy • Occupational therapy • Speech therapy • Dietetic input • Multidisciplinary team input • Social work input Secondary Prevention • Stop Smoking • Manage Comorbidities – Hypertension – Hyperlipdaemia – Diabetes Mellitus – Coronary artery disease = controlling risk factors Secondary Prevention • Bruits/Carotid Stenosis – Symptomatic • Stenosis > 70% – Surgery offers significant benefit • Stenosis 50-69% – Surgery offers modest benefit; especially those with hemispheric ischemia or no h/o DM • Stenosis < 50% – No surgical benefit Secondary Prevention • Bruits/Carotid Stenosis – Asymptomatic • Stenosis > 80% – May consider surgery • Stenosis 60-79% – Surgery only in select cases Secondary Prevention • Atrial Fibrillation – Aspirin vs Warfarin – Need to risk stratify patient • High Risk Patients – WARFARIN • • • • • Previous stroke, TIA, or systemic emboli H/O Hypertension Poor LV systolic function Age > 75 years Rheumatic/Prosthetic Valve disorder He skipped Secondary Prevention • Atrial Fibrillation • Moderate Risk Patients – If one risk factor WARFARIN OR ASPIRIN – If more than one risk factor WARFARIN • 65-75 years • DM • CAD with preserved LV systolic function • Low Risk Patients – ASPIRIN • < 65 • No CAD Secondary Prevention • TIAs – Evaluate for embolic source – Evaluate for carotid stenosis – Start with aspirin in most patients – If symptoms/progression despite aspirin may consider aspirin/dipyridamole/clopigogrel – If aspirin not tolerated may consider clopigogrel Long-term Effects • Loss of power and immobility – Physically dependent • Feeding – malnutrition • • • • • • Dressing disability Disorientation Poor communication Incontinence DVT Bcuz of immobility Bed sores Long-term Effects • Contractures • DVT • Pneumonia Bcuz of dysphagia, the food might get into the lungs causing infections • Depression • Unemployment Hemorrhagic Stroke • 15% of all strokes • Blood vessel in the brain ruptures – Hemorrhage into surrounding tissue • Damage from: – direct trauma to brain cells, expanding mass effects, – elevated intracranial pressure, – damaging mediators released, – vascular spasm, – loss of blood supply distally Hemorrhagic Stroke In the CT: there’s blood in the sulci of the brain • Subarachnoid – Blood leaks from cerebral vessel into subarachnoid space – If arterial, sudden and painful – Aneurysms and AVMs The most common presentation is severe headache started suddenly rst 6 hrs ex: warfarin will be reversed w/vit. K In MRI, you can see that it’s: • usually lobar • black spots which are silent previous hemorrhage 70+ (70 yrs old) called black holes • can cause dementia bright → acute dark → chronic The most common cause is trauma