STROKE/CEREBROVASCULAR ACCIDENT

DEFINITION: An abrupt onset of a neurological deficit that is attributable to a focal vascular cause.

EPIDEMIOLGOY:

• Second leading cause of death worldwide

• Ischemic stroke: Male>female
• Hemorrhagic stroke: Female (young) > Male

ETIOLOGY:

• Poor lifestyle (alcoholic, smoker, poor diet and sedentary)

• Comorbidities:
o Coronary heart disease, diabetes mellites, atrial fibrillation (embolic stroke),
atherosclerosis (thrombotic stroke), arteriovenous malformation (hemorrhagic stroke).

CLINICAL MANIFESTATION:

General:

• Sudden onset of weakness or numbness on one side of the body

• Sudden speech difficulty or confusion
• Sudden difficulty seeing in one or both eyes
• Sudden onset of dizziness, trouble walking or loss of balance
• Sudden, severe headache with no known cause

Clinical manifestation can vary depending on the location of infarction.

MEDICAL LITERATURE:

• There are three main pathogenic mechanisms

o Thrombotic occlusion
o Embolic occlusion
o Vascular rupture
• Stroke is classified by their mechanism of pathology. Mainly ischemic and hemorrhagic. Ischemic
is when we say an obstruction had occurred which cut off the blood supply towards the distal
tissues and hemorrhagic is when the blood vessel ruptures due to high pressure as we can see in
people with arteriovenous malformations. In ischemic stroke it is subclassified into two,
thrombotic and embolic. Thrombotic is when the obstruction is localized to the vessel and slowly
clogged up such as cases in atherosclerosis. Embolic is when a thrombus is dislodged and travels
to the narrower vessel and cause obstruction such as in atrial fibrillation. A decrease in cerebral
blood flow to zero causes death of brain within 4 to 10 minutes. Another classification to take
note is Transient ischemic attack which a patient will manifest a clinical sign of stroke for a time
period of less than 24 hours but usually TIA will only manifest less than an hour.
PATHOPHYSIOLOGY:

Ischemic stroke:

Occlusion of Blood vessel------------>>No blood flow----------->>No Nutrients to distal neurological cells-----

--->>cell death--------->>manifestation of neurological deficits

Hemorrhagic stroke:

Weak blood vessel---------->>Hypertension-------->>rupture blood vessel------->> bleeding------>>increase

intracranial pressure------->>herniation of the brain------>>brain damage--------->>manifestation of
neurological deficits.

EVALUATION:

Ancillary procedures:

Definitive

• CT scan- To rule out bleeding and visualization of infarct

Supportive

• Lipid Profile- expected abnormality contributed to disease are high LDL and low HDL
• PT and PTT- checking for clotting factor abnormality
• RBS- high blood sugar can contribute to high viscosity of blood

Physical Examinations:

• Sudden onset of the clinical manifestations of stroke as stated earlier.

TREATMENT:

Pharmaceutical:

• Platelet Inhibition: Aspirin

o The only platelet agent that has been proven to be effective for acute treatment of
ischemic stroke
o MOA: aspirin inhibits platelet aggregation by irreversible inhibition of cyclooxygenase 1
and 2 via acetylation which results to decreased formation of prostaglandin precursors,
thus inhibit the formation of thromboxane A2.
• Anticoagulant: Heparin
o MOA: heparin potentiates the action of antithrombin III, thereby inactivates thrombin as
well as activated Factors IX, X, XI, XII and plasmin.
• Mannitol
 o Increase urine flow in patients with acute renal failure, reduced raised intracranial
pressure and treat cerebral edema.
o Useful for hemorrhagic stroke where cerebral edema is anticipated.
o MOA: mannitol increases urinary output by inhibiting tubular absorption of water and
electrolytes. It raises osmotic pressure of the plasma allowing water to be drawn out of
body tissues.

Surgery:

• Refer patient to neurosurgery for hemorrhagic stroke

Supportive:

• Low salt and sugar diet

• Preventing secondary complications such as infections and DVT by proper interval of bed turning
and use of pneumatic compression stackings
• Refer to rehabilitation once the patient is stable.