‫سکته مغز‪+‬ی ایسکمیک‬

‫سپاس فراوان از‪:‬‬

‫استاد حمرتم نرځورایر داکرتامحد مسری حبیبیار‬

‫ترینی سال سوم صحت روان ‪1400‬‬ ‫گردآورنده‪ :‬حسینا عزیزی صورتگر‬
CONTENS:
 Definition
 Epidemiology
 Risk factor
 Classification
 Pathophysiology
 Types
 Symptoms
 Diagnosis
 Treatment
STROKE:
stroke is a serious life threatening
medical condition that happens when
the blood supply to part of the brain is
damaged.
 Epidemiology
• Third most common cause of death after cancer
and ischemic heart diasease
• Most common cause of severe physical disability
• Incidence and prevalence of stroke is on the rise
due to increasing adoption of unhealthy lifestyle.
• Approximately 800,000 people have a stroke each
year, about one every 40 sec , with one person
dying every 4 min.
• A stroke is a medical emergency , and treatment
must be sought as quickly as possible.
RISK FACTORS
NON-MODIFIABLE RISK FACTORS
• Age
• Gender
• Ethnicity
• Heredity
RISK FACTORS (cont’d)
MODIFIABLE RISK FACTORS
• Hypertension
• Cardiac Disease
• Diabetes Mellitus
• Smoking
• Alcohol
• High Cholesterol
• Illicit Drug Use (cocaine,methamphetamine)
• Migraines
RISK FACTORS (cont’d)
MODIFIABLE RISK FACTORS
• Oral Contraceptives
• Pregnancy
• Breastfeeding
• Haemostatic and Inflammatory Factors.
• Hyperhomocysteinemia
• Sickle cell anemia
• Asymptomatic Carotid Stenosis
• Transient Ischemic Attacks
• Lifestyle Factors (Obesity, Physical inactivity, Diet,
and heavy drinking).
Classification:
There are several criteria for classifying stroke

Time criteria

Vascular criteria

Etiology criteria
Pathology
criteria
 Pathology criteria:

 Ischemic stroke 90%

 Hemorrhagic stroke 10%

10th Edition Aminoff

What is Ischemic stroke?

• This is the most common type of

stroke.
• It happens when the blood supply
is blocked by blood clot or clump of
fat. This damages your brain cells
and they begin to die.
Ischemic stroke it self is classified according to:
• Time
• Etiology
• Vascular criteria
 1. Time:
There are three types of ischemic stroke due to the duration of symptoms
1. Transient Ischemic attack (TIA)
• The duration of symptoms is less than 24 hours
2. Reversible Ischemic Neurologic Deficit (RIND)
• The duration of symptoms is more than 24 hours and less than 21 days
3. Infarction
• The duration of symptoms is more than three weeks
2. Etiology factor:
Ischemic stroke is etiologicall divided into three parts.

Arterialthromboti
c

Embolic

Lacunar
ARTERIALTHROMBOTIC
• Also called thrombotic stroke or
cerebral thrombosis.
• This is when a blood clot forms in
an artery that supplies your brain
and blocks the blood supply.
• Symptoms therefore depend on
where the blood clot has formed.
CEREBRALEMBOLISM
• Also known as embolic stroke.
• This is when a blood clot forms
somewhere else in your body and
travels to your brain and blocks
the blood supply. The clot usually
forms in your heart or one of the
large arteries that supplies your
brain.
Cause of Embolic Stroke
• It has three causes

cardiac

non-cardiac

unknown
• cardiac:
1. Atrial fibrillation and other arrhythmias (most commonly embolism)
2. Myocardial infarction with wall thrombosis
3. Heart valve diseases with or without arrhythmia
4. Complications of heart surgery
5. Acute and subacute microbial endocarditis
6. Artificial valve
7. Non-microbial vegetations
8. Paradoxical embolism in congenital diseases
9. Atrial myxoma
10.Other causes such as mitral valve prolapse
• non-cardiac
1. Aortic atherosclerosis and carotid artery
2. Large cerebral artery thromosis (basilar, vertebral, midbrain)
3. Pulmonary thrombosis
4. Fat embolism
5. Tumors
6. Airborne embolism
7. Complications of neck and thoracic surgery

• unknown
Lacunar :
• 20% of all strokes
• Onset may be abrupt or gradual
• Lacunes are samll infarction (less
than 15mm) seen in the putamen,
pons, thalamus, caudate, and
internal capsule.
• Cause: occlusive arteriolar or
small artery disease (occlusion of
deep penetrating branches of
large vessels).
 Arterial criteria:
• ANTERIOR CEREBRAL ARTERY
• MIDDLE CEREBRAL ARTERY
• POSTERIOR CEREBRAL ARTERY
 Pathophysiology of Cerebral Ischemia
•
SIGNS & SYMPTOMS
 Abrupt onset of hemiparesis, momoparesis,or quadriparesis
Hemisensory deficits
Monocular or binocular visual loss
Visual field deficits
Diplopia
Dysarthria
Facial droop
Ataxia
Vertigo
Nystagmus
Aphasia
Sudden decrease in level of consciousness
 Sign and Symptom posterior (%) Anterior (%)
Headache 3 25
Change of consciousness 16 5
Aphasia 0 20
Vision problems 22 14
Diplopia 7 0
vertigo 48 0
Dysartheria 11 3
Drop attack 16 0
Hemiparesis 12 38
Hemisensory 9 33
DIAGNOSIS
• Physical Examination
• Clinical manifestation
• Imaging
 Management
• General Management
• Airway
• Breathing
• Circulation
• Hydration
• Blood glucose
• Temperature
• Pressure areas
• Incontinence
• Mobilisation
• Blood pressure
– Unless there is heart or renal failure, evidence of
hypertensive encephalopathy or aortic dissection, do not
lower blood pressure in first week as it may reduce
cerebral perfusion.
SEVERE HYPERTENSION
(SYSTOLIC BP>220 OR
DIASTOLIC BP>120mmHg)
• Treat with IV Labetalol or
Nicardipine infusion.
• For the administration of
Alteplase, the patient’s systolic
BP must be <185 and diastolic
BP<110mmHg.
• • Monitor for signs and
symptoms of brain swelling,
↑ICP and herniation.
• • Serial CTs are helpful in the
evaluation of deteriorating
patients.
• • As a temporizing measure,
treat with Mannitol and
hyperventilation.
Ischemic stroke therapies include the following:

Fibrinolytic therapy
Antiplatelet agents
Mechanical thrombectomy
MEDICINES
• Aspirin and Clopidogrel are used to
reduce your risk of blood clots forming
after a stroke.
• Aspirin is associated with reduced
morbidity and mortality in acute ischemic
stroke presenting <48 hours from onset.
ASPIRIN
 The most widely used medical therapy for TIAs is aspirin.
At low doses, it is an irreversible inhibitor of cyclooxygenase, which leads to
reduced thromboxane production and diminished platelet aggregability.
 At higher doses, it reduces prostacyclin generation within the vessel wall, a
theoretically undesirable effect because prostacyclin is vasodilator.
 Most studies have shown that aspirin taken in doses ranging from 80 to
1300 mg per day.
 ANTICOAGULATION THYERAPY:

Warfarin and Enoxaparin:

• Indication:
Reccurent TIA
Multifocal ischemic stroke
Posterior cerculation
Stroke inevulotion
Source of emboli
• Dose:Tab 2,5mg – 5mg
• INR= 2-3
ABCD2 ≥ 5 moderate to high stroke risk & in need for hospital
admission.
Refrence:
• Clinical Neurology 10th edition (Roger P. Simon, Michael J. Aminoff,
David A. Greenberg)
• Principles of Internal Medicine Harrison’s 2018
• Iranian Textbook of Clinical Neurology
• Medscape
• Internet (www.google.com)