STROKE (CVA)

Definition ‐The sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an
artery to the brain with or without signs of
1. focal higher cerebral dysfunction
2. hemisensory loss
3. visual defect
4. brain stem deficit
Classifications Transient ischemic attack (TIA) – symptoms resolve within 24 hours
Stroke – more than 24 hours
Progressing stroke –stroke in which the focal neurological deficit worsens after the patient first presents
Completed stroke – describes a stroke in which the focal deficit persists and is not progressing
Risk factors

Rapid
assessment
Of suspected
stroke

2. EXCLUDE HYPOGLYCEMIA :
 BEDSIDE BLOOD GLUCOSE TESTING
3. LANGUAGE DEFICIT :
 COMPREHENSION – RECEPTIVE DYSPHASIA
 ASK NAME OF PEOPLE OR OBJECT – NOMINAL DYSPHASIA
 ARTICULATION – DYSARTHRIA
4. MOTOR DEFICIT :
 SUBTLE PYRAMIDAL SIGNS
 PRONATOR DRIFT
 CLUMSINESS OF FINE FINGER MOVEMENT
5. SENSORY AND VISUAL INATTENTION :
 ESTABLISH ON ONE SIDE AT A TIME
 RETEST ON BOTH SIDE, AFFECTED SIDE WILL NO LONGER BE SEEN/FELT
 PERFORM CLOCK DRAWING TEST
6. TRUNCAL ATAXIA :
 SIT OR STAND WITHOUT SUPPORT
Classifications

Pathophysiology - Cerebral infarction

- Intracerebral haemorrhage
Cerebral infarction
 Cerebral infarction is mostly caused by thromboembolic disease secondary to atherosclerosis in the major
extracranial arteries.
 Source of emboli:
- 20% from the heart
- 20% from thrombosis in situ
 Vasodilatation initially maintains
cerebral blood flow(A)

 After maximal vasodilatation further

falls in perfusion pressure lead to a
decline in blood flow

 An increase in tissue oxygen

extraction, however, maintains the
cerebral metabolic rate for oxygen (B).

 Still further falls in perfusion, and

therefore blood flow, cannot be
compensated; cerebral oxygen
availability falls and symptoms appear,
then infarction (C).

 Symptoms of cerebral ischaemia

appear when the blood flow has fallen
to less than half of normal and energy
supply is insufficient to sustain
neuronal electrical function.

 Further blood flow reduction below the

next threshold causes failure of cell
ionic pumps and starts the ischaemic
cascade, leading to cell death.
Intracerebral haemorrhage
 It usually results from rupture of a blood vessel within the brain parenchyma.
 Nontraumatic intracerebral hemorrhage most commonly results from hypertensive damage to blood vessel walls
 Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to
neurological dysfunction.
 Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially
fatal herniation syndromes.
Causes and risk
factors

C.F of stroke
 1) Weakness :
- Unilateral weakness is the classical presentation of stroke.
‐ Reflexes are exaggerated due to increased tone (spasticity)
‐ Facial nerve palsy is often present.
2) Speech disturbance : Damage to dominant frontal or parietal lobe causes speech disturbance
3) Visual deficit : Can occur due to disturbance of blood flow to optic nerve or to occipital cortex
4) Sensory or visual neglect
- Damage to non dominant cortex
- caused by disturbance of blood flow in the internal carotid artery and ophthalmic artery,
leading to monocular blindness
5) Apraxia
‐ Inability to perform complex tasks
‐ The person may be having normal motor, sensory and cerebellar function
‐ Damage to parietal cortex
6) Ataxia
‐ Damage to cerebellum and its connections result in ataxia
‐ There may be associated diplopia and vertigo

These features are seen in hemorrhagic stroke:

Rare in ischemic stroke
 Sudden onset severe headache
 Seizure
 Coma
 Loss of consciousness
DDX
IX

1) CT :
‐ Excludes non stroke lesions like subdural haematomas and brain tumours.
‐ Can demonstrate intracerebral haemorrhage within minutes of stroke onset
‐ Abnormal perfusion of brain tissue can be imaged after contrast media (useful for ischaemic
stroke)
2) MRI
- MRI can detect ischaemia earlier than CT
- useful for abnormal perfusion
- It is more sensitive that CT in detecting strokes affecting the brain stem and cerebellum.
- Reliably distinguishes between haemorrhagic from ischaemic stroke even several weeks after
onset.

3) Vascular imaging
- Ischaemic strokes can be caused by atherosclerotic thromboembolic disease of extracranial
vessels
- Detection of extracranial vascular disease can establish why patient ad ischaemic stroke and
help in specific management.
- Example of vascular imaging are – Duplex ultrasound, MRA, CT Angiography

4) Cardiac IX
- Embolisms from the heart can cause ischaemic strokes
- Common causes are : atrial fibrillation, prosthetic heart valves and other valvular abnormalities
and recent myocardial infarction
- Example of investigations : ECG, echocardiogram
MX

CX

Subarachnoid haemorrhage
• Subarachnoid hemorrhage (SAH) is a life-threatening type of stroke caused by bleeding into the space surrounding
the brain
• The subarachnoid space is the area between the brain and the skull.
• It is filled with cerebrospinal fluid (CSF), which acts as a floating cushion to protect the brain
• When blood is released into the subarachnoid space, it irritates the lining of the brain, increases pressure on the
brain, and damages brain cells.
• At the same time, the area of brain that previously received oxygen-rich blood from the affected artery is now
deprived of blood, resulting in a stroke.
• Less common than ischemic stroke/intracerebral hemorrhage
• Affects 6/100000 (women>men), presents before 65
Causes • Aneurysm- 85% Berry Aneurysm from the brifurcation of cerebral arteries (Circles of Willis)
• Non aneurysmal hemorrhages- 10%(peri mencephalic hemorrhage)
• Arteriovenous malformation (AVM)- 5%
C.F SX
• Sudden severe thunderclap heachache- hours-days
• Vomitting
• High BP
• Neck pain
• Loss of consciousness
Signs
• Distressed and irritable
• Photophobia
• Neck stiffness
• Hemiparesis/aphasia-if intercerbral hematoma
• Third nerve palsy
• Subhyaloid hemorrhage in fundoscopy
IX • CT brain – 15% not detected
• Lumbar puncture (after 12 hours) – xanthochromia
• Cerebral angiography- optimal approach to prevent recurrent bleeding
• *if CT and LP negative- no SAH

• Nimodipine (30-60mg IV for 5-14 days followed by 360mg orally for further 7 days)
• To prevent delayed ischemia in acute phase
• Insertion of platinum coils into aneurysm (endovascular procedure)
• Surgical clipping of the aneurysm neck
• AVM- Surgical removal/blood vessel ligation/ injection of material to occlude the fistula
CX • Hydrocephalus
• Vasospasm- 5 to 10 days after SAH.
- Irritating blood byproducts cause the walls of an artery to contract and spasm. Vasospasm
narrows the inside diameter (lumen) of the artery and thereby reduces blood flow to that
region of the brain, causing a secondary stroke.
- Vasospasm occurs in 70% of patients after SAH
 Cerebral venous thrombosis
• Blood clot forms in the brain`s venous sinuses.
• This prevent blood from draining out of the brain.
• As a result, blood cells may break and leak blood into brain tissues forming a haemorrhage.

Epidemiology • This chain of event is part of stroke that can occur in adult and children.
• Thrombosis of the cerebral vein and venous sinuses is less common than arterial thrombosis.
• Large sinuses such as the superior sagittal sinus are most frequently involved
Causes

C.F • Cerebral venous sinus thrombosis usually present with symptoms of raised ICP, seizures and
focal neurological symptoms, but may vary according to the sinus involved.

IX • CT- and MR venography can confirm a diagnosis of cerebral venous thrombosis, but MR
venography is probably more sensitive in the acute phase.
• MR venography demonstrate a filling defect in the affected vessel

Ct contrast shows two cases of empty

delta sign due to thrombosis of the
superior sagittal sinus

MX • Anticoagulant, initially heparin followed by warfarin.

• In selected patients, the use of endovascular thrombolysis has been advocated.
• Management of underlying causes and complication, such as increased ICP
• About 10% of cerebral venous sinus thrombosis, particularly cavernous sinus thrombosis
associated with infection, which necessitate antibiotic treatment.
CX • Impaired speech
• Difficulty moving parts of the body
• Problems with vision
• Headache
• Increased fluid pressure inside the skull
• Pressure on nerves
• Brain injury
• Developmental delay