Lecture 4

OCTS 3704: Neurology - Stroke

Definition:
- Acute onset neurological fallout in vascular distribution
- Blood vessel disease
- Ischemic/ haemorrhagic
- Ischemic: embolic or thrombotic
- Associated conditions: IHD, peripheral vascular disease

Definition according to time:

- TIA
- RIND
- Complete stroke
(Time = NB – because one should consider giving the pt. rTPA)

Risk factors for a stroke:

Non-modifiable risks Modifiable Cardiac risk factors

- Age - Hypertension - Atrial fibrillation
- Male gender - Diabetes mellitus - Myocardial infarction
- Race - High cholesterol - Cardiomyopathy
- Genetic factors - Smoking - Valve lesions (mitral and aortic)
- Physical inactivity - Left ventricular dysfunction with mural
- Previous TIA thrombosis
- Carotid artery surgery
- Alcohol abuse

Embolism and thrombosis:

Embolism Thrombosis
- Clot from elsewhere (usually from heart/ large - Blood vessel wall itself= ill b.o.: atherosclerosis/
blood vv.) brain + occludes a vessel in the brain inflammatory process
- Oxygen supply to brain = cut off - Blood vessel also occludes
= that area of brain dies - Causes for thrombosis:
- Causes of embolism:  Atherosclerosis
 After myocardial infarction  Syphilitic aortitis
 Valve lesions (mitral and aorta)  Takayasu aortitis
 Cardiomyopathy e.g. post-partum, post-  Trauma internal carotid artery
radiation  Vasculitis associated with autoimmune
 Arrhythmia- esp. artrial fibrillation disease, e.g.: SLE, or secondary to infections
 After heart surgery e.g. HIV/ meningo- vascular syphilis
 Congenital heart lesions (right to left shunt)
 Ineffective endocarditis

Rare causes of ischemic stroke:

- Status migraine
- Hypercoagulability e.g.: antiphospholipid syndrome, thrombocytosis, polycythaemia

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Important causes for strokes – remembered anatomically:

HEART LARGE VESSELS SMALL VESSELS/ vasculitis/
- Myocardium - Aorta arch disease vasculopathy
 Myocarditis (e.g. post-  Syphilitic aortitis - HIV
partum)  Takayasu aortitis - Syphilitic
 Heart failure with dilated - SLE
ventricle/ atrium with - Common carotid artery
embolism  Trauma to neck BLOOD DISEASES:
- Endocardium  Atherosclerosis (with Hypercoagulability
 Ineffective endocarditis risk factors thereof) - Dehydration
 Congenital valve lesions, - Internal carotid artery, - Antiphospholipid syndrome
aorta + mitral valve pathology middle and anterior - Protein S and C deficiency
 Atrial myxoma cerebral artery - Antithrombin III deficiency
- Electric system of the hearts  Atherosclerosis - Others
 Atrial fibrillation (usually VASOSPASMS
chronic)
MIGRAINE

Pathophysiology of ischemic stroke:

- Blood vv. Occludes  vasodilation takes place
 Cytotoxic edema is present  energy production fails
 Over stimulation of neuronal glutamate receptors  intra neuronal accumulation of sodium,
chloride and calcium ions
 Mitochondrial injury
 Cell death

Ischemic penumbra:
- Blood vessel occlusion = causes critical area of ischemia in centre of stroke- with area around that
is: hypoxic - potentially salvageable
- Area around critical area = the ischemic penumbra
- NB that pt. be treated correctly - can help ischemic penumbra to recover

Important stroke syndromes:

- Anatomy: 3 major vv. That supply brain- each supply a surface+ pole of brain:

Anterior cerebral artery Middle cerebral artery Posterior cerebral artery

 Medial surface  Parietal surface  Inferior surface
 Frontal pole  Temporal pole  Occipital pole

Anterior and posterior circulation: Lateral

surface:

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Medial surface: Motor homunculus:

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Internal carotid artery ischemia (anterior circulation system):

- Depending on anatomy of circle of Willis- internal carotid artery occlusion may be:
asymptomatic/ only have ipsilateral Horner syndrome/ may have severe symptoms of both a MSA
and ASA infarction together

Possible clinical pictures of internal carotid artery occlusion:

 Asymptomatic
 Ipsilateral Horner syndrome
 Ipsilateral blindness (Ophthalmic artery)
 Homonymous hemianopia
 Contralateral hemiparesis (arm sometimes weaker than leg)
 Contralateral hemianesthesia
 Aphasia (Left hemisphere)
 Anosagnosia (Right hemisphere)

Ophthalmic artery:
- Ophthalmic a. = 1st branch of Internal carotid artery
- Ischemia in ophthalmic a. distribution  sudden
(20sec) deterioration of vision in one eye 
followed by: total blindness in that eye
Described as curtain going down from top of eye
field  bottom
- TIA in this area= amaurosis fugax/ transient
painless monocular blindness
 Episode last few seconds/ minutes
 NB indicator of atherosclerotic disease+
warning of upcoming stroke
- With funduscopy- one can sometimes see
cholesterol embolism in branches of retinal artery

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Middle cerebral artery TIA/ stroke:

- Contralateral hemiplegia with arm more involved than leg
- Contralateral upper motor neuron facial weakness- lower half of face
- Contralateral gaze paralysis
- Contralateral homonymous hemianopia
- L hemisphere lesion: dysphasia
- R hemisphere lesion: anosagnosia

Anterior cerebral artery stroke:

- Contralateral hemiplegia and sensory loss with leg more involved than arm
- Primitive reflexes and mental deterioration
- If pt. only has one ant. Cerebral a. that supplies both sides  occluded = pt. weak in both legs
with spastic paraparesis, sphincter incontinence, personality changes, primitive reflexes, dementia
 sensory system = should be normal = distinguish from spinal cord lesion
Ischemia of vertebrobasillar system (posterior circulation):
- Post. Circulation= vertebral aa. + basilar aa.+ cerebellar aa + post. Cerebellar aa.
- Supplies: brainstem+ cerebellum+ inf. Surface: brain + occipital lobes
- Depending on a. + distribution- post. Circulation ischemia = carious symptoms and signs
- Cranial nerve abnormalities and cerebellar signs = occur on same side as lesion
- Long tract signs (hemiplegia) = occur on other side

- Cranial nerve fallout – ipsilateral, hemiplegia contralateral:

- Reticular activation system- also in brainstem
 When affected= lose consciousness
+ NB factor in differential diagnosis of syncope (loss
consciousness, fainting
 Ask about associated symptoms: ataxia+ double vision
(person with cardiac reason for syncope= usually not have double vision- person with TIA of
vertebrobassillar system= double vision+ other cranial n. abnormalities)
- Cranial n. 1 and 2 does not run through brainstem
- In midbrain: CN 3,4,5, sensory
- In pons: CN 5 motor & CN 6,7,8 Sensory
- In medulla: CN 5 sensory , 8,9,10,11, 12
- In spine c1-5: cn 11

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Effect of stroke on spaces and symptoms:

Stroke in midbrain Stroke in pons Lateral medullar infarction with occlusion of

 III/ IV CN palsy ipsilateral
to lesion
 Contralateral hemiplegia
(corticospinal tract cross
over in medulla)
 V, VI, VII (LMN), posterior inferior cerebellar artery
cerebellar signs  Ipsilateral cerebellar signs
ipsilateral to lesion  Ipsilateral horner syndrome
 Contralateral  Ipsilateral IX & X CN abnormalities, with
hemiplegia sensation loss of soft palate, hoarseness,
swallowing problems
 Ipsilateral pain sensation loss of face
 Contralateral sensory loss of body

- Posterior cerebral - Clinical picture: post. Cerebral a. - Presentation: total basilar a.

artery supplies: occlusion occlusion
 Occipital lobe]  Homonymous hemianopia  Coma
 Inferior surface  Memory problems  Small pupils (miosis)
(temporal areas)  Hemiballisms (subthalamus)  Quadripareses
 Thalamus  Thalamic syndrome – contralateral  Total anaesthesia
 Midbrain sensation loss of face + half of  Fever
body. If sensation returns- pt,  Death
experience constant pain in that
half of body and face= thalamic
pain

Lacunar stroke:
- Small (3-15mm) deep cerebral, thalamic, pontine/ other brainstem infarcts- seen in: hypertensive
and diabetic pts.
- Often asymptomatic- can cause clinical syndromes
 Pure motor hemiplegia
 Pure sensory stroke
 Ataxic hemiparesis
 Dysarthria + clumsy hand
- = suspected when pt. has clinical pic of stroke BUT CT shows very small/ no infarction
- Mx: conservative, treat underlying cause (usually: diabetes/ hypertension)

Diagnosis of ischemic stroke:

- ASK following questions:
 What is the time span associated with stroke?
 If pt. present wth 4,5h + normal CT scan= qualify: rTPA
 TIA (less than 24hrs, usually <2hrs) – TIA= often warning of threatening stroke=
why medical emergency dr. needs to loof for cause and treat to prevent from
complete stroke to happen
 What is the underlying pathology?
 Infarction- embolic/ thrombotic
 Bleeding

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Aetiology/ causes:
Risk factors:

 Hypertension ( hypertensive  Alcohol abuse

retinopathy, proteinutia,
cardiomegaly, distinguish long
standing hypertension from reflexive
hypertension after stroke)
 Diabetes
 Hypercholestrolemia
 Smoking
 Valve lesions (mitral/ aorta)
 Atherosclerotic disease (previous
myocardial infarction, neck
murmurs, peripheral vascular disease
e.g. claudication, previous stroke)
 HIV
 Meningo-vascular syphilis
 Hypercoagulability

Distinguish between ischemic and haemorrhagic stroke:

- Hemorrhagic stroke pt.= often not totally awake- consciousness= supressed
- Hemoorhagic stroke pt. = often vomit
- If the patient is not awake or he has vomited, he will either have a bleed in the brain or a very
large ischemic stroke.
- Clinically you can often NOT distinguish. It has been proven that it is still safe to give a patient
with a stroke aspirin, even though the CT may later show a bleed. If the patient is awake enough
to swallow, give him Aspirin in the acute stage.

Acute Mx of stroke pts:

- Maintain airway + make sure pt. breath properly
(Glascow coma scale < 8/15= intubate pt.)
- Put up intravenous (IV) line to prevent dehydration + hypotension
( Saline 0.9% = correct fluid: isotonic + not over hydrate/ dehydrate brain)
NB check urea + electrolytes + glucose- take blood FBC, INR, PT, PTT
- Treat fever actively- treat infections – paracetamol IV/ oral, icepacks, fan
- Prevent hyperglycaemia (do glucotest q6h, very conservative mini-gliding scale)
- Prevent hypoglycaemia (normal glucose value up to 10mmol/l as stress response)
- Do not treat Blood pressure in acute stage!- Blood pressure goes up in acute stage b.o.: increase in
intracranial pressure- systemic bp nb to perfuse brian
if treat BP= perfusion to brain will decrease= ischemic penumbra gets workse
(A BP of 160/100 is acceptable in the acute phase of stroke (the first 10 days). It must only be
treated if it is higher than 220/120, and then never with sublingual or intravenous
antihypertensives. Start with an ACE inhibitor, e.g. Enalapril. A diastolic pressure of 100 –
110mm Hg is acceptable.)
- Give half aspirin (150mg) when see pt. is awake with ischemic stroke- if not awake= suspect
haemorrhagic stroke= not give aspirin
- An urgent CT scan will be done if the patient is not awake or has vomited (a hemorrhage might be
treatable by a neurosurgeon), or if the patient has arrived at hospital soon (before 4.5h has lapsed),
and he might qualify for rTPA. See later.
- All pts. with stroke must have a routine CT to confirm the diagnosis of stroke, as the differential
diagnosis is tumor, subdural bleed, tuberculoma, etc.

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If patient’s consciousness deteriorates- consider:

- The patient is dehydrated –do U&E, glucose.
- The patient has had a convulsion –observe, do EEG if necessary, treat if more than one
convulsion
- The patient has bled in the infarction –rescan, tell the family.
- The patient has developed cytotoxic brain edema and is herniating –hyperventilate, give mannitol
once or twice. The prognosis is poor. Treat underlying infections and keep fever down and
electrolytes normal.
- Or the patient might not have had a stroke and an alternative diagnosis should be considered, e.g.
encephalitis.
- A CEREBELLAR INFARCTION is an EMERGENCY, If the cerebellum swells, it presses on the
vital centers in the medulla, and the patient will stop breathing and die. Neurosurgical intervention
will save the patient’s life, and they do very well with decompression.

When to use anticoagulation:

- Antiplatelet tx- aspirin is given to all ischemic stroke
- Heparin - 50% advantage for stroke in evolution patients is neutralized by the 50% patients that
bleed from heparin. It is not used for stroke treatment anymore. It is used for DVT
prophylaxes. Use stockings for DVT prophylaxes if available.
- Warfarin
 Atrial fibrillation pt.’s with stroke – INR must be controlled between 2-3
 With metal valves: INR must be between 3-4- continue/ restart Warfarin
 If not metal valves- wait a week- 10 days after stroke (depends on size of stroke)- larger the
stroke= bigger chance of bleeding on it
- rTPA
 It is only given intravenously if a patient presents with a clinical stroke and has a CT scan
that shows no bleed and the middle cerebral artery distribution does not have more than a
third hypodensity,
 before 4,5 hours have passed from stroke onset. The sooner you give it, the better the
outcome.
 It has a list of indications and contraindications before it can be given.

Always look for underlying causes:

Risk factors:
 Hypertension (history)
 Diabetes (HbA1c)
 Hypercholesterolemia (fasting
lypogram)
 Smoking – pt. MUST stop if does not
want another stroke
 Alcohol in excess  stroke BUT 2
glasses of wine/day= protect aa.
Younger people with strokes: (<55yrs)
Causes not obvious= special investigation;
 FBC, ESR
 SMAC, TF, RPF+ TPHA, HIV, ANF
 Heartsonar, ECG, Dopppler carotid aa. in cas of
TIA /murmurs in neck
 Angiography (takayasu aortitis , sifilitic aortitis)
 Genetic diseases like proteien S and C deficiency,
antitrombin III deficiency, antiphospholipid
syndrome need to be investigated by coagulation
studies 6 weeks after the acute stroke.

Prevention of stroke:
(easier to prevent if identified risk factors and treated them)
 Treat hypertension effectively (ACE inhibitors
 Treat diabetes effectively

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 Stop smoking and abusing alcohol

 Take a Aspirin a day
 Treat high cholesterol
 Refer symptomatic D lesions of the internal carotid artery for vascular surgery
 Treat atrial fibrillation with warfarin, defibrillate if possible (cardiologist)
 Heartvalveproblems must be evaluated by a cardiologist
 Treat neurosyphiliswith 4 mUPen G q4h ivifor 10 –14 days
Vascular surgery:
- For stroke patients who have more than 50% occlusion of the internal carotid artery and who has
a symptomatic lesion.
- CT brain is important to exclude other reasons for hemiplegia.
- The patient must have had a good functional recovery after stroke or a TIA.

Cerebral haemorrhage:
Causes:
 Hypertension
 Arteriovenous malformation
 Aneurism
 Anticoagulation therapy
- Cerebral haemorrhage= acute onset of symptoms, often: raise intracranial Pressure signs
- Pt. = often not conscious+ vomited+ severe headache
- A CT scan is the special investigation of choice.
- A Hypertensive bleed is often deep in the brain matter, close to the internal capsula, while an
aneurismal bleed is more to the periphery of the brain.
- CT angiography is done if an aneurism or AVM is suspected, as it has implications of treatment.
- Careful treatment of hypertension is indicated, as is conservative measures. Corticosteroids are
not of value.
- Neurosurgical decompression of a hypertensive bleed is indicated if the patient deteriorates and
will survive anesthesia.