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Abdul Gofir
Neurology Department of
Medical Faculty
Gadjah Mada University
Stroke: Definition
Stroke is clinically defined as a
neurologic syndrome characterized
by acute disruption of blood flow to
an area of the brain and
corresponding onset of neurologic
deficits related to the concerned
area of the brain
Causes of Stroke
Almost 80% of
strokes are from
an emboli or a
thrombus
Embolic &
Thrombotic
strokes are
ISCHEMIC
< 15% of strokes
are from
hemorrhage, with
an even smaller
percentage
caused by
hypoperfusion
Ischemic
Injury
Apoptotic
Cell Death
Necrotic
Cell Death
Dr.J.Husada 11-2003
Causes of Ischaemic
STROKE
Blockade of blood flow by ateroma, emboli,
and ateroscelerotic
Embolic
Once in your
brain, the
embolus
eventually travels
to a blood vessel
small enough to
block its passage
The embolus
lodges there,
blocking the
blood vessel and
causing a stroke
ion
Smoking
Diabetes
Hyperlipidemia
Atrial
fibrillation
(non-valvular)
Risk
reduction with
treatment
30% - 40%
50%
reduction in hypertensive
diabetics with tight blood pressure
control
20-30% with statins in patients
with known coronary heart disease
68%
21%
(warfarin)
(aspirin)
Stroke: Classification
Ischemic stroke : Account for 80%. Results from
occlusion in the blood vessel supplying the brain
Thrombotic : Occlusion due to
atherothrombosis of small/large vessels
supplying the brain
Embolic : Occlusion due to embolus arising
either from heart (e.g. atrial fibrillation,
valvular disease) or blood vessel
Classification (cont.)
Hemorrhagic stroke : Account for 20%. Results from
rupture of blood vessels leading to bleeding in
brain
Intracerebral: Bleeding within the brain due to
rupture of small blood vessels. Occurs mainly
due to high blood pressure
Subarachnoid: Bleeding around the brain;
commonest cause is rupture of aneurysm.
Other causes: Head injury
Obesity
Smoking
Atrial fibrillation
Sedentary lifestyle
Drug abuse (e.g.
cocaine use)
Hormone
replacement therapy
Oral contraceptive
Modifiable Risk
Factors for Stroke6
Hypertension
Diabetes
Smoking
Hyperlipidemia
Carotid stenosis
Atrial fibrillation
Stroke: Symptoms
Onset
of stroke symptoms
varies as per type of stroke:
Thrombotic stroke: Develop
more gradually
Embolic stroke: Hits suddenly
Hemorrhagic stroke: Hits
suddenly and continues to worsen
Stroke: Symptoms
(cont.)
Dizziness
Confusion
Loss of balance/coordination
Nausea/vomiting
Numbness/weakness on one side of the body
Seizure
Severe headache
Movement disorder/speech disorder/blindness etc
(depending on the area of brain affected)
Mini stroke
Stroke symptoms last for less than 24 hours
(usually 10 to 15 mins)
Result as a brief interruption in blood flow to
brain
Every TIA is an emergency
TIA may be a warning sign of a larger stroke
Patients with possible TIA should be evaluated
by a physician
< 1 hour
Head CT
Ischemic Stroke
Cortical
syndrome
ECG
Echo
CARDIAC
EMBOLISM
Lacunar syndrome
Doppler
MRA
Angiogram
MRI
CT
Vasculopathy
Coagulopathy
LARGE ARTERY
SMALL
OTHER DETERMINED
ATHEROSCLEROSIS VESSEL DISEASE
CAUSE
CRYPTOGENIC
STROKE
Acute
Treatment
T-PA
t-PA Protocol
.9 mg/Kg, 10% as bolus of t-PA, 90%
over 60 minutes
no anticoags or antiplatelet agents
for 24 hrs
maintain bp in normal range
repeat CT in 24 hours and stop if ICH
suspected
Heparin
There is no large clinical trial in the
literature comparing i.v. heparin as
traditionally administered to placebo
International Stroke Trial: compared s.q.
heparin at comparable doses to asa and
neither in 19435 patients: result: heparin
was not beneficial
Lancet.
1997;349:1569-81
Heparinoids
TOAST trial: indicated no benefit for a
LMW heparinoid in stroke (ORG 10172)
Stroke.
1998;29:286
Management of acute
ischemic stroke
Management of acute
ischemic stroke (contd.)
Management of acute
ischemic stroke (contd.)
UPDATE ON MANAGEMENT OF
ICH (Pouratian 2003)
Medical interventions
- Cardiopulmonary optimization
(ABCSS)
- Blood pressure control
- ICP reduction
- Ultra-early hemostatic therapy
Surgical interventions
Labetolol: 5-100 mg/h by intermittent bolus doses of 10-40 mg or continuous drip (2-8
mg/min).
Esmolol: 500 g/kg as a load, maintenance use, 50-200 g/kg/min.
Hydralazine: 10-20 mg Q 4-6 h
Enalapril: 0.625-1.2 mg Q 6 h as needed.
Management of Acute
hemorrhagic stroke
RECOMMENDATIONS FOR
SURGICAL TREATMENT OF ICH
(Broderick 1999)
PREDICTORS OF EARLY
NEUROLOGIC
DETERIORATION IN ICH (Leira
2004)
Early neurologic deterioration (END) occurred in 22.9 % patients.
On admission:
Body temperature > 37.5 C (37.3 0.7 vs 36.4 0.5)
Neutrophil count by 1000-unit increase (10.8 2.9 vs 6.3 4.3)
Serum fibrinogen > 525 mg/dL (546 126 vs 396 119)
Within 48 hours:
Early ICH growth (48.2 vs 20.7)
Intraventricular bleeding (46.4 vs 29.5)
High systolic blood pressure (192 21 vs 179 27)
Source : Neurology 2004; 63: 461-467
Management of TIA
Hypertension/treatment
In general, antihypertensive drugs should be
withheld unless the calculated mean blood
pressure (the sum of the systolic pressure plus
double the diastolic pressure, divided by three) is
greater than 130 mm Hg or the systolic blood
pressure is greater than 220 mm Hg
Elevated blood pressure usually declines
spontaneously over the first 24 hours after stroke
onset and overzealous use of a calcium antagonist
and other antihypertensive drugs should be
avoided because they can further reduce cerebral
perfusion.
Antithypertensive
Treatment
Indicated for:
aortic dissection
acute myocardial infarction
heart failure
acute renal failure
hypertensive encephalopathy
thrombolytic therapy
Glucose
Elevated levels enhance neuronal
injury
Human studies >180 increases infarct
volume
Maintain levels betw 60 and 180
Blood Glucose
There is general agreement to
recommend control of hypoglycemia or
hyperglycemia after stroke (Levels of
Evidence III through V, Grade C).
Do not use D5W free water and Incr
glucose. Use 0.5 NS or NS i.v.
Temperature
Increase temp increases percentage
of poor outcome in stroke
Increase cerebral oxygen/substrate
consumption
Lancet 1996:422
Fever
Fever: Treatment
Treat any temperature elevations
Data is not in as to whether hypothermia
may be protective
CEREBRAL EDEMA
Hypo-osmolar fluids, such as 5%
dextrose in water, may worsen edema.
1/2NS or NS recommended
Mannitol
Mannitol (0.25 to 0.5 g/kg IV) given over
20 minutes rapidly lowers intracranial
pressure and can be given every 6
hours.57 The usual maximum daily dose
is 2 g/kg.57
Mannitol
Dose: - 25 to 50 g I.v. q 3-5 hrs.
Maximal dose of 2 g /KG/D.
Furosemide I.v. 20 to 80 mg q 4 to 12
hours to supplement mannitol.
Replacement fluids to maintain the
calculated serum osmolality at 300 to
320 mOsm per kilogram of water.
Secondary prevention of
stroke
Rehabilitation Program:
Physical therapy :
Mobilization
Walking
Major motor or sensory impairment of the
limbs
Prescription of devices, such as a cane or
walker
Occupational Therapy :