Stroke and Subarachnoid

Haemorrhage
By
Dr Anyamele Ibuchim
Introduction
Epidemiology
Brief Pathophysiology
Diagnosis
Radio-imaging
Treatment
Conclusion
Recommendations
 Introduction
• Stroke: Rapidly developing signs of focal or
global disturbance of cerebral function, lasting
>24hours or leading to death, with no
apparent cause other than that of vascular
origin. (WHO 1970)
• Two broad types, Ischaemic(85%) and
haemorrhagic(15%)
 Introduction cont’d
• However, advances in understanding of stroke
neuropathology and neuro-radiology revealed
inadequacies in this definition.
• AHA/ASA published a position statement in
2009 redefining Transient Ischaemic Attacks.
• This necessitated modifications in stroke
definition
 Introduction cont’d
• In 2013, the AHA/ASA brought out a
consensus document redefining Stroke,
Ischaemic stroke, silent CNS infarction,
Intracerebral hemorrhage and hemorrhagic
stroke, silent intracerebral hemorrhage,
subarachnoid hemorrhage, stroke from
cerebral venous thrombosis, and stroke not
otherwise specified.
 Introduction cont’d
• These guidelines were updated in 2018 and
2019 to reflect changes in therapeutic
interventions.
• However, for clarity, we’ll be looking at
 Ischaemic stroke
 Intracerebral haemorrhage, and
 Subarachnoid haemorrhage
 Introduction cont’d
• CNS Infarction: Brain, spinal cord or retinal cell
death attributable to ischaemia, based on
1. Pathological, radiological or other objective
evidence of brain, spinal cord or retinal focal
ischaemic injury in a defined vascular territory, or
2. Clinical evidence of focal brain, spinal cord or
retinal ischaemic injury based on symptoms
persisting > 24hrs or leading to death, and other
etiologies excluded.
 Introduction cont’d
• Ischaemic stroke: Rapidly developing signs of
neurological dysfunction caused by CNS
infarction.

• TIA: Transient episodes of neurological

dysfunction caused by focal brain, spinal cord
or retinal ischaemia without evidence of
infarction.
 Introduction cont’d
• Intracerebral Haemorrhage: A focal collection
of blood within the brain parenchyma or
ventricular system that is not caused by
trauma.
• Haemorrhagic Stroke: Rapidly developing
signs of neurological dysfunction caused by
Intracerbral Haemorrhage
 Introduction cont’d
• Subarachnoid Haemorrhage: Bleeding into the
space between the arachnoid membrane and
the pia mater of the brain or spinal cord
• Stroke from SAH: As defined for others
 Epidemiology
• Stroke is a major cause of morbidity and
mortality worldwide.
• Ischaemic strokes make up 85-87% of all
strokes
• According to the WHO, 15million people suffer
stroke worldwide each year
• Of this, 5million die, and another 5million are
left permanently disabled
 Epidemiology
• Stroke is a major cause of morbidity and
mortality worldwide.
• Ischaemic strokes make up 85-87% of all
strokes
• According to the WHO, 15million people suffer
stroke worldwide each year
• Of this, 5million die, and another 5million are
left permanently disabled
 Epidemiology cont’d
• In the US, about 795000 people experience
new or recurrent stroke
• Leading cause of disability and 5th leading
cause of death.
• Epidemiologic studies indicate that about
82%-92% of strokes in the US are ischaemic
 Epidemiology cont’d
• In 2015, Owolabi et al observed that
community based studies in Africa revealed an
age standardised annual stroke incidence of
316/100,000, and prevalence of 981/100000
• A 10 year review of Stroke in the southwest in
2005 by Ogun et al revealed that Ischaemic
stroke comprised 49% of the strokes reviewed.
Pathophysiology
Pathophysiology cont’d
Pathophysiology cont’d
Pathophysiology cont’d
 Pathophysiology cont’d
 Note Poiseuille equations on non-laminar flow

 Infarcted core gets cerebral blood flow of <

10ml/100g/min
 Ischaemic Penumbra gets < 25ml/100g/min of
CBF
 Pathophysiology cont’d
• Normal MAP -- 70mmHg – 100mmHg

• Normal ICP -- 5mmHg – 15mmHg

 Diagnosis
• Establish symptomatology clinically

• Confirm with Neuroimaging

 Radio-imaging
• Crucial in the modern management of stroke

• Modalities include
 CT Scan– Non-contrast and contrast
 CT Angiography
 MRI– Diffusion weighted images and FLAIR
sequences
 MRA
 Radio-imaging
• Ultrasonography, including Carotid Doppler and
Transcranial Doppler
• Nuclear imaging
 Positron Emission Tomography– Criterion
standard for quantifying areas of altered oxygen
and glucose consumption in the brain, and
demonstrating the ischaemic penumbra
 Single Photon Emission Computed Tomography
 Radio-imaging
• Angiography

Following a clinical diagnosis of stroke, the first

question to ask is
 Type; ischaemic, haemorrhagic or SAH
A quick answer has crucial implications in mgt.
 Computed Tomography
• Preferred modality in the emergent evaluation
of the stroke patient
• Ultimate aim at this time is to quickly rule out
intracerebral haemorrhage and SAH
• Non-contrast CT has high sensitivity in
detecting haemorrhage in the acute period
• Within the first 12 hours, sensitivity for
infarcts is low, about 31-60%
 Computed Tomography
• Some of the early[within 6hrs] features of
infarction include
 Subtle loss of grey-white matter differentiation
 Insular ribbon sign
 Vanishing basal ganglia sign
 Dense vessel sign or DOT sign
 Computed Tomography
• Subsequently, areas of hypodensity appear,
corresponding to the vascular territory
involved.
• Haemorrhages appear as hyperdense areas in
the brain parenchyma, ventricles and/or
subarachnoid space
 Computed Tomography

Insular ribbon sign

 Computed Tomography

Insular ribbon sign

 Computed Tomography

Dense middle cerebral artery sign

Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
 Magnetic Resonance Imaging
• Also used in the evaluation of stroke patients

• Uses strong magnetic fields and

radiofrequency pulses to generate proton
maps of different body areas.
• Several sequences exist:
 Magnetic Resonance Imaging
 T1 weighted

 T2 weighted

 Diffusion weighted, including

 DW1
 Apparent Diffusion Coefficient[ADC]
 B=0
 FLAIR Sequences
 Magnetic Resonance Imaging
• There could also be contrast enhancement with
gadolinum or similar agents.

• FLAIR sequences can detect areas of infarct in as

little as 3hours.
• T2 and DWI can detect ischaemic changes within
8 hours or less
• FLAIR very sensitive for SAH, with sensitivity
approaching 100% for large bleeds
 Magnetic Resonance Imaging
Appearance of bleeds in MRI depends on
various factors, including
 MRI sequence
 Duration of bleed
 Site of bleed
 Haematocrit etc
 Magnetic Resonance Imaging
Hyperacute stage
 Iso or Hypo-intense on T1W, Hyperintense on
T2W
Acute Stage
 Hypointense on T1W and T2W
Early Subacute Stage
 Hyperintense on T1W, Hypointense on T2W
 Magnetic Resonance Imaging
Late Subacute Phase
 Hyperintense on T1W and T2W
Chronic Phase
 Hypointense on T1W and T2W
Subarachnoid Bleed
 Hyperintense on T2W and FLAIR
 Hypointense on T1W
 Magnetic Resonance Imaging
Brain infarct appears hyperintense on T2W and
FLAIR
Appears hypointense on T1W
Magnetic Resonance Imaging
Magnetic Resonance Imaging
Magnetic Resonance Imaging
Magnetic Resonance Imaging
Magnetic Resonance Imaging
 Ultrasonography
 Carotid Doppler

 Transcranial Doppler
 Nuclear Imaging
• Positron Emission Tomography[PET] scan using
FDG-18, OXYGEN-15…
 Functional scanning used for measuring
oxygen and glucose consumption in various
areas of the brain
 Gold standard for demonstrating the
ischaemic penumbra
 However, not routinely available
 Nuclear Imaging
• Single Photon Emission Computed
Tomography
 ANGIOGRAPHY
• Non-invasive
 CT Angiography
 Magnetic Resonance Angiography

 Invasive
 Remains the gold standard
 However, seen less often in clinical practice
 ANGIOGRAPHY
• Useful when intra-arterial thrombolysis is
being contemplated, or thrombectomy.

• Also useful for endovascular therapy in

subarachnoid haemorrhage
 Treatment
• Depends on the type of stroke
 Thrombolytic therapy for acute ischaemic
stroke
 Endovascular Interventions for subarachnoid
haemorrhage
 Implement other treatment modalities
according to relevant guidelines
 Conclusion
Stroke is a major illness in the world, with high
mobidity and mortality

Neuro-imaging techniques are crucial in the

optimum management of stroke patients
 Recommendations
• The response time for neuro-imaging should
be shortened so as to ensure optimum
outcome

• A multidisciplinary teamn should be formed

for the mgt of acute stroke patients
• Thrombolytics should be made available, and
their cost significantly reduced
THANK YOU