Stroke

የህዝብ በህዝብ ለህዝብ

Abyot
from Harrison,DR Belachew and DR Yared
Handout
 Definition
• “An acute focal or diffuse neurologic deficit
lasting more than 24hours and caused by a
focal or diffuse insult to the brain that is of a
vascular origin” WHO

• Abrupt onset of focal neurologic deficit due to focal

vascular cause – earlier defn.
 CLASSIFICATION
THROMBOTIC-25%
-LACUNAR
-LARGE VESSEL
ISCHEMI
C-85% EMBOLIC-75%
-CARDIOEMBOLIC
-ARTEYTO ARTERY

STROKE
INTRAPARNCHYMAL

HEMORR
HAGIC- SAH
15%
PURE IVH
 Classification of Stroke
Ischemic Stroke (85% “Brain Infarct”)
Occlusive:
Thrombosis
Embolism
Anterior Circulation
Occlusion of carotid artery involve cerebral
hemispheres
Posterior Circulation
Vertebro-basilar artery distribution involve
brainstem or cerebellum
 Classification of Stroke

• Hemorrhagic Stroke
– Subarachnoid
• Aneurysm (most common)
• Arteriovenous malformation
– Intracerebral
• Hypertension (most common)
• Amyloid angiopathy in elderly
 1.Ischemic stroke
• Stroke caused by thrombosis or embolism
• Accounts for 85% of all strokes
 1.1. Embolism
• Arise from:
- Heart
- Extra-cranial arteries
- Rare: right side circulation: paradoxical
embolization
 Sources of cardiogenic emboli
• Valvular thrombi: MS, Endocarditis, prosthetic
valves
• Mural thrombi: MI
• AF
• Dilated cardiomyopahty
• Severe CHF
 Artery-to-Artery Embolic Stroke
• Thrombus formation on atherosclerotic plaques may embolize
• Diseased vessel may acutely thrombose
• Carotid atherosclerosis 10% of ischemic stroke
• Atherosclerosis within the carotid artery occurs most
frequently within the common carotid bifurcation and
proximal internal carotid artery
Others from
• Aortic Arch
• Common carotid
• Vertebral, Basilar arteries
• Arterial Dissection
 1.2.Thrombosis
• Divided in to:
- Large vessel
- carotid
- vertebro-basilar system
- Small vessel
- intracerebral arteries: branches of the circle
of Willis, posterior circulation
 Small-Vessel Stroke
• The term lacunar infarction refers to infarction following
atherothrombotic occlusion of a small artery in the
brain.
• Small-vessel strokes account for 20% of all strokes.
• Recovery is more rapid and complete than recovery
from large-vessel strokes
• The MCA stem, the arteries comprising the circle of Willis
(A1 segment, anterior and posterior communicating
arteries, and P1 segment), and the basilar and vertebral
arteries all give rise to 30- to 300-m branches that
penetrate the deep gray and white matter of the
cerebrum or brainstem.
• Thrombosis of these vessels causes small infarcts that are
referred to as lacunes (Latin for "lake" of fluid noted at
autopsy). These infarcts range in size from 3 mm to 2 cm
in diameter. Hypertension and age are the principal risk
factors
 Ctd
Arterial stenosis  turbulent blood flow 
↑risk of thrombus formation/ atherosclerosis/
platelet adherence  formation of blood clot 
embolize/occlude
 CTD
• Less common causes of thrombosis:
- Polycythemia
- Sickle cell anemia
- Protein c deficiency
- FMD
- Migraine: prolonged vasoconstriction
- Dissection of cerebral arteries: trauma/
arteritis
 Risk factors
• NONMODIFIABLE • MODIFIABLE
 age  Arterial hypertension
 Gender
 TIA
 Race/ethnicity
 family history  Prior stroke
 genetics  Asymptomatic carotid
stenosis
 Carotid disease
 Diabetes mellitus
 Dyslipidemia
 Smoking
 Risk Factors
• Age 80 Vs 20: 100X
• Hypertension : 4-5X
• Atrial Fibrillation : 5-17X
• Cardiac Disease : 2-4X
• Diabetes : 1.5 – 3X
• Cigarette Smoking : 1.5- 3X
 Pathogenesis of Stroke

• Ischemia: lack of circulating blood deprives the

neurons of oxygen and nourishment

 Acute Ischemic Injury

• The occlusion of a large vessel (such as MCA) is

rarely complete and cerebral blood flow (CBF)
depends on the degree of obstruction, and collateral
circulation

• Many factors influence progression and extent of

ischemic injury
 Conditions influencing progression and
extent of ischemic injury
• Rate & duration of the ischemic event
• Collateral circulation in the involved area of the
brain
• Systemic circulation & arterial blood pressure
• Coagulation abnormalities
• Temperature
• Glucose
 Ischemic cascade
• In seconds to minutes of loss of perfusion – initiation
of ischemic cascade  persistent  central area of
infarction  surrounded by an area of reversible IP

• Cellular level :
- Ischemic neuron becomes depolarized – due ↓of ATP
 membrane ion transport fails  influx of Ca 
release of NT(e.g glutamate) activation of NMDA
receptors  neuronal depolarization  ↑Ca  further
glutamate release  amplification of ischemic insult
 CTD
• Free radicals/arachidonic acid/NO  generated 
further neuronal damage

• Central goal of Rx in AIS  preserve the area of oligemia

in the IP  can be preserved:

- Limiting the severity of injury( neuronal protection)

- Reducing the duration of ischemia – restoring blood flow

• Macroscopic level: caused by extra-cranial
embolism or intracranial thrombosis

• Cellular level: ↓ blood flow  ischemic

cascade  and cerebral infarction death of
neurons
Atrial fibrilation

• Commonest cause
• Annual risk of stroke –5%
• High risk
Age > 60 yrs
HTN, DM,
Poor LV Function, CHF, Dilated chambers
Thyrotoxicosis,
Previous TIA / Stroke , MS , Prosthetic Valve
 Stroke – Signs and Symptoms

Ischemic
Carotid Circulation
Unilateral paralysis (opposite side)
Numbness (opposite side)
Language disturbance
Aphasia – difficult comprehension, nonsense,
difficult reading/writing
Dysarthria – slurred speech, abnormal
pronunciation.
Visual disturbance (opposite side)
Monocular blindness (same side)
 Stroke – Signs and Symptoms
• Ischemic
– Vertebrobasilar Circulation
• Vertigo
• Visual disturbance
– Both eyes simultaneously
• Diplopia
– Ocular palsy – inability to move to one side
– Dysconjugate gaze – asynchronous movement
• Paralysis
• Numbness
• Dysarthria
• Ataxia
 Clinical Manifestations
• The most common lacunar syndromes are the following:
1 Pure motor hemiparesis from an infarct in the posterior
limb of the internal capsule or basis pontis; the face, arm,
and leg are almost always involved;
2 pure sensory stroke from an infarct in the ventral
thalamus;
3 ataxic hemiparesis from an infarct in the ventral pons or
internal capsule;
4 dysarthria and a clumsy hand or arm due to infarction in
the ventral pons or in the genu of the internal capsule.