STROKE

Dr. AM Iyagba,
Medicine Department,
Faculty of Clinical Sciences,
College of Health Sciences,
University of Port Harcourt.
 Lecture outline
•Introduction
•Definition
•Risk factors
•Aetiology
•Classifications of stroke
•Basic neuroanatomy and neurophysiology
•Clinical features
•Investigations
•Treatment/Management phases
•Complications
•Poor prognostic features
 Introduction
•3rd most common cause of death world wide

•Most common form of neurological disability.

•Incidence is 240/100, 000/year.

•Two common types:

Haemorrhagic
Infarctive
Definition
•“Stroke is defined as a sudden onset
focal neurological deficit of vascular
origin lasting more than 24 hours and
may lead to death or disability”
•5 Key points in this definition:
Onset → sudden
Localization → focal (can be global)
Cause → vascular
Duration → >24 hours
Outcome → disability or death
Stroke in the young or young stroke

•This is defined as stroke occurring in

persons less than 45 years.

•Aetiology of this condition is very broad.

•Usually individuals lack classic risk

factors for stroke.
Aetiology of Stroke

•Infarction (thrombosis or embolism)-80%

•Primary intracerbral haemorrhage~15%

•Subarachnoid haemorrhage~5%

•Cerebral venous thrombosis~1%

 Aetiology 1-Ischaemic stroke
Atherothromboembolis Haematologic disorders
m Antiphospholipid syndr.
Carotid stenosis Thrombophillic states
Vertebral stenosis
Genetic disorders
Cardioembolism CADASIL
Small vessel disease or MELAS
lacunar stroke Sickle cell disease

Arterial dissection Infections

Meningitis
Inflammatory disorders HIV
SLE
Primary CNS angitis Others
Giant cell arteritis Migraine
Pregnancy
 Lacunar strokes
•These are small deep cerebral infarcts <1.5 cm in diameter due to
microatheroma and lipohyalinosis in the deep penetrating vessels
which are end-arteries.
•Examples include:
1.Pure motor strokes → posterior limb of internal capsule

2.Pure sensory stroke → thalamus

3.Sensory motor or mixed

4.Ataxic hemiparesis → pontine lesion

5.Dysarthria clumsy hand syndrome → lesion in pons or internal

capsule

6.Etat lacunae
 Aetiology 2-Cerebral haemorrhage
Intracerebral Subarachnoid
haemorrhage haemorrhage
•Small vessel disease •Aneurysm
•A-V malformations
•Trauma
•Amyloid angiopathy
•Tumors
•Cerebral venous
thrombosis
•Drug abuse e.g cocaine
•Moyamoya syndrome
•Haematologic disorders
Antiplatelets
Anticoagulants
Thrombolytic therapy
Coagulation disorders
Common sites of haemorrhage
 Classifications for stroke
1. Anatomical classification
Anterior circulation or carotid territory strokes
Posterior circulation or vertebrobasilar territory
strokes
2. Pathological classification
Infarctive stroke
Haemorrhagic stroke
3. Temporal classification
Transient ischaemic attack (TIA)
Reversible ischaemic neurologic deficit (RIND)
Stroke in evolution or evolving/progressive stroke
Completed stroke
Temporal classification of infarction
 Anatomy and physiology of stroke
•Circle of Willis

•Cerebral autoregulation

•Thresholds for cerebral ischaemia

•Homonculus

•Arterial blood supply of the hemisphere

Thresholds for cerebral ischaemia
Homonculus
•This is disproportionate
inverted representation
of the various body
parts on the surface of
the brain.
•Parts with skilled
function have largest
surface representation.
•Anterior cerebral artery
supplies leg area.
•Middle cerebral artery
supplies face and arm
areas
Arterial supply of the cerebral hemisphere
 Common clinical presentations

•Sudden hemiparesis

•Facial deviation

•Speech difficulties

•Loss of consciousness

•Seizures
 6 Key points in the body of history
1. How did it start? → temporal classification
2. What is the lesion? → haemorrhage or ischaemia
3. Where is the lesion? → ant or post. circulation or
both
4. Was there a warning preceding this event:
TIAs→ ischaemic stroke
Severe generalized headache → ICH
Sentinel headaches (low grade occipital headaches)
→SAH
5. Has there been a previous similar vascular event?
CAD→ chest pain, palpitations, breathlessness
PVD → intermittent claudication, rest pain
6. What other conditions could present like stroke ?
(differential diagnosis)
Haemorrhage vs Ischaemia from history
Parameter Haemorrhage Infarct
1.Onset sudden gradual
2.Activity yes usually none
3.Headache ++++ no or +
4.Vomitting +++ usually none
5.Seizures + usually no
6.LOC + -ve unless
massive
7.Neck pain + none
 Investigation of Stroke

1. Investigations to establish diagnosis

2. Investigations to identify risk factors

3. Additional investigations for stroke-in-

the-young patient
1. To establish diagnosis
•Brain CT scan

•Brain MRI

•Carotid doppler:- carotid stenosis or

carotid dissection

•Magnetic resonance venography:- venous

infarctions

•Cerebral angiography:- SAH

2. To identify risk factors
•ECG-determine cardiac rhythm, exclude MI
•ECHO-presence of valvular heart disease,
clot, patent foramen ovale
•CXR-features of long standing hypertension
•Lipid profile
•FBS/RBS-DM, exclude hyperglycaemia
•FBC-polycythaemia, thrombocythaemia,
thrombocytopenia
•ESR/CRP-vasculitis, endocarditis,
hyperviscosity
3. Additional investigations for young stroke

•Genotype (sickle cell disease)

•Homocysteine
•Cardiac enzymes
•Blood culture
•Toxicology screen
•Thrombophilia screen
Protein C, S and anti-thrombin III defects
Factor V Leiden mutation 20210GA
Antiphospholipid antibody
 CT Scans of ischaemic stroke
Massive hypodensity with mass Lacunar infarct-note black hole in
effect right basal ganglia region
 CT scans of haemorrhagic stroke

Intracerbral haemorrhage → SAH → hyperdensity in cisterns

hyperdensity in parenchyma and fissures
Differential diagnosis of stroke & TIA

Structural mimics Functional mimics

•Subdural •Todd’s paresis
haematoma •Hypoglycaemia
•Brain tumor •Migraine
•Brain abscess •Focal seizures
•Multiple sclerosis •Conversion disorder
•Peripheral nerve •Vestibular disorders
lesions
Consider an alternate diagnosis if:

•Absence of risk factors

•Age <45 years
•Fever at presentation
•Presence of papilloedema
•Fluctuating level of consciousness
•Prolonged/and or discontinuous evolution
of symptoms
 Stroke treatment phases

I. Acute phase [Day 1-7]

Emergency measures
May commence physiotherapy
II. Early sub-acute phase [Day 8-14]
Continuation of some acute phase treatment
Physiotherapy
III. Late sub-acute phase [Day 15-28]
 Physiotherapy
Blood pressure control
Discharge/follow up issues
IV. Chronic phase [Day 28-6 months]
Clinic follow-up
Continuation of physiotherapy
 Acute phase management measures

1. ABC of resuscitation

2. Cerebral oedema
IV 20% mannitol 250mls 8-12hrly x 48-72 hrs

3. Fluids
0.9% Normal saline: 1liter 12hrly
5%DW or 5%DS worsens neuronal damage

4. Hyperglycaemia
Sc insulin if BS >7mmol/l even if not DM
Discontinue in non-DM if BS is under control
5. Blood pressure
Blood pressure should never be drastically lowered in
stroke
A certain degree of elevated BP is needed to perfuse
ischaemic areas
Wait for 10-14 days, maximum 21 days
Lower blood pressure gradually if:
SBP ≥220mmHg
DBP≥120mmHg
MAP≥145mmHg
Use ACEIs e.g lisinopril, B-blockers e.g atenolol, CCB
e.g amlodipine.
Never use nifedipine!
6. Fever
Can be due to infection, DVT or direct result of cerebral
damage
Fever increases neuronal metabolism and infarct
size
Antipyretics e.g im or tablet paracetamol.
7. Antibiotics
Co-existing infection is poorly prognostic
Broad spectrum antibiotics
8. Statins
Give if certain of ischaemic stroke
Contraindicated with haemorrhagic type and SAH
Artovastatin 20-40mg daily is preferred
9. Seizures
AEDs-Phenytoin, carbamazepine
May give prophylactically for cortical bleeds
10. DVT Prophylaxis
Pneumatic or compressive stockings
LMWH e.g clexane 40mg sc bd x 5/7
11. Nursing care
Bladder care: catheters, bed pans,
Bowel care
Feeding: swallow test, nasogastric tube
Skin care: two hourly turning
 Complications of stroke
a)Cerebral b) Systemic
complications complications
•Depression •Aspiration
•Seizures •Infection-UTI &
•SIADH Chest
•Haemorrhagic •VTE
transformation •Fever
•Transtentorial •Pressure sores
herniation
•Acute hydrocephalus
Specific treatments of ischaemic stroke
•Thrombolysis
Beneficial in patients with major ischaemic strokes
with large penumbra presenting within 3hours of
onset.
Major complication is haemorrhagic transformation
Should be carried out in specialized centres
•Anti-platelets (Aspirin)
Give only if certain, its ischaemic stroke
CT first to exclude haemorrhage
Aspirin 300mg loading dose then 75mg daily; or
clopidogrel 75mg daily
Aspirin started within 48 hours reduces mortality
and recurrent stroke
•Anticoagulation
Immediate treatment with heparin reduces DVT and
PE
Associated with increased haemorrhage risk
LMWH is safer
AF or other cardioembolic stroke treat with aspirin
and start oral anticoagulation after 2 weeks
•Surgery
Hemicraniectomy for raised ICP due to malignant
MCA occlusion
Posterior fossa craniectomy for large cerebellar
infarcts
 Poor prognostic features
•Age
•Repeat stroke
•Strokes at multiple sites
•Brainstem especially cerebellar stroke
•Presence of co-morbidities e.g DM, CKD
•Uncontrolled hypertension
•Prolonged unconsciousness
•Hypo-glycaemia/severe hyper-glycaemia
•Aspiration pneumonia
•Pressure sores