STROKE

Dr. Paulos Efrem

AAU-CHS, SoM
Department of internal medicine
 INTRODUCTION
• Cerebrovascular diseases include some of the most
common and devastating disorders
• Ischemic stroke,

• Hemorrhagic stroke, and

• Cerebrovascular anomalies such as intracranial aneurysms and

arteriovenous malformations (AVMs).
Definition

• A stroke, or cerebrovascular accident, is defined by this abrupt onset

of a neurologic deficit that is attributable to a focal vascular cause.

• Thus, the definition of stroke is clinical, and laboratory studies

including brain imaging are used to support the diagnosis
Cont…
• The clinical manifestations of stroke are highly variable because of the
complex anatomy of the brain and its vasculature.
• Cerebral ischemia is caused by a reduction in blood flow that lasts
longer than several seconds.
• Neurologic symptoms are manifest within seconds because neurons
lack glycogen, so energy failure is rapid.
• If the cessation of flow lasts for more than a few minutes, infarction
or death of brain tissue results.
Cont…

• Transient ischemic attack (TIA)

• blood flow is quickly restored, brain tissue recovers fully

• Patient's symptoms are only transient

• All neurologic signs and symptoms resolve within 24 hours

• Stroke has occurred if the neurologic signs and symptoms last for >24
hours.
Epidemiology

• It is a second leading cause of death worldwide

• There is ~200,000 death per year in the US

Classification
• Ischemic - 85% • Hemorrhagic - 15%
• THROMBOTIC - 25% • Intraparenchymal
-Lacunar
• Subarachnoid
-large vessel
• EMBOLIC - 75% • Subdural
-cardioembolic
• Epidural
-artery to artery
-cryptogenic
-others
Cont…

• Ischemic and hemorrhagic strokes cannot be reliably differentiated on

the basis of clinical examination findings alone.

• Although nausea,vomiting, severe headache and loss of

consciousness is more common in hemorrhagic stroke.

• Imaging studies are required to differentiated between the two.

Ischemic Stroke

• Sudden loss of blood circulation to an area of the brain resulting in a

corresponding loss of neurologic function.

• Caused by occlusion of arterial blood flow to the brain,

• Which in turn is caused by either

• Extracranial embolism of clot to the large intracranial vessels, or

• Progressive thrombosis of small intracranial arterioles.

Pathophysiology

• Brain can’t tolerate decrease in blood flow for a long time

• If cerebral blood flow decreases below a critical level( 10-20ml/100gm

brain tissue/min versus 55ml/100gm/min), initiate cellular metabolic
failure.

• This results in cellular (cytotoxic edema) - increased cellular water

content
Cont…
• If blood flow is restored immediately - TIA

• The area deprived of blood supply has two regions

• The core infarction and

• The surrounding ischemic penumbra /which is the salvageable part/

• The extent of the infarction depends on

• Rate of occlusion

• The adequacy of collaterals

• Susceptibility of the brain tissue

Risk Factors
• Non-modifiable • Modifiable
• Age • Arterial hypertension

• Gender • TIA

• Race/ethnicity • Prior stroke

• Family history • DM

• Genetics • Dyslipidemia

• Smoking

• Excessive alcohol intake

• Obesity
Clinical Manifestations
• History
• Identify risk factors
• Hypertension
• Diabetes Mellitus
• Tobacco use
• High cholesterol
• In younger patients elicit a history of
• Recent trauma
• Coagulopathies
• Migraines
• OCPs
Cont…

• Common signs and symptoms of stroke include the abrupt onset of the following
• Hemiparesis

• Monocular or binocular visual loss

• Facial droop

• Aphasia

• Sudden decrease in the level of consciousness

Physical Examination

• Goals of physical examination

• Distinguish stroke from stroke mimics

• Localize the lesion

• Identify comorbidities
Diagnostic Studies

• A head CT is the initial study of choice for acute stroke, primarily to

evaluate for intracranial hemorrhage.

• MRI is best for characterizing the location and size of ischemic

strokes.

• ECG: The initial screening test for cardiac arrhythmias, especially AF.
Management
• ACUTE ISCHEMIC STROKE
1.Medical support
2.Thrombolysis
3.Anticoagulation
4.Neuroprotection
• RISK MODIFICATION
1.Manage HTN
2.Manage DM
3.Stop smoking and alcohol
Hemorrhagic Stroke
• Intra-parenchymal
• Associated with a high rate of mortality 50%

• Causes- HTN, trauma, cocaine and other illicit drug, hemorrhagic disorders,
vascular malformation
• Common sites Basal ganglia, pons, deep cerebellum

• Associated with change in consciousness and signs of increased ICP

Management
• Management of hypertension

• Management of increased ICP

• Surgery - hematoma evacuation

• Treat other causes – like bleeding

Subarachnoid Hemorrhage

• Causes
• Saccular aneurysm

• Head trauma

• Bleeding from vascular anomaly

• Extension from ICH

• Idiopathic
Pathophysiology

• The aneurysm ruptures at the base of the brain to the Subarachnoid

space and adjacent parenchyma

• Increased ICP is caused by the blood in the SA space or the

parenchyma, acute hydrocephalus and loss of vascular auto
regulation
Clinical Features
• SAH is associated with increased ICP
• Headache, vomiting & loss of consciousness

• Headache – “worst headache in my life”, thunderclap headache

• Meningeal irritation signs may be seen

• Definitive management is surgically.

Thank You!