STROKE: TIME LOST IS

BRAIN LOST
RICARE | ROMUGUERA | ROSERO
November 21, 2019
OBJECTIVES 1 To present a case regarding Cerebrovascular Disease

2 To define Cerebrovascular Diseases and differentiate between infarct

and hemorrhage based on clinical symptoms and ancillary tests

3 To discuss the risk factors of the said diseases and relate it to the case
presented

4 To discuss the pathophysiology of Cerebrovascular Diseases

5 To discuss the management of Cerebrovascular Diseases

6 To discuss the prognosis of Cerebrovascular Diseases

CASE
PRESENTATION
PATIENT PROFILE
R.D
59 MALE

Married

Filipino

Catholic

Born and currently resides in

Occidental Mindoro

Born on January 1, 1960

Right-handedness
CHIEF COMPLAINT:

RIGHT SIDED
WEAKNESS
History of Present Ilness
Day of Consult
(+) right sided
weakness
(+) facial
1 day PTC
asymmetry
Admitted due to suspicion (+) slurring of
of CVD infarct speech
Meds given:
At the District Mannitol 100cc bolus- 100cc Q8
On IFC
Hospital Citicholine 1g
Salbutamol + Ipatropium
(+) gained nebulization
consciousness Ceftriaxone 2g loading dose
(+) on IFC
(+) right sided
2 days PTC Still advised for CT Scan
weakness
(+) loss of thus THOC (PGH)
(+) facial asymmetry
consciousness (+) slurring of speech
(?) head and right Advised admission
knee trauma
(+) unable to arouse
brought to the
nearest hospital
Past Medical History
(+) S/P CVD (2016)
• presenting with L-sided weakness
consulted LH with eventual resolution
• Maintenance: ASA 80mg OD, Nifedipine 20mg OD
Simvastatin 20mg OD – poor compliance

Hypertension (2016)
• Maintenance: Losartan 50mg OD – poor compliance

COPD (2016)
• Last attack: September 2019, on Salbutamol inhaler OD

S/P Appendectomy (1975)

(-) Diabetes Mellitus, (-) Thyroid Diseases

(-) Cardiac Diseases (-) TB (-) Allergies
Family History

(+) Hypertension – paternal

(-) Diabetes Mellitus – paternal
(-) Bronchial Asthma
(-) Thyroid Diseases
(-) Cardiac Diseases
(-) TB
Personal and Social History

(+) Chronic Smoker – 42 pack-years

(+) Frequent alcoholic – almost everyday
1-2 bottles/day (beer)
(+) History of MAP use – allegedly no
recent use
(-) Formal schooling
Farmer
Review of Systems

General: (-) loss of appetite (-) fever

Respiratory: (+) cough (+) exertional dyspnea (-) hemoptysis
CVS: (-) chest pain (-) orthopnea (-) PND (-) palpitations
Gastrointestinal: (-) abdominal pain (-) melena (-) hematochezia (-)
diarrhea (-) constipation
Genitourinary: (-) dysuria (-) hematuria, (-) oliguria (-) nocturia
Endocrine: (-) polyphagia (-) polyuria (-) polyphagia
Hematologic: (-) purpuric lesions (-) pallor (-) cyanosis (-) jaundice
Musculoskeletal: (-) joint pains (-) muscle atrophy
Neurologic: (-) urinary incontinence (-) fecal incontinence (-) seizures
(-) headache (-) change in behavior
 Physical Examination

VITAL SIGNS: BP: 160/100 HR: 65 RR: 24 O2 sat: 95% T: 36.7

Weight: 75kg (estimated)

GENERAL: awake, conscious, coherent, tachypneic

SKIN: (-) pallor, (-) erythema, (-) jaundice, (-) hyper/hypopigmentation, good
turgor, not dry, no laxity, no lesions, normal hair texture and distribution
normal nails
HEENT: Hair has normal texture and equally distributed, head is symmetrical,
no mass nor tenderness, normal, symmetrical facial expression; eyes are
symmetrical, eyebrows are well distributed, pink palpebral conjunctiva,
symmetrical external nose, (-) nasal discharge; Ears - mobile pinna, (-)
masses, (-) discharges, swelling, tenderness; (-) oral lesions and masses
 Physical Examination

CHEST AND LUNGS: Symmetrical chest expansion, no accessory muscle

use, (+) wheezes on bilateral lower lung fields, (-) stridor

HEART: Regular rate and rhythm, S1>S2 on the apex, S2>S1 on the base,
no extra heart sounds and no murmurs

ABDOMEN: globular, soft, no masses, normal bowel sounds, non-tender

EXTREMITIES: (+) bruises on the right knee, (-) varicosities, (-) masses,
(-) deformity, full and equal pulses
 Physical Examination
NEUROLOGIC PHYSICAL EXAMINATION:
Awake, oriented to 3 spheres, follows commands, good registration, recall,
naming, repetition, calculation cannot elicit due to no formal education;
(-) aphasia (-) apraxia (-) agnosia (-) R-L confusion
CN I: (-) anosmia
CN II, III, IV, VI – 3/3 EBRTL, intact VF, full and equal EOMs
CN V: sluggish corneal on the right
CN VII: (+) central facial paralysis, right
CN VIII: intact gross hearing
CN IX, X: dysphonia
CN XI: shoulder lag on the right
CN XII: tongue deviated to the right
 Physical Examination
NEUROLOGIC PHYSICAL EXAMINATION:

MOTOR: SENSORY: REFLEXES:

4/5 5/5 100% 100% 2 2

2 2
4/5 5/5 100% 100%
2 2

2 2
 Physical Examination
NEUROLOGIC PHYSICAL EXAMINATION:

(-) dysmetria (-) dysdiadochokinesia (-) nystagmus

cannot assess tandem gait or Romberg’s
(-) Kernigs (-) Brudzinski (-) nuchal rigidity
 Is there a lesion?
Where is the lesion?
What is the lesion?
Is there a lesion?

YES NO
Where is the lesion?

Level
Localize
Lateralize
 LOCATING THE LESION
CNS vs PNS CNS: brain and spinal cord
PNS: cranial nerves + ganglia
UMN vs LMN
exiting the skull through the
SUPRATENTORIAL foramina and spinal nerves +
vs ganglia
INFRATENTORIAL

LATERALITY

LEVEL OF LESION
 LOCATING THE LESION
CNS vs PNS

UMN vs LMN

SUPRATENTORIAL
vs
INFRATENTORIAL

LATERALITY

LEVEL OF LESION
 LOCATING THE LESION
CNS vs PNS RIGHT SIDED
HEMIPARESIS
UMN vs LMN

SUPRATENTORIAL
vs
INFRATENTORIAL
LEFT CEREBRAL
LATERALITY
LESION
LEVEL OF LESION
 LOCATING THE LESION
CNS vs PNS

UMN vs LMN

SUPRATENTORIAL
vs
INFRATENTORIAL

LATERALITY

LEVEL OF LESION
WHERE IS THE LESION?
WHERE IS THE LESION?
WHERE IS THE LESION?
▪ Specific dysfunction ▪ widespread
▪ Loss of sensation motor and
▪ Hemiplegia/hemiparesis sensory
▪ CN2 deficits deficits
▪ Seizures ▪ impaired
▪ Headache respiratory and
circulatory
functions
▪ impaired level
of
consciousness
▪ CN deficits
(CN III-XII)
▪ cerebellar
signs
 LOCATING THE LESION
❑ Rule in cortical involvement: hemiparesis
CNS vs PNS on the contralateral side, absence of
movement disorder and visual field defect
❑ Rule out putamen involvement: no
UMN vs LMN
contralateral hemiplegia
❑ Rule out thalamus involvement: no
SUPRATENTORIAL contralateral hemisensory deficits
vs ❑ Rule out pontine involvement: absence of
INFRATENTORIAL locked in syndrome and deficits in lateral eye
movement
LATERALITY ❑ Rule out cerebellar involvement: absence
of gait disturbances
LEVEL OF LESION ❑ Rule out parietal lobe involvement – no
sensory deficits on the both sides of the body
LOCATING THE LESION:
LOCATION
MOTOR INVOLVEMENT:
Cortex -> Corona Radiata -> posterior limb of internal
capsule -> brainstem -> spinal cord
LOCATING THE LESION:
LOCATING THE LESION:
LOCATION

Plain cranial CT scan (11/19/19):

Hypodensities at left internal capsule, right
lentiform nucleus, right temporal lobe and right
cerebellum
 IMPRESSION:
Acute CVD probably infarct, left MCA territor,
subcortical, atherothrombotic
Hypertension St. II, uncontrolled
COPD suspect in AE
Substance use (Nicotine, MAP)
S/P CVD, right with no residuals (2016)
STROKE

“Among all the neurologic diseases of adult life,

stroke ranks first in frequency and importance.”
STROKE

•A "brain attack"
•An emergency
•Treatable
•Preventable
RISK FACTORS
● Hypertension
● Atrial fibrillation
● Diabetes mellitus
● Cigarette smoking
● Hyperlipidemia.
● Others: hypercoagulable state and the use of
contraceptives
CLASSIFICATION OF STROKE

ISCHEMIC
vs
HEMORRHAGIC
ISCHEMIC STROKE

● Due to occlusion of a cerebral blood vessel

and causes cerebral infarction.
● The resultant neurologic syndrome
corresponds to a portion of the brain that is
supplied by one or more cerebral vessels.
ISCHEMIC STROKE
ISCHEMIC STROKE
● Classified by the underlying cause of the vascular
occlusion
○ Atherosclerosis with superimposed thrombosis.
○ Cerebral embolism
○ Occlusion of small cerebral vessels within the
parenchyma of the brain.
○ Other pathologic processes not associated
with occlusion of cerebral vessels,
Atherothrombosis
● Evolution of clinical phenomena is more variable
● Preceded by minor signs or one or more transient
attacks of focal neurologic dysfunction, TIAs
● Thrombotic stroke syndrome may develops as a single
episode, but typically the whole stroke evolves over a
few minutes or hours or less.
○ Characteristic is a "stuttering" or intermittent
progression of neurologic deficits extending over
several hours or a day or longer.
● Occurrence of the stroke during sleep
Atherothrombosis
● Atheromatous plaques preferentially form at branching
points and curves of the cerebral arteries
○ Internal Carotid Artery; at its origin from the common
carotid
○ Cervical part of the Vertebral Arteries and at their junction
to form the basilar artery
○ Main bifurcation of the Middle Cerebral Arteries
○ Proximal Posterior Cerebral Arteries as they wind around
the midbrain
○ Proximal Anterior Cerebral Arteries as they pass
anteriorly and curve over the corpus callosum
Cerebral Embolism
● Most common cause o f ischemic strokes
● Develops most rapidly, "like a bolt out of the blue."
○ Full-blown picture evolves within seconds
● Embolic material consists of a fragment that has broken
away from a thrombus within the heart ("cardioembolic")
○ Distal end of a thrombus within the lumen of an occluded or
severely stenotic carotid or vertebral artery, or a clot that
originates in the systemic venous system, infected material
from endocarditis.
○ Fat, tumor cells, fibrocartilage, amniotic fluid or air
Cerebral Embolism
● The embolus becomes arrested at a bifurcation or other
site of natural narrowing of the lumen of an intracranial
vessel.
● Resultant infarction is pale, hemorrhagic, or mixed
○ Hemorrhagic infarction nearly always indicates
embolism
● Most commonly affected: MCA (superior division)
DIAGNOSTIC MANAGEMENT

URGENT BRAIN IMAGING: Mandatory in all patients with sudden

neurologic deterioration or acute stroke
- Non contrast CT or brain MRI - to exclude immediately hemorrhage
- Check for CBG - hypo/hyperglycemia may mimic stroke
- O2 saturation

ff
Other ancillary tests (but should not be the cause of delay):
- ECG - concomittant acute MI
- CBCPC
- Troponin I
- Coagulation studies
DIAGNOSTIC MANAGEMENT

Diagnostics done for the patient:

- Plain CT Scan
- CXR AP, Pelvis AP, right knee AP/L
- CBC, Na, K, Crea, Bun, Ca, Mg, AST, ALT, ALP
- PT PTT ff
- Urine MAP
- Urinalysis
- FBS, LP
- HBA1C
- CBG monitoring
THERAPEUTIC MANAGEMENT

● FLUIDS: Plain isotonic saline without dextrose - agent of

choice
● NGT (if necessary) - for swallowing assessment; risk for
aspiration pneumonia
● FEVER CONTROL - always rule out other causes of fever (ex.
infection); fever may contribute further
ff to ischemic brain injury
● BP CONTROL - for those who are not treated with
anti-thrombolytic, increase in BP should not be treated acutely
(permissive hypertension of MAP of 110-130) unless BP is
>220/>120
● STATINS - can be started once oral medications can be given
safely
THERAPEUTIC MANAGEMENT

Treatment given to the patient:

- ASA 80mg 1 tab ODPC

- Atorvastatin 80mg 1 tab ODHS
- Paracetamol 500mg 1 tab Q4 for fever
- Lactulose 30cc ODHS ff
- Salbutamol + Ipatropium nebulization q^
- Montelukast 10mg 1 tab ODHS
- Salmeterol + Fluticasone 250/2 inhaler 2 puffs BID