Professional Documents
Culture Documents
Stroke
Stroke
10
Ischemic Strokes
• Large Vessel Occlusion of the Major Vessels of the Neck
Outside the Cranial Vault i.e. Carotid or Vertebral Occlusion
• Large or Medium Sized Vessels in the Cranial Vault i.e.
Middle Cerebral or Basilar occlusion
• Embolic material breaking away from the heart and
occluding a vessel down stream so called cardiogenic
embolus
• Embolic material breaking away from carotid or basilar
atheromatous disease in the neck or within the cranium
and blocking a vessel down stream so called artery to
artery embolus
• Small Vessel Occlusions of penetrating vessels which take
off at right angles so called “Lacunar Strokes”
Many Causes of Stroke
16
Lacunar Strokes
• Small Penentrating Blood Vessels
• Pure Motor Stroke
• Pure Sensory Stroke
• Ataxia-Hemiparesis
• Clumsy Hand Dysarthria
• Excellent prognosis for recovery
Stroke Mimics
• Hypoglycemia
• Hyperglycemia
• Seizure
• Subdural
Hematoma
Stroke Differential Diagnosis
Ancillary Diagnostic Tests
• In selected patients
– Duplex / Doppler ultrasound
– MRA or CTA
– Diffusion and perfusion MR or perfusion CT
– Echocardiography, Chest X-ray
– Pulse oximetry and arterial blood gas analysis
– Lumbar puncture
– EEG
– Toxicology screen
DWI
ADC
Perfusion MRI Weighted Image
Perfusion Diffusion Mismatch The
HOLY GRAIL
Acute
Emergency Diagnostic Tests
• Mismatch Concept
– Mismatch between tissue abnormal on DWI and
tissue with reduced perfusion may reflect tissue at
risk of further ischaemic damage1
– There is disagreement on how to best identify
irreversible ischaemic brain injury and to define
critically impaired blood flow2
– There is no clear evidence that patients with
particular perfusion patterns are more or less likely
to benefit from thrombolysis3
1: Jansen O et al. Lancet (1999) 353:2036-2037
2: Kane I et al. Stroke (2007) 38:3158-3164
3: Albers GW et al. Ann Neurol (2006) Guidelines
60:508-517Ischaemic Stroke 2008
TPA 3-4.5 Hours
• ECASS 3 CRUCIAL EFFICACY NOT CLEAR: SAFETY IS
• Excludes anyone on Coumadin even if INR is
normal
• Excludes anyone over 80
• Excludes NIH Stroke Scale Score over 25
• Excludes patients with HTN and DM
• Does not compare to other therapies i.e. mixed
IV/IA or IA TPA
Blood Pressure Management
• Do NOT Treat BP in Ischemic Stroke unless it is
over 220/120 or the patient is having an MI,
Dissection or Acute Glomerulonephritis
• Stop ALL HOME BP Meds, Trandelenberg,
Raise BP???
• The key is the shift of the auto-regulatory
curve to the right in hypertensives and the
need to maintain perfusion
• Small Changes IN Local Perfusion NOT
represented by lowering of BP may cause
deterioration or fluctuation
PFO: A LONG STORY
• Percutaneous Device Closure of Patent Foramen Ovale for
Secondary Stroke Prevention
• A Call for Completion of Randomized Clinical Trials A Science
Advisory From the American Heart Association/American
Stroke Association and the American College of Cardiology
Foundation The American Academy of Neurology affirms the
value of this science advisory
• AJC ARTICLE
• Size
• ASD
• ASA
• ???Anti-Platelets vs Anti-Coagulation
Stroke as an Emergency
• Background
– Stroke is the most important cause of morbidity
and long term disability in Europe1
– Demographic changes are likely to result in an
increase in both incidence and prevalence
– Stroke is also the second most common cause of
dementia, the most frequent cause of epilepsy in
the elderly, and a frequent cause of depression2,3
Guidelines
1: Gabriel S et al.: Cochrane Review (2005) Ischaemic Stroke 2008
CD002229
Risk Factor Management
Recommendations (1/4)
Blood pressure should be checked regularly. High blood
pressure should be managed with lifestyle modification and
individualized pharmacological therapy (Class I, Level A) aiming
at normal levels of 120/80 mmHg (Class IV, GCP)
Guidelines
1: Viscoli CM et al.: N Engl J Med (2001) Ischaemic Stroke 2008
345:1243-9.
Sleep-disordered Breathing
• Background
– Sleep-disordered breathing (SDB) is both a risk
factor and a consequence of stroke
– More than 50% of stroke patients have SDB, mostly
in the form of obstructive sleep apnoea (OSA).
– SDB is linked with poorer long-term outcome and
increased long-term stroke mortality1
– Continuous positive airway pressure is the
treatment of choice for OSA.
Guidelines
1: Antithrombotic Trialists' Collaboration: Ischaemic
BMJ (2002) Stroke 2008
324:71-86
Antithrombotic Therapy
• Background: Dipyridamole plus aspirin
– Relative risk reduction of vascular death, stroke or
myocardial infarction with the combination is
significantly greater (RR 0.82; 95%CI 0.71-0.91)
than with aspirin alone1,2
– ARR 1.0% per year (NNT 100)2
– Incidence of dipyridamole induced headache may
be reduced by increasing the dose gradually3
Guidelines
1: Kastrup A et al.: Acta Chir Belg (2007) Ischaemic Stroke 2008
107:119-28
CREST STUDY
• Landmark NIH Clinical Trial Comparing Two
Stroke Prevention Procedures Shows Surgery
and Stenting Equally Safe and Effective
• Opportunities Exist to Target the Treatment to
the Patient
Intracranial Occlusive Disease
• Background
– Extracranial-Intracranial bypass is not beneficial in
preventing stroke in patients with MCA or ICA stenosis
or occlusion1
– No randomized controlled trials have evaluated
angioplasty, stenting, or both for intracranial stenosis
– Several non-randomized trials have shown feasibility
and acceptable safety of intracranial stenting, but the
risk of re-stenosis remains high2,3
Guidelines2):S61-8.
1: Steiner T et al.: Neurology (2001) 57(Suppl Ischaemic Stroke 2008
Elevated Intracranial Pressure
• Malignant MCA/hemispheric infarction
– Pooled analysis of three European RCTs (N=93)1,2:
• Significantly decreases mortality after 30 days
• Significantly more patients with mRS <4 or mRS <3 in the
decompressive surgery group after one year
• No increase of patients surviving with mRS=5
– Surgery should be done within 48 hours1,2
– Side of infarction did affect outcome1,2
– Age >50 years is a predictor for poor outcome3
1: Vahedi K et al.: Lancet Neurol (2007) 6:215-22 Guidelines Ischaemic Stroke 2008
Elevated Intracranial Pressure
Recommendations (1/2)
Surgical decompressive therapy within 48 hours after symptom
onset is recommended in patients up to 60 years of age with
evolving malignant MCA infarcts (Class I, Level A)
Osmotherapy can be used to treat elevated intracranial
pressure prior to surgery if this is considered (Class III, Level C)
Guidelines
1: Gerberding JL: Ann Intern Med (2002) Ischaemic Stroke 2008
137:665-70c
Management of Complications
• Deep vein thrombosis and pulmonary embolism
– Risk might be reduced by good hydration and early
mobilization
– Low-dose LMWH reduces the incidence of both DVT
(OR 0.34) and pulmonary embolism (OR 0.36), without
a significantly increased risk of intracerebral (OR 1.39)
or extracerebral haemorrhage (OR 1.44)1,2