9.

Peripheral pulses and stroke

Atherosclerosis

Reduced elasticity & Increased arterial stiffness

Increased pulse pressure

Cardiovascular disease

Stroke
10. Subarachnoid hemorrhage
• Thunderclap headache of
sudden onset
• Described as the “worst
headache of my life”
• Nausea
• Vomiting
• Diplopia
• Signs of meningismus due to
irritant blood causing neck and
back pain.
11. Types/kind of heart murmur in stroke
• Atrial fibrillation is a common cause of cardioembolic stroke in
ischaemic stroke having AF.
• CAD, hypertension, heart failure, and valvular heart disease are the
most common causes of AF.
• Thrombus can be caused by paroxysmal AF due to rheumatic MS.
• Rheumatic heart disease  cardiac inflammation and scarring
triggered by an autoimmune reaction to infection with group A
streptococci  thickened and restricted valve leaflets  valve
stenosis and/or regurgitation
• One of the most common complications of rheumatic MS is AF .
• In rheumatic MS, AF may initially be paroxysmal, but eventually it
becomes chronic as the MS and left atrial dilatation progress.
• AF may cause systemic embolism from mural thrombus
development in the left atrium leading to stroke.
12. Mechanisms on how diabetes mellitus develop atrial fibrillation
and eventually causing stroke
• Diabetes mellitus - risk factor for the development of atrial
fibrillation (AF)
• The pathophysiology of diabetes-related AF is not fully understood
• Inflammation might play a role in the generation, maintenance,
and perpetuation of AF, although the mechanism of AF is still
elusive
• Increased CRP and IL-6
• CRP was two-fold higher in AF patients
• Left ventricular (LV) hypertrophy has been associated with DM and
abnormal glucose tolerance
• Automatic nerve system plays an important role in both the
initiation and/ or the maintenance of AF in humans
13. Significance of using contrast medium in
Cranial CT scan
• Contrast dye helps highlight some areas better on
CT images. For example, it can highlight and
emphasize blood vessels, intestines, and other
areas. The dye is given through an intravenous
line inserted into a vein of your arm or hand.
14. Hypokalemic periodic paralysis vs Stroke

HPP STROKE
Hypokalemia Abrupt onset

Large, carbohydrate meal Bulbar involvement

Vigorous exercise Headache

No bulbar and respiratory Troubled walking

muscles involvement
Usually weakness of the arms Loss of balance
and legs
Depends on the location of the
lesion
15. Significance of International Normalized ratio (INR)
• International normalized ratio (INR) - used to assess the
risk of bleeding or the coagulation status of the patients.
• Patients taking oral anticoagulants are required to
monitor INR to adjust the VKA doses because these vary
between patients.
• INR is derived from prothrombin time (PT) which is
calculated as a ratio of the patient’s PT to a control PT
standardized for the potency of the thromboplastin
reagent developed by the World Health Organization
(WHO) using the following formula:
INR = Patient PT ÷ Control PT
3. PE findings in atrial fibrillation
• Atrial fibrillation - abnormal electrical activity within the atria of
the heart, causing them to fibrillate.
• Characterized as a tachyarrhythmia
• Blood flow through the heart becomes turbulent and has a high
chance of forming a thrombus (blood clot), which can ultimately
dislodge and cause a stroke.
• Atrial fibrillation is the leading cardiac cause of stroke.
• Physical examination findings:
– irregular pulse
– irregular jugular venous pulsations
– variations in the intensity of the first heart sound
– absence of a fourth heart sound heard previously during sinus
rhythm
A diagnosis must be confirmed with electrocardiography (ECG).
5. Serum magnesium and serum potassium
• Magnesium depletion  secondary potassium depletion.
• Inability of the cell to maintain the normally high
intracellular concentration of potassium:
• increase in membrane permeability to potassium
and/or
• inhibition of Na+-K-ATPase
• The cells lose potassium, which is excreted in the urine.
• Repletion of cell potassium requires correction of the
magnesium deficit
• Magnesium deficiency impairs Na-K-ATPase, which would
decrease cellular uptake of K+
1. Mechanism of orthopnea
• Orthopnea is the sensation of breathlessness in the
recumbent position, relieved by sitting or standing.
Orthopnea is caused by pulmonary congestion during
recumbency.
• Horizontal position/recumbency  redistribution of blood
volume from lower extremities and splanchnic beds to the
lungs  additional volume cannot be pumped out by the left
ventricle (CHF – overloaded pulmonary circulation +
reabsorption of edema fluid from previously dependent parts
of the body)  significant reduction in vital capacity and
pulmonary compliance  shortness of breath
• Pulmonary congestion decreases when the patient assumes a
more erect position, and this is accompanied by an
improvement in symptoms.
2. Mechanism of proxysmal nocturnal dyspnea
3. Diffusing capacity of the lungs for carbon monoxide
(DLCO)
• a measure of how easily carbon monoxide (CO)
molecules transfer from the alveolar gas to the
hemoglobin of the red cells in the pulmonary circulation
• patient inhales a single breath containing a minute
amount of CO and holds it for 10 seconds. The breath is
then exhaled and the exhaled breath is analyzed for CO.
The change in the concentration of the CO is then
multiplied by the single breath TLC to calculate the DLCO.
• In COPD, the DLCO decreases with increasing severity of
disease. This is because in emphysema, the lung has lost
alveoli, resulting in a lower surface area available for
diffusion.
• Body plethysmograph
4. Blood viscosity and blood cholesterol
• Inc blood viscosity  total peripheral resistance 
reduce blood flow  decrease perfusion
• Highly viscous blood  cause abrasions to the vessel wall
 turbulent blood flow  cause further damage 
initiates atherosclerotic process resulting in plaque
formation
• Too much cholesterol in your blood  fatty deposits to
build up in your arteries  arteries narrowed and stiff 
harder for blood to flow.
• It also increases the chance of a blood clot developing.