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STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN,
STROKE
STROKE
Hawler Medical University College of Medicine Community Health
Hawler Medical University
College of Medicine
Community Health

Prepared by:

Hawraz Faris Saadi

BSN, Master Student

STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
STROKE Hawler Medical University College of Medicine Community Health Prepared by: Hawraz Faris Saadi BSN, Master
Introduction
Introduction

Neurological deficit of cerebrovascular cause that

persists beyond 24 hours or is interrupted by death

within 24 hours.

Stroke is the third most common cause of death and

the second most common cause of neurologic

disability after Alzheimer's disease.

third most common cause of death and the second most common cause of neurologic disability after
third most common cause of death and the second most common cause of neurologic disability after
third most common cause of death and the second most common cause of neurologic disability after
third most common cause of death and the second most common cause of neurologic disability after
Type of Stroke
Type of Stroke

1. Ischemic stroke

2. Hemorrhagic stroke

Type of Stroke 1. Ischemic stroke 2. Hemorrhagic stroke 11/9/2017 3
Type of Stroke 1. Ischemic stroke 2. Hemorrhagic stroke 11/9/2017 3
Type of Stroke 1. Ischemic stroke 2. Hemorrhagic stroke 11/9/2017 3
Type of Stroke 1. Ischemic stroke 2. Hemorrhagic stroke 11/9/2017 3
Ischemic stroke
Ischemic stroke

In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the

brain tissue in that area, its about 80% of stroke There are four reasons:

1) Thrombosis 2) Embolism 3) Systemic hypoperfusion 4) cerebral venous sinus thrombosis

four reasons: 1) Thrombosis 2) Embolism 3) Systemic hypoperfusion 4) cerebral venous sinus thrombosis 11/9/2017 4
four reasons: 1) Thrombosis 2) Embolism 3) Systemic hypoperfusion 4) cerebral venous sinus thrombosis 11/9/2017 4
four reasons: 1) Thrombosis 2) Embolism 3) Systemic hypoperfusion 4) cerebral venous sinus thrombosis 11/9/2017 4
four reasons: 1) Thrombosis 2) Embolism 3) Systemic hypoperfusion 4) cerebral venous sinus thrombosis 11/9/2017 4
Ischemic stroke Cont.  Stroke without previous reasons is "cryptogenic" (of constitutes 30-40% of all

Ischemic stroke Cont.

Stroke

without

previous

reasons

is

"cryptogenic" (of

constitutes 30-40% of all ischemic strokes

unknown

origin),

termed

this

reasons is "cryptogenic" (of constitutes 30-40% of all ischemic strokes unknown origin), termed this 11/9/2017 5
reasons is "cryptogenic" (of constitutes 30-40% of all ischemic strokes unknown origin), termed this 11/9/2017 5
reasons is "cryptogenic" (of constitutes 30-40% of all ischemic strokes unknown origin), termed this 11/9/2017 5
reasons is "cryptogenic" (of constitutes 30-40% of all ischemic strokes unknown origin), termed this 11/9/2017 5
Hemorrhagic stroke
Hemorrhagic stroke

Is a bleeding into brain tissue or meningeal spaces , its about 20% of strokes.

There are two main types of hemorrhagic stroke:

1) Cerebral hemorrhage

2) Subarachnoid hemorrhage

 There are two main types of hemorrhagic stroke: 1) Cerebral hemorrhage 2) Subarachnoid hemorrhage 11/9/2017
 There are two main types of hemorrhagic stroke: 1) Cerebral hemorrhage 2) Subarachnoid hemorrhage 11/9/2017
 There are two main types of hemorrhagic stroke: 1) Cerebral hemorrhage 2) Subarachnoid hemorrhage 11/9/2017
 There are two main types of hemorrhagic stroke: 1) Cerebral hemorrhage 2) Subarachnoid hemorrhage 11/9/2017
Types of hemorrhagic stroke 1) Cerebral hemorrhage (also known as intracerebral hemorrhage), which is basically
Types of hemorrhagic stroke 1) Cerebral hemorrhage (also known as intracerebral hemorrhage), which is basically
Types of hemorrhagic stroke 1) Cerebral hemorrhage (also known as intracerebral hemorrhage), which is basically
Types of hemorrhagic stroke 1) Cerebral hemorrhage (also known as intracerebral hemorrhage), which is basically
Types of hemorrhagic stroke
Types of hemorrhagic stroke

1) Cerebral hemorrhage (also known as intracerebral hemorrhage), which is basically bleeding within the

brain itself (when an artery in the brain bursts, flooding the surrounding tissue with blood).

2) Subarachnoid hemorrhage which is basically bleeding that occurs outside of the brain tissue but still within

the skull, and precisely between the arachnoid mater and pia mater.

Signs and symptoms  Stroke symptoms typically start suddenly, over seconds to minutes, and in
Signs and symptoms  Stroke symptoms typically start suddenly, over seconds to minutes, and in
Signs and symptoms  Stroke symptoms typically start suddenly, over seconds to minutes, and in
Signs and symptoms  Stroke symptoms typically start suddenly, over seconds to minutes, and in
Signs and symptoms
Signs and symptoms

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not

progress further. The symptoms depend on the area of the brain affected. The more extensive

the area of the brain affected, the more functions

that are likely to be lost.

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11/9/2017 9
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11/9/2017 9
1. Early recognition
1. Early recognition

Various

systems

have

been

recognition of stroke.

proposed

to

increase

Different findings are able to predict the presence or absence of stroke to different degrees.

Sudden-onset face weakness, arm drift and abnormal speech are the findings most likely to lead to the correct identification of a case.

arm drift and abnormal speech are the findings most likely to lead to the correct identification
arm drift and abnormal speech are the findings most likely to lead to the correct identification
arm drift and abnormal speech are the findings most likely to lead to the correct identification
arm drift and abnormal speech are the findings most likely to lead to the correct identification

2. Subtypes

If the area of the brain affected contains one of the three

prominent central nervous system pathwaysthe

spinothalamic tract, corticospinal tract, and dorsal column symptoms may include:

a) hemiplegia and muscle weakness of the face

b) numbness

c) reduction in sensory or vibratory sensation

d) initial flaccidity

weakness of the face b) numbness c) reduction in sensory or vibratory sensation d) initial flaccidity
weakness of the face b) numbness c) reduction in sensory or vibratory sensation d) initial flaccidity
weakness of the face b) numbness c) reduction in sensory or vibratory sensation d) initial flaccidity
weakness of the face b) numbness c) reduction in sensory or vibratory sensation d) initial flaccidity

2. Subtypes Cont.

If the cerebral cortex is involved, can produce the following

symptoms:

a)

aphasia (difficulty with verbal expression, auditory comprehension, reading and writing)

b)

dysarthria (motor speech disorder resulting from neurological injury)

c)

apraxia (altered voluntary movements)

d)

visual field defect

e)

memory deficits (involvement of temporal lobe)

voluntary movements) d) visual field defect e) memory deficits (involvement of temporal lobe) 11/9/2017 12
voluntary movements) d) visual field defect e) memory deficits (involvement of temporal lobe) 11/9/2017 12
voluntary movements) d) visual field defect e) memory deficits (involvement of temporal lobe) 11/9/2017 12
voluntary movements) d) visual field defect e) memory deficits (involvement of temporal lobe) 11/9/2017 12

3. Associated symptoms

a) Loss of consciousness

b) Headache

c) vomiting usually occur more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing the brain.

d) If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke

are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an
are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an
are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an
are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an
Risk Factors Non Modifiable Modifiable Age High Blood pressure Gender (Male < Female) Cigarette
Risk Factors Non Modifiable Modifiable Age High Blood pressure Gender (Male < Female) Cigarette
Risk Factors Non Modifiable Modifiable Age High Blood pressure Gender (Male < Female) Cigarette
Risk Factors Non Modifiable Modifiable Age High Blood pressure Gender (Male < Female) Cigarette
Risk Factors
Risk Factors

Non Modifiable

Modifiable

Age

High Blood pressure

Gender (Male < Female)

Cigarette smoking

Race

Polycythaemia

Heredity

Excessive alcohol intake

Previous Vascular event

Diabetes mellitus

 

Heart Diseases (HF)

 

Hyperlipidemia 11/9/2017

14

AHA GUIDELINES FOR PRIMARY

PREVENTION OF

CARDIOVASCULAR DISEASES AND STROKE

AHA GUIDELINES FOR PRIMARY PREVENTION OF CARDIOVASCULAR DISEASES AND STROKE 11/9/2017 15
AHA GUIDELINES FOR PRIMARY PREVENTION OF CARDIOVASCULAR DISEASES AND STROKE 11/9/2017 15
AHA GUIDELINES FOR PRIMARY PREVENTION OF CARDIOVASCULAR DISEASES AND STROKE 11/9/2017 15
AHA GUIDELINES FOR PRIMARY PREVENTION OF CARDIOVASCULAR DISEASES AND STROKE 11/9/2017 15

1. RISK ASSESSMENT

1. RISK ASSESSMENT 11/9/2017 16
1. RISK ASSESSMENT 11/9/2017 16
1. RISK ASSESSMENT 11/9/2017 16
1. RISK ASSESSMENT 11/9/2017 16

A. Risk factor screening

Goal: Adults should know the levels and significance of risk

factors as routinely assessed by their primary care provider.

Recommendations :

1) Risk factor assessment in adults should begin at age 20 y.

2) Family history of CHD should be regularly updated.

Smoking status, diet, alcohol intake, and physical activity should be assessed at every routine evaluation.

3)

status, diet, alcohol intake, and physical activity should be assessed at every routine evaluation. 3) 11/9/2017
status, diet, alcohol intake, and physical activity should be assessed at every routine evaluation. 3) 11/9/2017

A. Risk factor screening Cont.

4)

Blood pressure, body mass index, waist circumference, and

pulse ,should be recorded at each visit (at least every 2 y).

5) Fasting serum lipoprotein profile (or total and HDL cholesterol if fasting is unavailable) and fasting blood glucose should be measured according to patient’s risk for

hyperlipidemia and diabetes, respectively (at least every 5

y; if risk factors are present, every 2 y).

for hyperlipidemia and diabetes, respectively (at least every 5 y; if risk factors are present, every
for hyperlipidemia and diabetes, respectively (at least every 5 y; if risk factors are present, every

B. Global risk estimation

All adults 40 y of age should know their absolute risk of

developing CHD.

Goal: As low risk as possible.

Recommendations :

1)

Every 5 y (or more frequently if risk factors change), adults, especially those >40 y of age or those with >2 risk

factors, should have their 10-y risk of CHD assessed with a multiple risk score

or those with >2 risk factors , should have their 10-y risk of CHD assessed with
or those with >2 risk factors , should have their 10-y risk of CHD assessed with

B. Global risk estimation Cont.

2)

Risk factors used in global risk assessment include age, sex,

smoking status, systolic (and sometimes diastolic) blood

pressure, total (and sometimes LDL) cholesterol, HDL cholesterol, and in some risk scores, diabetes.

3) Persons with diabetes or 10-y risk > 20% can be considered at a level of risk similar to a patient with established

cardiovascular disease (CHD risk equivalent). Equations for calculation of 10-y stroke risk are also available.

disease (CHD risk equivalent). Equations for calculation of 10-y stroke risk are also available . 11/9/2017
disease (CHD risk equivalent). Equations for calculation of 10-y stroke risk are also available . 11/9/2017

2. RISK INTERVENTION

2. RISK INTERVENTION 11/9/2017 21
2. RISK INTERVENTION 11/9/2017 21
2. RISK INTERVENTION 11/9/2017 21
2. RISK INTERVENTION 11/9/2017 21

A. SMOKING

Goal:

Complete cessation. No exposure to environmental tobacco smoke.

Recommendations :

1)

Ask about tobacco use status at every visit.

2)

In a clear, strong, and personalized manner, advise every tobacco user to quit.

at every visit. 2) In a clear, strong, and personalized manner, advise every tobacco user to
at every visit. 2) In a clear, strong, and personalized manner, advise every tobacco user to

A. SMOKING Cont.

3)

Assess the tobacco user’s willingness to quit. Assist by

counseling and developing a plan for quitting.

 

4)

Arrange

follow-up,

referral

to

special

programs,

or

pharmacotherapy.

 

5)

Urge avoidance of exposure to secondhand smoke at work or home

or pharmacotherapy.   5) Urge avoidance of exposure to secondhand smoke at work or home 11/9/2017
or pharmacotherapy.   5) Urge avoidance of exposure to secondhand smoke at work or home 11/9/2017

B. BLOOD PRESSURE CONTROL

Goal:

I. <140/90 mm Hg

II. <130/85 mm Hg if renal insufficiency or heart failure is present

III. <130/80 mm Hg if diabetes is present

mm Hg if renal insufficiency or heart failure is present III. <130/80 mm Hg if diabetes
mm Hg if renal insufficiency or heart failure is present III. <130/80 mm Hg if diabetes
mm Hg if renal insufficiency or heart failure is present III. <130/80 mm Hg if diabetes
mm Hg if renal insufficiency or heart failure is present III. <130/80 mm Hg if diabetes

B. BLOOD PRESSURE CONTROL Cont.

Recommendations :

1) Promote healthy lifestyle modification. Advocate weight reduction; reduction of sodium intake; consumption of fruits, vegetables, and low-fat dairy products; moderation of alcohol intake; and physical activity in persons with BP of >130 mm Hg systolic or 80 mm Hg diastolic.

2)

For

initiate drug therapy if BP is > 130 mm Hg systolic or 85 mm

with

Hg

diabetes).

persons

with

renal

insufficiency

or

heart

failure,

diastolic

(>80

mm

Hg

diastolic

for

patients

persons with renal insufficiency or heart failure, diastolic (>80 mm Hg diastolic for patients 11/9/2017 25
persons with renal insufficiency or heart failure, diastolic (>80 mm Hg diastolic for patients 11/9/2017 25

B. BLOOD PRESSURE CONTROL Cont.

3) Initiate drug therapy for those with BP >140/90 mm Hg if 6 to 12 months of lifestyle modification is not effective,

depending on the number of risk factors present. Add BP medications, individualized to other patient requirements and characteristics (e.g, age, race, need for drugs with

specific benefits).

to other patient requirements and characteristics (e.g, age, race, need for drugs with specific benefits). 11/9/2017
to other patient requirements and characteristics (e.g, age, race, need for drugs with specific benefits). 11/9/2017

C. DIETARY INTAKE

Goal: An overall healthy eating pattern.

Recommendations :

1)

Advocate consumption of a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, poultry, and lean meats.

2)

Match

energy

intake

with

energy

needs

and

make

appropriate changes to achieve weight loss when indicated.

intake with energy needs and make appropriate changes to achieve weight loss when indicated. 11/9/2017 27
intake with energy needs and make appropriate changes to achieve weight loss when indicated. 11/9/2017 27

C. DIETARY INTAKE Cont.

3) Modify food choices to reduce saturated fats (< 10% of calories), cholesterol (< 300 mg/d), and trans-fatty acids b

substituting grains and unsaturated fatty acids from fish, vegetables, legumes, and nuts.

4) Limit salt intake to < 6 g/d.

5)

Limit alcohol intake (<2 drinks/d in men, <1 drink/d in women) among those who drink.

6 g/d. 5) Limit alcohol intake (<2 drinks/d in men, <1 drink/d in women) among those
6 g/d. 5) Limit alcohol intake (<2 drinks/d in men, <1 drink/d in women) among those

D. PHYSICAL ACTIVITY

Goal: At least 30 min of moderate-intensity physical activity on

most days of the week.

Recommendations :

1)

If cardiovascular, respiratory, metabolic, orthopedic, or neurological disorders are suspected, or if patient is middle-aged or older and is sedentary, consult physician before initiating vigorous exercise program

is middle-aged or older and is sedentary, consult physician before initiating vigorous exercise program 11/9/2017 29
is middle-aged or older and is sedentary, consult physician before initiating vigorous exercise program 11/9/2017 29

D. PHYSICAL ACTIVITY Cont.

2)

Moderate-intensity activities are equivalent to a brisk walk

(1520 min per mile).

 

3)

Additional

benefits

are

gained

from

vigorous-intensity

activity for 2040 min on 35 d/wk.

4) Recommend resistance training with 810 different exercises, 12 sets per exercise, and 1015 repetitions at moderate intensity > 2 d/wk.

lifestyle

5)

Flexibility

training

and

an

increase

in

daily

activities should complement this regimen.

d/wk. lifestyle 5) Flexibility training and an increase in daily activities should complement this regimen. 11/9/2017
d/wk. lifestyle 5) Flexibility training and an increase in daily activities should complement this regimen. 11/9/2017

E. WEIGHT MANAGEMENT

Goal:

Achieve and maintain desirable weight (body mass index 18.524.9 kg/m2). When body mass index is >25 kg/m2, waist circumference at iliac crest level < 40 inches in men, < 35 inches in women.

>25 kg/m2, waist circumference at iliac crest level < 40 inches in men, < 35 inches
>25 kg/m2, waist circumference at iliac crest level < 40 inches in men, < 35 inches

E. WEIGHT MANAGEMENT Cont.

Recommendations :

Initiate weight-management program through caloric restriction and increased caloric expenditure as appropriate. For overweight/obese persons, reduce body weight by 10% in first year of therapy.

as appropriate. For overweight/obese persons, reduce body weight by 10% in first year of therapy. 11/9/2017
as appropriate. For overweight/obese persons, reduce body weight by 10% in first year of therapy. 11/9/2017

F. DIABETES MANAGEMENT

Goal: Normal fasting plasma glucose (< 110 mg/dL) and near

normal HbA1c (< 7%).

Recommendations :

1) Initiate appropriate hypoglycemic therapy to achieve near- normal fasting plasma glucose or as indicated by near-

normal HbA1c. 2) First step is diet and exercise. 3) Second-step therapy is usually oral hypoglycemic drugs. 4) Third-step therapy is insulin.

exercise. 3) Second-step therapy is usually oral hypoglycemic drugs. 4) Third-step therapy is insulin. 11/9/2017 33
exercise. 3) Second-step therapy is usually oral hypoglycemic drugs. 4) Third-step therapy is insulin. 11/9/2017 33
Secondary prevention 1) Secondary prevention must be seen as a continuation of primordial prevention and
Secondary prevention 1) Secondary prevention must be seen as a continuation of primordial prevention and
Secondary prevention 1) Secondary prevention must be seen as a continuation of primordial prevention and
Secondary prevention 1) Secondary prevention must be seen as a continuation of primordial prevention and

Secondary prevention

1) Secondary prevention must be seen as a continuation of primordial prevention and primary prevention, It forms

2)

an important part of an overall strategy.

The aim of secondary prevention recurrence and progression of Stroke.

is to prevent the

3) Despite advances in treatment

Tertiary prevention

1. To prevent complication

2. Rehabilitations

a) Motor-skill exercises. These exercises can help improve your muscle strength and

coordination. You might have therapy to

strengthen your swallowing

help improve your muscle strength and coordination. You might have therapy to strengthen your swallowing 11/9/2017
help improve your muscle strength and coordination. You might have therapy to strengthen your swallowing 11/9/2017
help improve your muscle strength and coordination. You might have therapy to strengthen your swallowing 11/9/2017
help improve your muscle strength and coordination. You might have therapy to strengthen your swallowing 11/9/2017

Tertiary prevention Cont.

b) Mobility training :You might learn to use

mobility

aids,

such

as

a

walker,

canes,

wheelchair or ankle brace

c) Constraint-induced therapy. An unaffected

limb is restrained while you practice moving

the affected limb to help improve its function.

An unaffected limb is restrained while you practice moving the affected limb to help improve its
An unaffected limb is restrained while you practice moving the affected limb to help improve its
An unaffected limb is restrained while you practice moving the affected limb to help improve its
An unaffected limb is restrained while you practice moving the affected limb to help improve its
Tertiary prevention Cont. d) Range-of-motion therapy. Certain exercises tension and treatments muscle can ease
Tertiary prevention Cont. d) Range-of-motion therapy. Certain exercises tension and treatments muscle can ease
Tertiary prevention Cont. d) Range-of-motion therapy. Certain exercises tension and treatments muscle can ease
Tertiary prevention Cont. d) Range-of-motion therapy. Certain exercises tension and treatments muscle can ease

Tertiary prevention Cont.

d) Range-of-motion therapy. Certain exercises

tension

and

treatments

muscle

can

ease

(spasticity)

motion.

and help

you regain

of

range

e) Functional electrical stimulation. Electricity is applied to weakened muscles, causing them to contract.

Tertiary prevention Cont.

f) Robotic technology. Robotic devices can

assist impaired limbs with performing

repetitive motions,

g) Therapy for cognitive disorders.

Occupational therapy and speech therapy can

help you with lost cognitive abilities, such as memory, processing, problem-solving, social skills, judgment and safety awareness.

abilities, such as memory, processing, problem-solving, social skills, judgment and safety awareness. 11/9/2017 38
abilities, such as memory, processing, problem-solving, social skills, judgment and safety awareness. 11/9/2017 38
abilities, such as memory, processing, problem-solving, social skills, judgment and safety awareness. 11/9/2017 38
abilities, such as memory, processing, problem-solving, social skills, judgment and safety awareness. 11/9/2017 38

Tertiary prevention Cont.

h) Therapy Speech

for

therapy

communication

can

help

you

disorders.

lost

abilities in speaking, listening, writing and comprehension.

Alternative medicine. Treatments such as

massage, herbal therapy, acupuncture and oxygen therapy are being

regain

i)

medicine. Treatments such as massage, herbal therapy, acupuncture and oxygen therapy are being regain i) 11/9/2017
medicine. Treatments such as massage, herbal therapy, acupuncture and oxygen therapy are being regain i) 11/9/2017
medicine. Treatments such as massage, herbal therapy, acupuncture and oxygen therapy are being regain i) 11/9/2017
medicine. Treatments such as massage, herbal therapy, acupuncture and oxygen therapy are being regain i) 11/9/2017

References

1. Nicki R., Brian R., Stuart H., (2010) Davidson’s Principles and Practice of Medicine.

2. Park K. (2015) Park’s textbook of preventive and social medicine.

6. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke- rehabilitation/art-20045172
6. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke- rehabilitation/art-20045172
6. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke- rehabilitation/art-20045172
6. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke- rehabilitation/art-20045172
6. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke- rehabilitation/art-20045172