Stroke

WHO def.
Rapidly developing clinical sign of focal(at times
global) disturbance of cerebral function, lasting
for more than 24h or leading to death with no
apparent cause other than of vascular origin
 History
• Onset
• Progression
• Associated Features
• Evalution of risk factors
 examination
• Complete Neurological Examination
. Conscious level
. GCS
. NIHSS
. Motor
. CN examination
. Sensory
. Reflexes
 aeitology
• Ischemic stroke
1. Atherothromoembolism.
carotid and vertebral disease
intracranial disease
aortic arch disease
2. Cardioembolism.
3. Small vessel disease.
4. Arterial dissection.
5. Inflammatory vascular disorder.
gaint cell arteritis
systemic vasculatides..SLE.
Primary angitis
6. Haematological disorders
antiphospholipid antibody synd.
sickle cell disease
thrombophillic states
7. infections
meningitis.. eg. TB
HIV
8. others
migraine
COC, pregnancy
 Cerebral Haemmorrhage 15%
• Intracranial haemmorrhage.
.small vessel disease.. Htn
. AVM
.cerebral amyloid angiopathy
. Tumors
. Cerebral venous throbosis
. Haemotogical disorders:
anticoagulants, antiplatelets, and
thromolytic therapy
. Drug abuse… cocaine
. Myomoya syndrome.
 Subarachnoid Haemmorrhage
• Aneurysm.
• Trauma.
• Dural AV fistula.
• AV malformation
 Risk factors.
• Age more than 75y
• Hypertension
• Smoking
• Diabetes
• IHD
• A.fib
• Previous TIA
 Immediate Investigations
• Should be performed witin 24h
• CT
reveals lesion in 50%
• Susceptibilty weightated image SWI
more sensitive than ct for haemmorrhage
• T2 weighted images
show lesion in 90% by 24h
• Diffusion Weightates images
show changes within mins
useful to distinguish acute from chronic
• Imaging of extracranial vessels
carotid and vertebral usg
MR or CT angiography
should be performed in all pts with TIA or moderatev stroke.
 Investigations
• Blood tests Ist line
. FBC and ESR
. Ca
. U/E, creatinine, LFTs
. Thyroid function
. Cholestrol.
. Clotting screen.
 Investigations
• Blood test 2nd line

. Thrombophillia screen:
protein c, s, and antithrombinIII defect
factorV leiden mutation
antiphospholipid antibody; cardiolipin
antibody
lupus anticoagulant
IgM, IgG, beta 2 glycoprotein antibody

. Blood cultures- bacterial endocarditis

. Homocystine.
. Lactate
. Cardiac enzymes
 Investigations
• Other
urine analysis
ECG
Echocardiogram and TOE
 Management
General Management
• Admission in stroke unit
• ABC Airway, Breathing, Circulation
• Blood pressure should be<220/120 in ischemic and
<185/150in haemmorrhagic
• Oxygen target 92%
• Blood glucose optimal management
• Pyrexia
• Swallowing and Nutrition
• Physiotherapy
• DVT Prophylaxis
• Seizure
• Depression
 Specific treatment of acute stroke
Acute Ischemic Stroke
• Thromolysis and Thrombectomy
only if patient presents within 4.5hrs and
haemorrhage have been excluded
Antiplatelet drugs
. Aspirin 82-300mg.
• Anticoagulation only if patient have arrthymia
 Management
• Surgery
. Carotid endartrectomy
69-99% occlusion
haemodynamic instabity
ipsilateral
 Management
acute intracranial haemorrhage
• Stop
• Hydrocephalus
• STITCH Trial
 Prevation of ischemic stroke
Primary prevention
• Atheroembolism

Avoidance of risk factors

HTN
DM
Smoking
hypercholestrolaemia
. Carotid stenosis
. ACST
. A.FIB

• Primary ICB
HTN is major risk factor
.