STROKE

• Domínguez Medina John Michael

• Murillo Cortez Emily María Dr. Alberto Campodónico
 STROKE
A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain.
Second leading cause of death worldwide.
Classification of Stroke
Two major categories:

• Ischemic •Hemorrhagic
strokes Caused when a blood strokes,
vessel supplying the
brain is occluded by a Caused when a
clot. cerebral artery
ruptures.
Responsible for 75%
of all strokes.

Both forms are life threatening.

 Ischemic strokes

It is a pathological clinical disorder of

the central nervous system that occurs
as a result of the compromise of the
vessels that supply oxigen, this
dysfunction is due to a circulatory
alteration due to occlusion of the brain
arterial tree determining functional and
vital commitment of the affected
territory.
Pathophysiology
• The thrombus can form in an artery affected by
atherosclerosis. Atherosclerosis is a process that is
characterized by plaque buildup inside the artery.

• This plaque makes the arterial wall thicker,

narrowing the vessel. Plaque is made up of fat,
cholesterol, fibrin (a coagulant substance) and
calcium. As plaque builds up in the arteries, blood
circulates more slowly and difficultly, facilitating
coagulation.

• A blood vessel narrowed by atherosclerosis is more

likely to be blocked by a clot, thus interrupting
blood flow.
 Pathophysiology
EMBOLUS
• This is caused by a blood clot that
originates in another place in the body,
usually the heart, and travels through the
blood to the brain. This clot clogs an
artery that leads to or is inside the brain.

• The embolus reaches a point where it

cannot keep moving forward and gets
stuck, obstructing a small cerebral artery
and interrupting the flow of blood to the
brain.
 Signs
And
Symptoms
 Diagnosis
• Primarily clinical evaluation

• Neuroimaging.
- TC: This is done first to exclude
intracerebral hemorrhage, subdural or
epidural hematoma, and a rapidly growing,
bleeding, or suddenly symptomatic tumor.

• Evaluation to identify the cause:

• For cardiac causes, testing typically includes ECG,
telemetry or Holter monitoring, serum troponin, and
transthoracic or transesophageal echocardiography.

• For vascular causes, testing may include magnetic

resonance angiography (MRA), CT angiography (CTA),
carotid and transcranial duplex ultrasonography, and
conventional angiography. The choice and sequence of
testing is individualized, based on clinical findings.

• For blood-related causes (eg, thrombotic disorders),

blood tests are done to assess their contribution and
that of other causes. Routine testing typically includes
CBC, platelet count, PT/PTT, fasting blood glucose, and
lipid profile.
 Treatment
• General stroke treatments.
• Acute antihypertensive therapy only in certain circumstances.
• Antiplatelet therapy.
• For acute treatment, sometimes reperfusion with recombinant tissue
plasminogen activator (IV or thrombolysis-in-situ), and/or mechanical
thrombectomy.
• Sometimes anticoagulation.
• Long-term control of risk factors.
• Sometimes carotid endarterectomy or stenting.
 HEMORRHAGIC STROKE

A hemorrhagic stroke is bleeding (hemorrhage) that suddenly interferes

with the brain's function. This bleeding can occur either within the
brain or between the brain and the skull.
 Pathophysiology
 Usually occurs spontaneously
 Caused by vascular rupture with bleeding into brain
 Mass effect can further cause bleeding and hematoma
expansion from neighboring vessels
 Hemorrhages commonly occurs at the basal ganglia,
thalamus, pons, or cerebellum
 Hemorrhagic strokes account for about 20% of all
strokes, and are divided into categories depending on the
site and cause of the bleeding.
 It is the one that affects the fifth and sixth
Intracerebral decade of life. Bleeding occurs from a broken
hemorrhage blood vessel within the brain.
Some things that increase the risk for this
kind of hemorrhage are
• High blood pressure (hypertension)
• heavy alcohol use
• advanced age
• use of cocaine or amphetamines.
In rare cases, intracerebral hemorrhage may
happen because of a leaking arteriovenous
malformation (AVM), which is an abnormal
and weak-walled blood vessel that connects
an artery and a vein. This weak blood vessel
is present from birth.
 It is an Acute emergence of blood in the
Subarachnoid subarachnoid space.
hemorrhage Is more frequent in adolescents and young adults.
Bleeding from a damaged blood vessel causes
blood to accumulate at the surface of the brain.
Blood fills a portion of the space between the
brain and the skull, and it mixes with the
cerebrospinal fluid that cushions the brain and
spinal cord. As blood flows into the cerebral
spinal fluid, it increases pressure on the brain,
which causes an immediate headache.
In the days immediately following the bleeding,
chemical irritation from clotted blood around the
brain can cause brain arteries that are near to this
area to go into spasm. Artery spasms can damage
brain tissue. Most often, a subarachnoid
hemorrhage happens because of a leaking
saccular aneurysm but it also can occur because
of leakage from an arteriovenous malformation.
 Signs and symptoms

Intracerebral hemorrhage Subarachnoid hemorrhage

• Sudden weakness • A very severe headache that starts suddenly
• Paralysis or numbness in any part of the body • Loss of consciousness
• Inability to speak
• Nausea and vomiting
• Inability to control eye movements correctly
• Vomiting • Inability to look at bright light
• Difficulty walking • Stiff neck
• Irregular breathing • Dizziness
• Stupor • Confusion
• Coma
• Seizure
• Loss of consciousness
 Diagnosis
• Clinical history and physical examination
Test Results
Head CT • Differentiates hemorrhagic from ischemic stroke
Lumbar puncture • If a subarachnoid hemorrhage is suspected. This fluid is
examined to see if it contains blood
Labs • Chem panel – for conditions that have similar
presentation
• CBC – thrombocytopenia
• PT/PTT – w/o coagulopathy as cause
MRI • For aneurysm or arteriovenous malformation as a cause of
CT bleeding
angiography • Recommended in all patients <45 years of age and in all
Invasive patients with intracerebral hemorrhage in lobar brain regions
angiography

Management of cerebral
edema and intracranial
hypertension
• Osmotic diuretics; intravenous
mannitol; loading dose of 1g / kg,
the dose can be repeated every 6
hours.
• Barbiturates; thiopental sodium
in doses of 1-5 mg / kg
intravenously to induce a
barbiturate coma.
• Others: surgical evacuation,
ventricular catheter placement
(ventriculostomy).
Treatment
Pharmacological treatment
Management of hypertension Seizure management
• Blood pressure should be kept moderately • Intravenous antiepileptic drugs
high to maintain adequate perfusion of the
area. should be administered if there are
• If the systolic blood pressure is greater than seizures to prevent their
185 mmHg, hypotensive management is recurrence, an option is phenytoin.
started orally with labetalol at a dose of 100
mg every 12 hours.
• If it is not possible to use the oral route , we
need to give urgent intravenous hypotensive
treatment; Labetalol at an initial dose of 20
mg (4 ml) in 5 minutes by intravenous bolus
• When the diastolic blood pressure is greater
than 140 mmHg, the patient is admitted to the
intensive care unit and intravenous sodium
nitroprusside is administered.
 Treatment
Surgical management

If necessary, a surgeon will cut the skull

If bleeding occurred because of an
bone to decrease the compression of the
abnormally formed blood vessel,
brain tissue. In some cases, surgery is
surgery may be appropriate to prevent a The surgical management is Indicated in patients
necessary to remove a large portion of the
hemorrhage from happening again. An with:
clot after a hemorrhage, but in most
aneurysm can be repaired by placing a
patients, the body eventually reabsorbs
surgical clip.
the clotted blood on its own.

Cerebellar
hematomas Superficial
with decreased lobar Hematomas
stage of hematomas open to
consciousness, with ventricles that
signs of compressive generate
brainstem neurological hydrocephalus.
compression, deterioration.
or obstructive
hydrocephalus.