Stroke.pdf

Stroke Mostafa Yousif Rahim Clinic Zone – Medicine Zone Contents - Definition - Types of Stroke - Pathogenesis - Risk Factors - Presentation - Investigation - Initial Management - Stroke Thrombolysis - Stroke Thrombectomy - Prevention  Definition - A stroke is an acut...

Stroke Mostafa Yousif Rahim Clinic Zone – Medicine Zone Contents - Definition - Types of Stroke - Pathogenesis - Risk Factors - Presentation - Investigation - Initial Management - Stroke Thrombolysis - Stroke Thrombectomy - Prevention  Definition - A stroke is an acute onset of a focal neurological deficit of vascular origin which lasts > 24hrs. - Blood supply to the brain has two sources → Internal Carotid and Basilar Arteries. - Internal carotids supply the anterior and middle cerebral arteries, known as the anterior circulation. - Basilar arteries supply the posterior cerebral artery in 70% of people (posterior circulation). - Anterior and posterior communicating arteries in Circle of Willis provide collateral circulation in cases of carotid artery stenosis. Types of Stroke - Five types of Stroke - Ischemic stroke - Hemorrhagic stroke - Transient Ischemic Attack (mini-stroke) - Brain Stem Stroke - Cryptogenic Stroke (Stroke of unknown cause) Pathogenesis - 70% of strokes happen in those aged >70 years, but can occur at any age. - Cerebral infarction (80%) occur in those with: - Thrombosis secondary to atherosclerosis, hypertension and arteritis - Cerebral embolism from AF, valve disease/replacement, post-MI - An episode of hypoperfusion Cerebral Hemorrhage (20%) is associated with: - Hypertension (Rupture of small arteries of the brain) - Subarachnoid Hemorrhage - Arteriovenous Malformations - Intracranial tumors - Bleeding disorders (including anticoagulants).  Risk Factors - Hypertension (High Blood Pressure) - Previous stroke or transient ischemic attack (TIA) - High Cholesterol - Heart Disease (Coronary Artery Disease) - Diabetes - Obesity - Sickle cell disease - Diet high in saturated fat - Alcohol drinking - Not getting enough physical activity - Family History - Common among older adults. - More common in women.  Presentation - Stroke preceded by neck pain may indicate carotid/vertebral artery dissection or subarachnoid hemorrhage. - Headache is an unusual presentation of ischemic stroke and may indicate cerebral hemorrhage. - Do Examination thoroughly by: - Assessment of mental status /GCS and signs of meningeal irritation. - Examination of pupils, fundi and cranial nerves. - Assessment of motor function (tone, power and reflexes). - Assessment of sensory function (including speech and comprehension). - Examination of cerebellar signs (co-ordination, speech) - Check for sources of embolism (AF, murmurs, carotid bruits) ROSIER Score - Used for stroke recognition - Criteria: - Facial Weakness (Asymmetrical) 1 point - Arm weakness (Asymmetrical) 1 point - Leg weakness (Asymmetrical) 1 point - Speech Disturbance 1 point - Visual field defect 1 point - Loss of consciousness or syncope - 1 Point - Seizure - 1 Point Stroke is unlikely if score is 0 or lower. Investigations - Examine and investigate first to exclude other conditions. - Confirm the diagnosis of stroke. - BMG, FBC, ESR, U&E, Blood Glucose, ECG, CXR. - Apply pulse oximeter (if SpO2 < 94%, consider ABG). - Cardiac Monitor Investigations - Arrange emergency non-contrast enhanced CT scan where: - Stroke thrombolysis or thrombectomy may be indicated. If considering thrombectomy, also perform CT contrast angiography. - The patient is on oral anticoagulant and/or has a bleeding tendency.. - GCS is 180 mmHg and/or diastolic BP is 105-140 mmHg, consider thrombolysis if BP reduces to