2022 Stroke Lecture (Updated Guidelines)

A VIEWPOINT AND MANAGEMENT ON
CEREBROVASCULAR & RELATED DISORDERS

FOR ALLIED HEALTH WORKERS AND PRACTITIONERS
References:
• Harrison’s Principle of Internal Medicine (21st Ed)
M.M. Haradji Elino • JNC 7 & 8 Hypertension Guidelines
• Neurology & Neurosurgery Illustrated (5th Ed)
September 10, 2022 1:00 PM • Stroke Society of the Philippines - Handbook of Stroke (6th Ed)
Multipurpose Hall SSGH • Tintinalli’s Emergency Medicine (9th Ed)
OUTLINE I – INTRODUCTION
Definition, Risk, Prevalence
INTRODUCTION Classification by Types, Onset, Severity & Lesion Location
II – CLINICAL APPROACH
CLINICAL APPROACH High Suspicion: F.A.S.T.
Presentation by Lesion
IMAGING Stroke Mimickers
III –IMAGING: THE BASICS AND THE STROKE ON CT

MANAGEMENT The Basics on Plain Cranial CT Scan
Infarct, Bleed, SAH, Hemorrhagic Conversion & Malignant Infarct
PREVENTION Bleed volume estimation – Kothari Method
IV – MANAGEMENT
Ischemic (TIA & Infarct)
Hemorrhagic (Intracerebral Bleed & SAH)
V – PREVENTION
Primordial & Primary Prevention
Secondary Prevention
Tertiary Prevention
OUTLINE
INTRODUCTION
Cerebrovascular disease (CVD)
is the umbrella term for any abnormality in the brain resulting
CLINICAL APPROACH from a vascular pathologic process such as occlusion (by embolus
or thrombus), alteration in blood flow, or vessel rupture.
IMAGING
MANAGEMENT Stroke
on the other hand, is specifically the type caused by
PREVENTION
cerebrovascular disease that results from two major mechanisms:
ischemia and hemorrhage.
֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1
֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6
֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X.
OUTLINE Term Definition
INTRODUCTION a type of ischemic stroke with a transient episode of neurological

Transient Ischemic
dysfunction caused by focal brain, spinal, or retinal ischemia, without
Attack
CLINICAL APPROACH evidence of acute infarction in which clinical symptoms last within 24
(TIA)
hours, typically less than an hour
IMAGING
a type of ischemic stroke caused by vessel occlusion that causes the
Infarction
MANAGEMENT reduction or cessation of blood flow which eventually leads to tissue
(CVD Infarct)
death or infarction of the brain parenchyma
PREVENTION
Intracerebral a type of hemorrhagic stroke in which the alteration of the blood flow
Hemorrhage is the bleeding from a ruptured blood vessel dissipating to the brain
(CVD Bleed) parenchyma
Subarachnoid a type of hemorrhagic stroke in which the alteration of the blood flow
Hemorrhage is the bleeding from a ruptured saccular aneurysm, vascular formation
(SAH) or fistula, extending to subarachnoid space.
OUTLINE
INTRODUCTION
Stroke
the second leading cause of death following ischemic heart
CLINICAL APPROACH disease and the third leading cause of disease burden worldwide.
IMAGING
In the Philippines, mortality for Cerebrovascular Disease is 82.8
MANAGEMENT per 100,000 person-years.
PREVENTION
OUTLINE HOSPITAL BASED REGISTRY 2011
INTRODUCTION HOSPITAL NUMBER

ISCHEMIC HEMORRHAGIC
STROKE STROKE
CLINICAL APPROACH
Philippine General Hospital 1656 54% 46%
IMAGING
St. Luke’s Medical Center-Quezon City 413 76% 24%
MANAGEMENT
The Medical City 665 83% 17%
PREVENTION
University of Santo Tomas Hospital 514 67% 33%
Makati Medical Center 543 70% 30%
Jose Reyes Memorial Medical Center 1056 59% 41%
SIMPLIFIED CLINICAL STROKE CLASSIFICATION*

ONSET SEVERITY** TYPES LATERALITY LOCATION BY CLINICAL
(Parenchymal)
No severity TRANSIENT ISCHEMIC
classification
ATTACK
HYPERACUTE MILD ACA TERRITORY

(0-6 hours) NIHSS 0-5 (Parenchymal)
GCS 13-15 CVD INFARCT MCA TERRITORY
ACUTE
(6-72 hours) MODERATE
NIHSS 6-21 LEFT OR RIGHT PCA TERRITORY
SUBACUTE GCS 10-12
(3days-3weeks) (Parenchymal) VERTEBRAL ARTERY TERRITORY
SEVERE
CHRONIC CVD BLEED
NIHSS >22
(>3weeks) GCS 3-9 BASILAR ARTERY TERRITORY
Has own severity (Subarachnoid Space)

classification; SUBARACHNOID
Grade 1-5 HEMORRHAGE
* sample: “Acute Moderate CVD Infarct vs Bleed, Left MCA Territory” ** NIHSS as the gold standard for severity classification vs GCS Ischemic Stroke Hemorrhagic Stroke
֍ Ossama Y. Mansour,0.Y., Megahed, M.M., Elghany, E.A. (2015). Acute ischemic stroke prognostication, comparison between Glasgow Coma Score, NIHS Scale and Full Outline of UnResponsiveness Score in intensive care unit. Alexandria Journal of Medicine, Volume 51, Issue 3, 2015, Pages 247-253, ISSN 2090-5068. https://doi.org/10.1016/j.ajme.2014.10.002.
NATIONAL INSTITUTE OF HEALTH STROKE SCALE (1 of 3)
1A: Level of consciousness 1C: 'Blink eyes' & 'squeeze hands' 3: Visual fields
0 Alert; keenly responsive 0 Performs both tasks 0 No visual loss

1 Arouses to minor stimulation 1 Performs 1 task 1 Partial hemianopia
2 Repeated stimulation to arouse 2 Performs 0 tasks 2 Complete hemianopia
2 Movements to pain 3 Patient is bilaterally blind+3
2: Horizontal extraocular movements
3 Postures or unresponsive 3 Bilateral hemianopia+3
0 Normal
1B: Ask month and age 4: Facial palsy
1 Gaze palsy can be overcome
0 Both questions right 1 Gaze palsy corrects with 0 Normal symmetry
1 1 question right oculocephalic reflex 1 Flat nasolabial fold or smile asymmetry
2 0 questions right 2 Gaze palsy cannot be overcome 2 Paralysis (lower face only)
1 Dysarthric/intubated/trauma 3 Complete paralysis (upper/lower face
NIHSS 0-5: Mild Stroke

NIHSS 6-21: Moderate Stroke
NIHSS >22 : Severe Stroke
֍ Appelros P, Terent A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004; 17(1):21-7. Epub 2003 Oct 3. PubMed PMID: 14530634.
5A: Left arm motor drift 6A: Left leg motor drift 7: Limb Ataxia
0 No drift for 10 seconds 0 No drift for 10 seconds 0 No ataxia
1 Drift, but doesn't hit bed 1 Drift, but doesn't hit bed 1 Ataxia in 1 Limb
2 Drift, hits bed 2 Drift, hits bed
2 Ataxia in 2 Limbs
2 Some effort against gravity 2 Some effort against gravity
0 Does not understand
3 No effort against gravity 3 No effort against gravity
0 Paralyzed
4 No movement 4 No movement
0 Amputation/joint fusion
0 Amputation/joint fusion 0 Amputation/joint fusion
5B: Right arm motor drift 6B: Right leg motor drift
0 No drift for 10 seconds 0 No drift for 10 seconds

1 Drift, but doesn't hit bed 1 Drift, but doesn't hit bed
2 Drift, hits bed 2 Drift, hits bed
2 Some effort against gravity 2 Some effort against gravity
3 No effort against gravity 3 No effort against gravity NIHSS 0-5: Mild Stroke
4 No movement 4 No movement NIHSS 6-21: Moderate Stroke
0 Amputation/joint fusion 0 Amputation/joint fusion
8: Sensation 10: Dysarthria

0 Normal; no sensory loss 0 Normal
1 Mild-moderate loss: less sharp/more dull 1 Mild-moderate dysarthria: slurring but can be understood
1 Mild-moderate loss: can sense being touched 2 Severe dysarthria: unintelligible slurring
2 Complete loss: cannot sense being touched at all 2 Mute/anarthric
2 No response, quadriplegic, coma/unresponsive 0 Intubated/unable to test
9: Language/aphasia 11: Extinction/inattention

0 Normal; no aphasia 0 No abnormality
1 Mild-moderate aphasia: some obvious changes, 1 Visual/tactile/auditory/spatial/personal inattention
without significant limitation 1 Extinction to bilateral simultaneous stimulation
2 Severe aphasia: fragmentary expression, inference 2 Profound hemi-inattention (ex: does not recognize own hand)
needed, cannot identify materials 2 Extinction to >1 modality
3 Mute/global aphasia: no usable speech/auditory
comprehension; coma/unresponsive NIHSS 0-5: Mild Stroke
NIHSS 6-21: Moderate Stroke
FREE
DOWNLOADABLE
For NIHSS
MOBILE APP
iOS and Android

OUTLINE High Suspicion of Stroke FACIAL ASSYMETRY
INTRODUCTION F Have the person smile or show his or her teeth. If

one side doesn't move as well as the other or it
seems to droop, that could be sign of a stroke.
CLINICAL APPROACH
ARM DRIFT
STROKE !
DIAGNOSTIC APPROACH
MANAGEMENT
A Have the person close his or her eyes and hold his
or her arms straight out in front for about 10
seconds. Look for weakness or drift.
SLURRED SPEECH
PREVENTION
"Anosognosia"
Patients with stroke often do
S Have the person say simple, familiar saying. If the
person slurs the words or gets some words wrong,
or is unable to speak, that could be sign of stroke.
not seek medical assistance
on their own because they
T
TIME
may lose the appreciation If any of the above 3 is present, then patients are
that something is wrong. advised to seek immediate hospital consultation.
The F.A.S.T. Slogan (Cincinnati Pre-hospital Stroke Recognition Tool)

OUTLINE Presentation by Lesion (Simplified)
INTRODUCTION You can probably determine the territory of lesion while awaiting for cranial imaging
A. Brain Parenchyma (Infarct or Bleed)

CLINICAL APPROACH
Brain Parenchyma Major Feature*
IMAGING
Contralateral weakness of the Lower Extremity is very
Anterior Cerebral Artery
MANAGEMENT prominent than Upper Extremity; (Weakness LE > UE);
Territory
"ALEUE"
PREVENTION Contralateral weakness of the Upper Extremity is very
Middle Cerebral Artery
prominent than Lower Extremity; (Weakness UE > LE);
Territory
“MUELE"
Posterior Cerebral Bilateral visual loss or Visual Hallucinations or

Artery Territory Hemianopia
*See SSP Handbook of Stroke 6th Edition for Comprehensive Guide
OUTLINE Presentation by Lesion (Simplified)
INTRODUCTION You can probably determine the territory of lesion while awaiting for cranial imaging
B. Brainstem and Cerebellar (Infarct or Bleed)

CLINICAL APPROACH
Other Deep Parenchyma Major Feature*
IMAGING Vertebral Artery Territory Vertigo symptoms, Ipsilateral extremity and Ipsilateral
(Cerebellar) Tongue Deviation
MANAGEMENT
Basilar Artery Territory
PREVENTION Quadriplegia, Somnolence or Coma
(Brainstem)
C. Subarachnoid Space (Bleed)
Nonparenchymal Major Feature
Subarachnoid “Thunderclap” headache; some cases complains very

Hemorrhage pungent odor where in fact there is none"
*See SSP Handbook of Stroke 6th Edition for Complete Guide
OUTLINE Stroke Mimickers
INTRODUCTION Upper and Lower Facial Hemiparesis are always present with no motor weakness.
Bell’s Palsy (Stroke is usually with lower facial hemiparesis may have upper facial, associated
CLINICAL APPROACH with motor deficits)
IMAGING Transient paralysis following a seizure disappears quickly;

Todd’s paralysis can be secondary to a chronic or post infarct
MANAGEMENT
PREVENTION No persistent or associated motor deficits;

Syncope Regain full consciousness and functionality in minutes after event
Meningitis/ Fever, immunocompromised state may be present, meningismus;

encephalitis detectable on lumbar puncture
INTRODUCTION Complicated
History of similar episodes, preceding aura, headache
migraine
CLINICAL APPROACH
IMAGING Brain neoplasm Chronic Fever, Chronic Headache, Focal neurologic findings; signs of infection;
or abscess detectable by imaging
MANAGEMENT
PREVENTION Epidural/subdural History of trauma, anticoagulant use, bleeding disorder;

hematoma detectable by imaging
Can be detected by bedside glucose measurement;

Hypoglycemia history of diabetes mellitus
INTRODUCTION
Hyponatremia History of diuretic use, neoplasm, excessive free water intake.
CLINICAL APPROACH
IMAGING Hyperglycemic
Extremely high glucose levels, history of diabetes mellitus.
crisis
MANAGEMENT
PREVENTION Wernicke’s History of alcoholism or malnutrition; triad of ataxia, ophthalmoplegia, and

encephalopathy confusion.
detected by particular toxidromes and elevated blood levels. Phenytoin and

Drug toxicity carbamazepine toxicity may present with ataxia, vertigo, nausea, and abnormal
reflexes.
INTRODUCTION Labyrinthitis / Predominantly vestibular symptoms; patient should have no other focal findings;
Vertigo can be confused with cerebellar stroke.
CLINICAL APPROACH
IMAGING Ménière’s
History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness.
Disease
MANAGEMENT
PREVENTION Myasthenia Motor functions that gradually weakens overtime when on repeated use, then
Gravis may regain strength when allowed to rest; associated with Thymic Tumor
Multiple Gradual onset. Patient may have a history of multiple episodes of neurologic
sclerosis findings in multifocal anatomic distributions.
Basics of Cranial CT
OUTLINE
INTRODUCTION
Computerized tomography (CT) Scan
CLINICAL APPROACH uses Xrays to generate cross-sectional, two-dimensional images of the

body. Images are acquired by rapid roation of the Xray tube 360o around
IMAGING the patient.
MANAGEMENT
CT findings are usually described by density as: isodense/
PREVENTION hypodense/hyperdense.
Each pixel (2D image units) is displayed on an arbitrary scale Hounsfield

units (HU). The higher the Hounsfield units the denser the image
(hyperdense), and the lower the hounsfield units the darker the image
(hypodense).
֍ Lindsay, K.W., Bone, I., & Geraint, F. (2011). Neurology and neurosurgery illustrated - 5th Edition. 2011 Elsevier Ltd. ISBN 978-0-443-06957-4
OUTLINE
INTRODUCTION
CSF Brain Bone Air
CLINICAL APPROACH
IMAGING
MANAGEMENT
Hounsfield units
PREVENTION
-1000 -500 0 +500 +1000
Blood (Acute)
Air Gray Matter Bone

White Matter
CSF
Water
OUTLINE
INTRODUCTION
Computerized tomography (CT) Scan
• Higher the density = whiter is the appearance
• Lower the density = darker the appearance
CLINICAL APPROACH • Brain is the reference density; anything that has same density is isodense
IMAGING
High Density Low Density Mixed Densities
MANAGEMENT • Blood
• Calcification - Tumor
• Infarction
PREVENTION • Arteriovenous • Tumour
• Tumour
Malformation • Abscess
• Abscess
• Aneurysm • Arteriovenous
• Edema
• Hamartoma Malformation
• Encephalitis
May occur in normal scans: • Contusion
• Resolving
• Calcification of the pineal • Hemorrhagic Infarct
Hematoma/Hemorrhage
gland, choroid plexus,
basal ganglia and falx)
Worms Coffee Bean

Remember these guide terms Angry
1. Coffee Bean Cut
2. Worms Cut
3. Angry Cut Happy
4. Happy Cut
5. Star Cut
6. X-factor Cut Star
Xfactor
Remember these guide terms Coffee Bean Sulci with CSF

1. Coffee Bean Falx Cerebri
2. Worms
3. Angry
4. Happy Gray Matter
5. Star
6. X-factor
Frontal lobe White Matter
(Centrum semiovale)
Gray-White Differentiation
Parietal lobe
Sulcus with CSF
Remember these guide terms Worms Lateral Ventricles with CSF

1. Coffee Bean (Frontal Horn)
2. Worms
3. Angry
4. Happy
5. Star Caudate Nucleus
6. X-factor Frontal lobe
Lateral Ventricles with CSF
(Occipital Horn)
Parietal lobe
Occipital lobe

1. Coffee Bean (Frontal Horn)
2. Worms
3. Angry Caudate Nucleus
4. Happy
5. Star Globus pallidus Basal Ganglia
6. X-factor
Putamen
Internal Capsule
Thalamus

(Occipital Horn)
Remember these guide terms Happy

1. Coffee Bean Lateral Ventricles with CSF
2. Worms
3. Angry
(Frontal Horn)
4. Happy
5. Star
6. X-factor
Third Ventricles with CSF
Sylvian Cistern with CSF
Quadrigeminal Cistern
With CSF
Remember these guide terms Star Frontal Lobe

1. Coffee Bean
2. Worms
3. Angry
4. Happy
5. Star Sylvian Cistern Temporal Lobe
6. X-factor
with CSF
Suprasellar Cistern
with CSF Cerebellum
Cerebellopontine cistern
with CSF
Pons
4th Ventricle
with CSF
Remember these guide terms Xfactor

1. Coffee Bean Temporal Lobe
2. Worms
3. Angry
4. Happy
5. Star
6. X-factor Sphenoid Bone Cerebellum
Temporal Bone
Pons
4th Ventricle
Occipital Bone
Worms Coffee Bean

1. Coffee Bean
2. Worms
3. Angry Happy
4. Happy
5. Star
6. X-factor Star
Xfactor
Blood Supply of the Brain
Angry Worms
Coffee Bean
Middle Cerebral Artery (MCA) Anterior Cerebral Artery (ACA) Posterior Cerebral Artery (PCA) Basilar Artery Vertebral Artery
& its branches & its branches & its branches & its branches & its branches
Blood Supply of the Brain
Xfactor Happy
Star
Middle Cerebral Artery (MCA) Anterior Cerebral Artery (ACA) Posterior Cerebral Artery (PCA) Basilar Artery Vertebral Artery
& its branches & its branches & its branches & its branches & its branches
The ABCs for Cranial Scan: A Basic Approach
A B C S
Asymmetry Brain CSF Skull

& Artifact Parenchyma Spaces
ABCs for Cranial Scan: The Basic Approach
A
Asymmetry
& Artifact Motion Artifact in Cranial CT Cranial Imaging Asymmetry due to head not properly positioned
Look for:
• Total Cranial Assymetry due to improper head positioning
• Motion Artifact or Machine Artifact
• These may affect Diagnosis
֍ Barrett,J. F., & Keat, N. (2004). Artifacts in CT: recognition and avoidance. Radiographics : a review publication of the Radiological Society of North America, Inc, 24(6), 1679–
1691. https://doi.org/10.1148/rg.246045065
B Look for
• Brain Midline Displacement: (Falx Cerebri) –
Cerebral Edema / Mass Effect on affected side.
• Brain Sulcus
A. Effacement of Sulcus – due to Mass
Effect
B. Widened and Shallow Sulcus – Increased
CSF (in case of hydrocephalus) or Atrophy
Brain • Brain Gray-White Junction
Parenchyma A. Loss of Gray and White Matter
Differentiation – Infarction (Cell
Death/ Cytotoxic Edema)
B. Accentuation of the Border – Vasogenic
Edema (Tumor/Abscess)
No Midline Displacement, Normal Sulcal • Brain Densities: Look for abnormal
Effacement, Normal Gray-White Border, No
any other hypo/hyperdensities
Hyperdensities and Hypodensities
C
CSF
Spaces Normal Hypodense Cisterns, Fissures & Ventricles
(Cisterns, Fissures &
Ventricles ) Look For
• Hyperdensities in these areas, may confer Subarachnoid Hemorrhage
• Relative Attenuation on these areas may suspect Hydrocephalus
Skull
Depressed Skull Fracture Depressed Skull Fracture on “Bone Window” View (Right)
Look for
• Osteolytic Process
• Skull Depression or Fracture
Forbes, J. A., Reig, A. S., Tomycz, L. D., & Tulipan, N. (2010). Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion. Journal of
neurosurgery. Pediatrics, 6(1), 23–28. https://doi.org/10.3171/2010.3.PEDS09441
NORMAL Acute CVD Infarct PCA Territory
Middle Cerebral Artery (MCA) Anterior Cerebral Artery (ACA) Posterior Cerebral Artery (PCA)
territory territory territory
NORMAL CVD Bleed (Pontine)

NORMAL Subarachnoid Hemorrhage

Malignant Acute CVD Infarct Subacute CVD Infarct

Right Middle Cerebral Artery Territory Right Middle Cerebral Artery Territory
Cardioembolic NIHSS 8 Cardioembolic NIHSS 5
ACA
MCA MCA
PCA
After 6 days; Cleared to start Antithrombotics

The term “Malignant Infarct” is applicable only for Stroke in MCA with >50% infarction on its territory in the hemisphere
Acute CVD Infarct Right Frontal Lobe; Hemorrhagic Stroke Conversion in

and Right Occipital Lobe; Right Frontal Lobe; Subacute CVD Infarct
Cardioembolic; NIHSS 10 Right Occipital Lobe; NIHSS 20
After 6 days
Kothari Method: The Bleed Volume Estimation
KOTHARI METHOD
Volume Estimation applicable only for Brain Parenchymal Bleed (not Intraventricular nor Subarachnoid)
Choose the CT Scan Image Slice with Largest Follow the formula Below
lesion, then get the following where:
A - Width of the largest lesion (or any diameter of

the largest lesion) in centimeters
B - Length of the largest lesion (or diameter
A x B xC
perpendicular to line A) in centimeters
C - Total Number of CT scan slices with lesion:
•Set value of 1 for each slice with >75% of the
largest lesion;
2
•Set value of 0.5 for each slice with 25-75% of
the lesion
•No value for slices with <25% of the lesion. Conversion units: 10mm = 1cm
Slice 4 Slice 3 Slice 2 Slice 1
Slice 8 Slice 7 Slice 6 Slice 5

Slice 6
A : 24mm or 2.4cm
B : 36mm or 3.6cm
Slice 4: Value = 0.5 Slice 3: Value = 0.5 Slice 2: No Value Slice 1: No Value
25%-75% 25%-75% <25% No lesion
Slice 8: No Value Slice 7: Value = 1 Slice 6 Largest Lesion Slice 5: Value = 1
<25% >75% 100% >75%

Acquired Values: A = 2.4cm; B = 3.6cm; C= 3cm
Estimated volume =
A x B x C
2
2.4cm x 3.6cm x 3cm
=
2
= 12.96 cc
OUTLINE Initial Approach Mainstay Therapy

•Ensure ABC (Airway-Breathing Circulation) •Start Antithrombotics for Transient Ischemic
INTRODUCTION Attack and Infarct Noncardioembolic
•Assess and Address Clinical Signs/Symptoms
of Increase Intracranial Pressure •Stabilize and Delay Antithrombotic based on
Severity for Infarct Cardioembolic to prevent
CLINICAL APPROACH •Identify and Control Hemorrhagic Conversion
Comorbidities/Precipitants of Stroke
•Control Hypertension and Decompression for
IMAGING •History and Thorough PE Hemorrhagic Stroke
MANAGEMENT CORE
Monitoring and Severity Assessment Secondary Insults & Complication Prevention
PREVENTION •Determine Severity (NIHSS /GCS) •Ensure Neuroprotection
•Monitor Neuro Vital Signs: A. Glucose (140-180mg/dL)
Temperature B. Oxygenation >94%
Pulse Rate C. MAP within 110-130
Respiratory Rate D. Body temp 35-37°C
BP + MAP •Preventive Measures for Complications: DVT,
Pupils Size Aspiration, Stress Ulcers, Bedsores
O2 saturation •Seizure Precaution
| NIHSS – National Institutes of Health Stroke Scale | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | BP – Blood Pressure | DVT – Deep Vein Thrombosis
Ischemic Mainstay Therapeutics

Stroke
Severity/Feature Initial Approach & Monitoring Diagnostics
(Refer to Specialist)
• Neurodysfunction NONCARDIOEMBOLIC
• Ensure Airway-Breathing-Circulation • Start Antiplatelets Aspirin (ASA) 160-325 mg/day as
resolves within 24 hrs • CBC, RBS, PT, APTT,
TIA • Address Increased Intracranial early as possible and continue for 14 days. May be
• No presence of • ECG, CXR
Pressure (ICP) if signs and symptoms considered: ASA 80 mg + clopidogrel 75 mg
Infarct • Non-contrast Cranial CT
present due to cerebral infarct edema • Ensure Neuroprotection
(NCCT) scan; or
• History-PE Identify Comorbidities/Risk A. Glucose (140-180mg/dL)
• Cranial MRI-diffusion weighted
• Preferred IVF: NSS B. Oxygenation >94%
imaging (DWI)
Mild NIHSS score: 0 – 5 • NPO temporarily C. MAP within 110-130
• Further diagnostics if
CVD Infarct ~ GCS 13-15 • Bedrest; maintain supine position; Head D. Body temp 35-37°C
considering stroke mimics
of bed elevation to 15 to 30 degrees E. Head Bed Elevation 15-30°
(Infection, Toxicology,
• NVS: Temperature, Pulse Rate, • For CVD Infarct
Metabolic Imbalance etc)
Respiratory Rate, BP + MAP, Pupils Size, A. Ictus within 4.5hours: Consider IV
• Recommend carotid ultrasound
& O2 sat thrombolysis with recombinant tissue
(UTZ) to document extracranial plasminogen activator (rt-PA)
Moderate NIHSS score: 6 – 21 • Blood Glucose monitoring
stenosis; B. Ictus within 4th to 6th hour: Consider intra-
CVD Infarct ~ GCS 10-12 • Perform and Monitor Stroke Scale NIHSS
• Recommend transcranial arterial (IA) thrombolysis (specialized centers).
(Gold Standard for Assessing Severity),
Doppler (TCD) studies or CT or • Control/treat risk factors (i.e Cardiac Disease,
GCS;
MR angiography (CTA/MRA) Hyperlipidemia, Diabetes, etc)
• Treat BP if MAP >130
• For 2Decho, if suspect Valvular • Complication Prevention: DVT, Aspiration, Pressure
(MAP = SBP + 2 DBP ÷ 3)
& Septal Defects, Dilated sores, Stress Gastric Ulcer, Constipation, etc
Severe NIHSS score: >22 • Avoid Precipitous drop (Avoid >15%
Cardiomyopathy • Soft diet for alert patients; or nasogastric tube
CVD Infarct ~ GCS 3-9 drop from baseline MAP) within 24
feedings otherwise, and with poor Gag reflex
hours, for CVD Infarcts
• Decompressive Craniectomy for Malignant Infarct
*National Institutes of Health Stroke Scale as the goldstandard for severity classification | CVD – Cerebrovascular Disease | MAP – Mean Arterial Pressure | SBP – Systolic Blood Pressure | DBP – Diastolic Blood Pressure | DVT – Deep Vein Thrombosis
Ischemic Mainstay Therapeutics

Stroke
• Neurodysfunction IF CARDIOEMBOLIC !
• Ensure Airway-Breathing-Circulation • Anticoagulation is the mainstay with or without
resolves within 24 hrs • CBC, RBS, PT, APTT,
TIA • Address Increased Intracranial Antiplatelets. NOACs is preferable.
• No presence of • ECG, CXR
Pressure (ICP) if signs and symptoms TIA - Start Anticoagulation after 1 day from Acute
Infarct • Non-contrast Cranial CT
present due to cerebral infarct edema event
(NCCT) scan; or
• History-PE Identify Comorbidities/Risk NIHSS <8: Suggest repeat scan after 3 days from
• Cranial MRI-diffusion weighted
• Preferred IVF: NSS Acute event; if no Hemorrhagic conversion start
imaging (DWI)
Mild NIHSS score: 0 – 5 • NPO temporarily Anticoagulation.
• Further diagnostics if
CVD Infarct ~ GCS 13-15 • Bedrest; maintain supine position; Head NIHSS 8-15 Suggest repeat scan after 6 days from
considering stroke mimics
of bed elevation to 15 to 30 degrees Acute event; if no Hemorrhagic conversion start
(Infection, Toxicology,
• NVS: Temperature, Pulse Rate, Anticoagulation.
Metabolic Imbalance etc)
Respiratory Rate, BP + MAP, Pupils Size, NIHSS ≥16 - Suggest repeat scan after 12 days
• Recommend carotid ultrasound
& O2 sat from Acute event; if no Hemorrhagic conversion
(UTZ) to document extracranial start Anticoagulation.
Moderate NIHSS score: 6 – 21 • Blood Glucose monitoring
stenosis; • May have Aspirin (ASA) 160-325 mg/day for 14 days,
CVD Infarct ~ GCS 10-12 • Perform and Monitor Stroke Scale NIHSS
• Recommend transcranial if Anticoagulation is contraindicated.
(Gold Standard for Assessing Severity),
Doppler (TCD) studies or CT or • Ensure Neuroprotection
GCS;
MR angiography (CTA/MRA) • Control/treat risk factors (i.e Cardiac Disease,
• Treat BP if MAP >130
• For 2Decho, if suspect Valvular Hyperlipidemia, Diabetes, etc)
(MAP = SBP + 2 DBP ÷ 3)
& Septal Defects, Dilated • Complication Prevention: DVT, Aspiration, Pressure
Severe NIHSS score: >22 • Avoid Precipitous drop (Avoid >15%
Cardiomyopathy sores, Stress Gastric Ulcer, Constipation, etc
CVD Infarct ~ GCS 3-9 drop from baseline MAP) within 24
• Soft diet for alert patients; or nasogastric tube
hours, for CVD Infarcts
feedings otherwise, and with poor Gag reflex
Hemorrhagic Mainstay Therapeutics

Stroke
GENERAL MANAGEMENT
• CBC, RBS, PT, APTT, • ICP monitoring – recommended in patients with
Mild NIHSS score: 0 – 5 • ECG, CXR GCS ≤ 8. See management of Increased ICP
CVD Bleed ~ GCS 13-15 • Early neurology and/or neurosurgery consult for
• Ensure Airway-Breathing-Circulation • Non-contrast Cranial CT all ICH cases. See criteria for surgical intervention
• Address Increased Intracranial (NCCT) scan • Monitor and maintain target SBP ≈140 mm Hg
Pressure (ICP) due to bleed during the first week.
• History-PE Identify Comorbidities/Risk • Lumbar Tap if CT is • Ensure Neuroprotection
Moderate NIHSS score: 6 – 21 • Preferred IVF: NSS equivocal for SAH A. Glucose (140-180mg/dL)
CVD Bleed ~ GCS 10-12 • NPO temporarily B. Oxygenation >94%
• Bedrest; maintain supine position; Head • Consider contrast CT scan, C. MAP within 110-130
of bed elevation to 15 to 30 degrees Four-vessel cerebral D. Body temp 35-37°C
• NVS: Temperature, Pulse Rate, angiogram, Magnetic E. Head Bed Elevation 15-30°
Respiratory Rate, BP + MAP, Pupils Resonance Angiogram if the • Prophylactic AEDs are generally not recommended;
Severe NIHSS score: >22 patient is: may give for clinical seizures and proven subclinical
Size, & O2 sat
CVD Bleed ~ GCS 3-9 A. < 45 years old or electrographic seizures.
• Blood Glucose monitoring
B. Normotensive • Monitor/correct for metabolic parameters and
• Perform and Monitor Stroke Scale
C. lobar ICH coagulation/ bleeding abnormalities
NIHSS (Gold Standard for Assessing
D. Uncertain cause of ICH • Complication Prevention: DVT, Aspiration, Pressure
Severity), GCS sores, Stress Gastric Ulcer, Constipation, etc
Has its own classification of E. Suspicion Aneurysm,
SAH severity AVM, or vasculitis • Soft diet for alert patients; or nasogastric tube
(See different slide) feedings otherwise, and with poor Gag reflex
• For Coagulation/Platelet disorder, refer to Specialist
Hemorrhagic Mainstay Therapeutics

Stroke
Asymptomatic/mild headache,
SAH Grade I slight nuchal rigidity, • CBC, RBS, PT, APTT, ADDITIONAL (SAH SPECIFIC)
GCS 15 normal mental status; • ECG, CXR • Calcium Channel Blockers: Nimodipine 60 mg
no motor deficit every 4 hours by mouth or via NGT for 3 weeks is
• Ensure Airway-Breathing-Circulation • Non-contrast Cranial CT recommended.
Moderate to severe headache, • Address Increased Intracranial (NCCT) scan • Management of Increased ICP: may have Mannitol
SAH Grade II nuchal rigidity, no neurological Pressure (ICP) due to bleed 0.5 to 1.5g per body weight kg every 3-6 hours; may
GCS 13-14 deficit other than cranial nerve • History-PE Identify Comorbidities/Risk • Lumbar Tap if CT is continue up to 7 days. See management of Increased
palsy; no motor deficit • Preferred IVF: NSS equivocal for SAH ICP
• NPO temporarily • Fludrocortisone or hypertonic saline for
Drowsiness, confusion or mild • Bedrest; maintain supine position; Head • Consider contrast CT scan, hyponatremia caused by syndrome of inappropriate
SAH Grade III
GCS 13-14
focal signs of bed elevation to 15 to 30 degrees Four-vessel cerebral antidiuretic hormone (SIADH) or salt-wasting.
with motor deficits • NVS: Temperature, Pulse Rate, angiogram, Magnetic
Respiratory Rate, BP + MAP, Pupils Resonance Angiogram if the • Surgical Intervention
Size, & O2 sat patient is: • Obliteration of the aneurysm from the circulation
Stupor, moderate to severe
SAH Grade IV hemiparesis, possibly early • Blood Glucose monitoring A. < 45 years old as early as possible is the main goal of SAH
GCS score 7-12 decerebrate signs; B. Normotensive treatment. This can be achieved through surgical
• Perform and Monitor Stroke Scale
with or without motor deficits C. lobar ICH clipping or endovascular coiling.
NIHSS (Gold Standard for Assessing
D. Uncertain cause of ICH • Early, immediate surgery is recommended for
Severity), GCS Grade I-III to minimize the risk of a devastating
Deep coma, decerebrate E. Suspicion Aneurysm,
SAH Grade V AVM, or vasculitis rebleed.
rigidity, moribund appearance;
GCS 3-6
with or without motor deficits
Clinical Features Specific Therapies for ICP Surgical Intervention?
Increased
SURGICAL EVACUATION /DECOMPRESSION
Intracranial Pressure • Mannitol 20% IV. Give 1.5 g/kg for a deteriorating
Any of the following: patient then 0.5-1.5 g/kg every 3-6 hours. May May benefit from intervention if with:
administer up to 7 days as indicated. Hypertonic • Lobar, supratentorial, basal ganglia or thalamic
CVD Infarct • Deteriorating level of sensorium saline is an option. hemorrhage with volume >30 cc
• gradually peaks up to 72 • Serum osmolality at 300-320 mosmol/kg • Cerebellar hemorrhage >3 cm
hours; • Cushing’s triad: [2(Na) + Glucose/18 + BUN/2.8] • Intraventricular hemorrhage with moderate to
• cerebral edema (cytotoxic Hypertension • Maximize Bed Head Elevation to 30 to 45O to severe hydrocephalus
and vasogenic) mass effect Bradycardia, assist venous drainage.
• Presence of Aneurysm, AV malformation or
may extend up to 10 days Irregular respiration • Careful Intubation if with respiratory failure:
cavernous angioma
Pulse oximetry SaO2 <90%, or
CVD Bleed & SAH • Anisocoria ABG)PaO2 <60mmHg, or
NON-SURGICAL CANDIDATES
• usually progressive unequal pupillary sizes ABG PaCO2 > 55 mmHg
deterioration within 12 hours • Short term Hyperventilation (6 hours) by adjusting
tidal volume to achieve target pCO2 30–35 mmHg. • Patients with small hemorrhages (<10 cc) with
to 72 hours; • Nausea and Vomiting
• ICP catheter insertion for monitoring & therapeutic minimal neurological deficits
• variable onset depending on • Patients with GCS <5 except those who have
Bleed Volume and • Optic Disc Edema / Papilledema lowering:
A. GCS ≤ 8 cerebellar hemorrhage and brainstem
concomitant cerebral edema on Funduscopy
B. Significant IVH & hydrocephalus. compression
• Patients with pontine or midbrain hemorrhage
| ICP – Intracranial Pressure | CPP – Cerebral Perfusion Pressure | ABG – Arterial Blood Gas | Na – Sodium | GCS – Glasgow Coma Scale | IVH – Intraventricular Hemorrhage | BUN – Blood Urea Nitrogen
OUTLINE LEVELS OF STROKE PREVENTION
INTRODUCTION PRIMORDIAL PREVENTION NO RISK FACTORS

To prevent development of Risk Factors
Health Education PRESENT
CLINICAL APPROACH
PRIMARY PREVENTION Lifestyle Modifications RISK FACTORS
(Controlled BP, Sugar, Cholesterol, Stress PRESENT
DIAGNOSTIC APPROACH To prevent development of Stroke
Reduction, Antithrombotic for Cardiac Problems)
MANAGEMENT SECONDARY PREVENTION Lifestyle Modifications STROKE HAS

(Controlled BP, Sugar, Cholesterol, Stress
To prevent recurrence of new Stroke HAPPENED
Reduction, Antithrombotic for Cardiac Problems)
PREVENTION
TERTIARY Lifestyle Modifications
PREVENTION and
To prevent
complications of Post Stroke Rehabilitation & STROKE HAS
Stroke HAPPENED
Complication Prevention
For Deep Vein Thrombosis, Aspiration Pneumonia, Stress
Ulcers, Bed Sores, Post Cicatrial Seizure, Muscle Atrophy,
Fractures, Memory Related Disorders, and Malnutrition
For Complete Guide of Lifestyle Modification, see JNC 7 & JNC 8 Guideline for Hypertension
For Complete Guide for Post Stroke Rehabilitation &Complication Preventions, see SSP Handbook of Stroke 6th Edition
Special thanks to the
Sulu Sanitarium General Hospital – Public Health Unit
for the distribution of this material

2022 Stroke Lecture (Updated Guidelines)

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A VIEWPOINT AND MANAGEMENT ON

CEREBROVASCULAR & RELATED DISORDERS

III –IMAGING: THE BASICS AND THE STROKE ON CT

OUTLINE Term Definition

INTRODUCTION a type of ischemic stroke with a transient episode of neurological

OUTLINE HOSPITAL BASED REGISTRY 2011

INTRODUCTION HOSPITAL NUMBER

Makati Medical Center 543 70% 30%

Jose Reyes Memorial Medical Center 1056 59% 41%

SIMPLIFIED CLINICAL STROKE CLASSIFICATION*

HYPERACUTE MILD ACA TERRITORY

Has own severity (Subarachnoid Space)

NATIONAL INSTITUTE OF HEALTH STROKE SCALE (1 of 3)

0 Alert; keenly responsive 0 Performs both tasks 0 No visual loss

NIHSS 0-5: Mild Stroke

NATIONAL INSTITUTE OF HEALTH STROKE SCALE (2 of 3)

0 No drift for 10 seconds 0 No drift for 10 seconds

NATIONAL INSTITUTE OF HEALTH STROKE SCALE (3 of 3)

8: Sensation 10: Dysarthria

9: Language/aphasia 11: Extinction/inattention

iOS and Android

OUTLINE High Suspicion of Stroke FACIAL ASSYMETRY

INTRODUCTION F Have the person smile or show his or her teeth. If

The F.A.S.T. Slogan (Cincinnati Pre-hospital Stroke Recognition Tool)

OUTLINE Presentation by Lesion (Simplified)

A. Brain Parenchyma (Infarct or Bleed)

Posterior Cerebral Bilateral visual loss or Visual Hallucinations or

OUTLINE Presentation by Lesion (Simplified)

B. Brainstem and Cerebellar (Infarct or Bleed)

C. Subarachnoid Space (Bleed)

Nonparenchymal Major Feature

Subarachnoid “Thunderclap” headache; some cases complains very

OUTLINE Stroke Mimickers

IMAGING Transient paralysis following a seizure disappears quickly;

PREVENTION No persistent or associated motor deficits;

Meningitis/ Fever, immunocompromised state may be present, meningismus;

OUTLINE Stroke Mimickers

PREVENTION Epidural/subdural History of trauma, anticoagulant use, bleeding disorder;

Can be detected by bedside glucose measurement;

OUTLINE Stroke Mimickers

PREVENTION Wernicke’s History of alcoholism or malnutrition; triad of ataxia, ophthalmoplegia, and

detected by particular toxidromes and elevated blood levels. Phenytoin and

OUTLINE Stroke Mimickers

CLINICAL APPROACH uses Xrays to generate cross-sectional, two-dimensional images of the

Each pixel (2D image units) is displayed on an arbitrary scale Hounsfield

Air Gray Matter Bone

Worms Coffee Bean

Remember these guide terms Coffee Bean Sulci with CSF

Sulcus with CSF

Remember these guide terms Worms Lateral Ventricles with CSF

Lateral Ventricles with CSF

Lateral Ventricles with CSF

Remember these guide terms Happy

Sylvian Cistern with CSF

Remember these guide terms Star Frontal Lobe

Remember these guide terms Xfactor

Worms Coffee Bean

Asymmetry Brain CSF Skull