STROKE

Samuel Easaw
 Prerequisite knowledge
Anatomy of brain esp its blood supply
Pharmacology of common drugs used in
stroke
 After this lecture you should
know
What is stroke
Stroke classifications
Risk factors
Clinical presentation
Management, including secondary
prevention
 Definition
(WHO) Rapidly developing signs of focal
(or occasionally global) disturbances of
cerebral function lasting longer than 24
hours (unless interrupted by death) with no
apparent cause other than of vascular origin
Transient Ischaemic Attack (TIA)
A clinical syndrome characterised by an
acute loss of focal cerebral or monocular
function with symptoms lasting less than 24
hours and which is thought to be due to
inadequate cerebral or ocular blood supply
as a result of arterial thrombosis or
embolism
 New definition of TIA
(AHA/ASA, 2009)
A transient episode of neurological
dysfunction caused by focal brain, spinal
cord or retinal ischaemia without acute
infarction
 Epidemiology
Commonest cause of chronic neurological
disability in adults
3rd leading cause of death in USA and 2nd
worldwide
More common in males and elderly
Preventable to large extent by optimal
control of risk factors, esp HT, DM, AF
(Primary prevention)
 CLASSIFICATION OF
STROKE
Cerebral infarction (locally 70%, west 85%)
cerebral thrombosis, artery-to-artery
embolism; cardioembolism
Cerebral haemorrhage (locally 30%, west
15%) primary cerebral haemorrhage
(25%,10%); spontaneous subarachnoid
haemorrhage (5% locally and west)
 Subclassification of ischaemic
strokes
TOAST (Trial of org 10172 in acute stroke
treatment) Classification according to
major pathophysiological mechanisms
5 subtypes
1. Large artery atherosclerosis
2. Cardioembolism
3. Small vessel occlusion
4. Stroke of other determined aetiology
5. Stroke of undetermined aetiology
OXFORDSHIRE COMMUNITY
STROKE PROJECT (OCSP)
CLASSIFICATION OF
ISCHAEMIC STROKE

based on initial clinical

presentation
 1.) Total Anterior Circulation Stroke /
Infarct (TACS / TACI)
All of the following 3 features hemiplegia
(+/- hemisensory loss),hemianopia, new
disturbance of higher cerebral function
(dysphasia, cognitive impairment,
visuospatial loss, etc)
 2. Partial Anterior Circulation Stroke /
Infarct (PACS / PACI)
2 out of above 3; or new disturbance of
higher function alone; or partial motor +/-
sensory deficit less extensive than for LACI
(eg confined to one limb or face and hand
but not to whole arm)
 3. Lacunar Stroke / Infarct (LACS /
LACI) - only motor and/or sensory deficit
hemiplegia and/or hemisensory loss,
(pure motor stroke most common lacunar
syndrome), may have dysarthria, ataxia or
clumsiness of one side or one limb
 4. Posterior circulation stroke / infarct
(POCS / POCI) cranial nerve palsies
AND contralateral motor/sensory deficit;
BILATERAL motor/sensory deficits;
nystagmus; cerebellar signs; isolated
homonymous hemianopia
 Risk factors
Age
HT
DM
Hyperlipidaemia
Smoking
Cardiac causes AF, AMI, valvular lesions,
dilated cardiomyopathy, PFO
Genetic factors
 Thrombophilic disorders (esp young
strokes) polycythaemia, thromobocytosis,
protein C def, protein S def, antithrombin
III, antiphospholopid antibody syndrome,
hyperhomocysteinaemia, etc)
AVM, aneurysm for haemorrhagic stroke
Bleeding tendency - for haemorrhagic
stroke
 Clinical presentation
1. Acute focal neurological deficit/syndromes
(discuss)
2. Sudden LOC/coma
3. Acute confusional state
4. Seizures
5. Can be clinically silent
 6. Sometimes does not present acutely but
chronically from cumulative effect of
multiple small strokes/ small vessel
cerebrovascular disease gait apraxia,
vascular parkinsonism, vascular dementia,
incontinence
 Differential Diagnoses
Usually straightforward
Hypoglycaemia
Partial seizures
Hemiplegic migraine
Brain tumours vascular eg meningioma;
bleed into tumours
Cervical myelopathy
Demyelinating disease
 Investigations
Blood sugar capillary
CT brain scan
ECG
Bloods
Carotid duplex ultrasound/ MRA
CXR
Specialised ixs if indicated
 Management
Primary prevention very impt
Acute mx admit stroke unit, airway, O2,
circulation, assessment (NIHSS)
- consider thrombolysis with
rTPA if within 4.5 hours
- aspirin 300mg stat (crushed)
followed by 150 mg daily (if aspirin
intolerant, clopidogrel or ticlopidine)
 - high dose statin atorvastatin 80mg
daily
- do not lower BP (why? - discuss)
- insulin if hyperglycaemic
- nasogastric tube if necessary, till
able to swallow
- chest and limb physiotherapy
- mannitol if indicated
 - may need prophylactic H2 antagonist
or PPI
- DVT prevention
- treat complications infection, GI
bleeding, fits, etc
 Subsequent mx
Carotid endarterectomy or angioplasty with
stenting if indicated
Antiplatelet for life
Optimally control all risk factors
pharmacological and lifestyle modification
Treat any underlying cause if present
 Stroke in young patient
Haemorrhagic ateriovenous malformation,
aneurysm, bleeding tendency, drug abuse
Ischaemic cardioembolic (AF, rheumatic
heart disease, congenital heart ds, PFO, etc),
prothrombotic states (protein C, S,
antithrombin III def., antiphospholipd
antibody syndrome, etc), vasculitis
 Venous thrombosis & infarction
Thrombosis of intracranial dural venous
sinuses and veins
Dx often missed or delayed
Present with headache and other sx of raised
intracranial pressure, cognitive impairment/
encephalopathic syndrome, less likely with
focal neurological deficit
 Diagnosis index of suspicion, esp in
clinical contexts; CT/MRI/MRV may see
thrombosed sinuses, cerebral oedema,
oblieration of CSF spaces, venous infarcts
+/- haemorrhagic transformation (not in
classical arterial territory/bilateral); blood
ixs for prothrombotic states; D-dimer
 Treatment immediate anticoagulation,
treat cause if any, relieve raised intracranial
pressure mannitol, acetazolamide,
occasionally may need optic nerve sheath
fenestration or VP shunt if vision
compromised by high intracranial presssure
 Questions
1. What is a stroke?
2. What is a TIA?
3. How would you classify strokes?
4. Describe the immediate and long term
mx of a patient who is just admitted under
your care with an acute stroke.
5. What are possible causes for stroke in a
young person? How would you ix him/her?
Thank you