Stroke Basics

Dr N Brey

MBChB III
  Definition & Importance
 Take away
 Stroke concepts
 Types
 Blood supply
 Causes
Overview  Clinical presentation
(3 presentations)
 Mimics & Chameleons
 Oxfordshire Classification
 Videos
 Investigations
 Treatment
 Acute
 Long term prevention
 Stroke was defined Abystroke
the World Health
occurs whenOrganization
a blood vessel (WHO)
that more
than 40 years ago ascarries
“rapidly developing
oxygen clinical signs
and nutrients to theofbrain
focalis(or
global) disturbance either blocked
of cerebral by a clot
function, or bursts
lasting more(orthan 24
Definition ruptures).
hours or leading to death, withWhen that happens,
no apparent part ofthan
cause other the that
of vascular origin.” brain cannot get the blood (and oxygen) it
needs, so it and brain cells die.
Now added sub-clinical strokes to the definition
  Acute neurological event due to a vascular cause lasting less than
Definition 24 hours

TIA  …but most resolve within an hour

Importance
 1.Disability
– Leading cause of adult disability

It’s a big
problem 2.Dementia – 2nd commonest (vascular)

3.Mortality– Top 3
 An emergency
Strokes are… Treatable
Preventable
Oligaemia = ↓ blood flow, but normal function
Penumbra = neurological fallout but potentially viable tissue
SNL = Selective Neuronal loss
Infarction = Neurological fallout, cells have died
Untreated
Location
Location
Location
Types

20-25%
75-80%
Types

 Venous Sinus Thrombosis

Represents 1% (if considered along with stroke)

  Unable to distinguish between ischaemic and haemorrhagic
strokes!!
 May help to determine if it is a small or a large vessel that is
Clinical involved.

 Remember the degree of weakness ≠ necessarily size of the stroke

 How to think about stroke

What caused Current Prevention of

the stroke deficits complications
and recurrence
Circle of Willis
Posterior
Circulation
Anterior
Circulation
(Ant. Cerebral)
Subclavian
→Vertebral
→ Basilar
MCA:
horizontal
section
Anterior
Circulation
(Middle
Cerebral)
  Haemorrhage : 20%
 Hypertensive bleed
 Aneurysms eg SAH

Stroke  Vascular Malformation - AVM

 Tumour
Causes 

Bleeding diathesis
Cerebral Amyloid Angiopathy – Lobar haemorrhages (in elderly)
 Haemorrhagic transformation of an ischaemic OR venous infarct

  Cardiac origin of emboli: 20-30%
Stroke Causes  Atherosclerosis (thrombo-embolic): 25%
- Ischemia:  Small vessel disease: 20%
80%  Hypertension
 Diabetes
 Smoking
 Alcohol
 No cause found: 20%
Sources of
emboli
1. Left Atrium

2. Left Ventricle

3. Aorta

4. Carotid
  Nonatherosclerotic vasculopathy:
Virchows Triad 5-10%
 Fibromuscular Dysplasia
 Carotid & vertebral dissection
 6-10% patients 30-50y
 Arteriitis: (Takayasu,
Ischaemic isolated CNS angiitis, SLE,
Wegeners, HIV, infective
stroke causes)
– other causes  Hematological causes: 5%
 SC disease, Hemoglobin SC disease, PNH
 Polycythemia / Thrombocytosis /
Leukaemia
 TTP / DIC / Disorders of fibrinolysis
 Pregnancy, Cancer, Nephrotic syndrome,
acute infection,…
Think about constituents  Hypercoagulable states
• Too many cells  Antiphospholipid syndromes
• Abnormal cells  Hyperhomocysteinemia
• ↑clotting risks
80+% of Risk
factors are
modifiable
 Atrial Fibrillation
 Risk factors:
 Age 50-60 y: 7% of strokes attributable to AF
 Age 80-90 y: 36 % of strokes attributable to AF
Cardio-Embolic  Potentially more if using monitoring devices
Stroke
  Patients at high risk
 mechanical cardiac valves,
 dilated cardiomyopathy,
Cardio-  myocardial infarction (AMI) within the last month
Embolic  left ventricular or atrial thrombi,
Stroke  infective endocarditis
  The most common arrhythmia
 1 of 6 strokes are due to AF (1 in 3 of pts > 80)
Atrial  In patients with non valvular AF the stroke risk exceeds 7% per
year
Fibrillation and  Rheumatic heart disease patients have a 17-fold increase
Stroke compared to age-matched controls
 Recent data suggests a significant proportion of cryptogenic
stroke is due to paroxysmal AF

Fuster V, Circulation 2011; 123: e269-e367

Is (Some)
Cryptogenic
Stroke
Really
Undetected
AF?
Asymptomatic
AF Episodes
Both Arms
Monitoring for
AF
AF monitoring
Carotid Disease
Stroke
Etiologies
  Very Important and common
 Strokes are a result of neuronal injury due to an alteration in the
blood supply
 Last at least 24 hours +

Summary  TIA’s typically last 1 hour +/-

 Impaired neuronal function may improve with reperfusion
 Most strokes are ischaemic , less often haemorrhagic
 Always try to find the underlying cause to prevent recurrence

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