STROKE

Definition: In 1970, WHO defined stroke as a neurological deficite of cardiovascular

origin that persists beyond 24 hours.
This definition shows that tissue damage due to stroke may be reversible and with a time
frame of 24hours being chosen abitrarily. This 24hrs limit divides stroke from TIA, which
is a related symdrome of stroke symptoms that resolves completely zithin 24 hours. Stroke
of unknown origin is termed cryptogenic stroke and constitutes 30-40% of all ischemic
strokes.
Stroke is a medical condition in which poor blood flow to the brain results in cell death.
Reduced blood flow to brain cells may lead to ischemia or bleeding into brain cells due to
artery blockage or breakup. Signs and symptoms occure soon after the stroke has occured.

TYPES OR CLASSIFICATION OF STROKE

Two main classifications exist.
1. Ischemic stroke: tipically caused by blood clot in an artery resulting in brain death
to the affected area.
2. Hemorrhagic stroke: caused by blood leaking into or around the brain fro m
ruptured blood vessel, alloeing blood to pool in the affected area thus increasing
pressure in the brain.

EPIDEMIOLOGY FOR STROKE

Stroke is the second leading caues of death and the first cause of acquired handicap
worldwide. Stroke in the DGH is associated with a high case fatality rate and hypertension
remains the number one risk factor.Ischemic stroke accounted for 52% of consultation
cases while 48% were hemorrhagic (Yacouba N, et al 2014). The prevalence of stroke is
higher in males than females partly explained by the hormonal differences and lifestyle of
men who tend to consume alcohol and tobacco more than women in our setting.In-hospital
mortality due to stroke in 26.8% ( Touré et al), significantly lower in developed countries
(13% to 14%), and is relatively lower in developing countries around 19%.

CAUSES OF STROKE
1. Thrombotic stroke: caused by a thrombus (blood clot) formed around
atherosclerotic plaques.
2. Embolic stroke: refers to arterial embolism ( blockage of an artery) by an embolus,
a travelling particleor debris in the arterial blood stream originating from
elsewhere.
3. Cerebral hypoperfusion: it is due to a reduction in blood flow to all parts of the
brain, mostly due to heart failure from cardiac arrest.
4. Cerebral hemorrhage: occurs in small arteries and arterioles and is commonly
due to hypertension.
5. Spasm of the artery: may occure due to cocain.

PATHOPHYSIOLOGY OF ISCHEMIC STROKE

 It occurs because of loss of blood suply to the brain, innitiating the ischemic
cascade. Blood cells stop functioning if deprived of blood for more than 60-90
seconds, and after approximately 3hours, will suffer irreversible damage leading to
infarction or death the affected tissues.
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  Atherosclerosis may disrupt blood supply by narrowimg the lumen of blood vessels
leading to reduction in blood flow.
 Since blood vessels in the brain are now blocked, the brain become low in energy
and thus resorts to using anaerobic metabolism within the region of brain tissue
affected by the ischemia. Anaerobic metabolism produces lactic acid and less
amount of ATP. As lactic acid accumulates, it irritates and destroy cells thereby
disrupting the normal acid base balance in the brain. This is known as ischemia
penumbra.
 As oxygen and glucose become depleted in ischemic brain tissues, the production
of ATP fails, leading to failure of the energy-dependent process necessary for tissue
cell survival. This sets off a series of interrelated events that results in cellular
injury and death.
 Ischemial also induces the production of oxygen free radicals and other reactive
oxygen specieswhich reacts with and damege a number of cellular and extracellular
elements.

SIGNS AND SYMPTOMS OF STROKE.

The earlier you get the diagnosis and treatment for stroke, the better the prognosis will be.
Therefore recognising and understanding the signs and symptoms of stroke is very
important. Presenting symptoms include:
 Dizzyness
 Numness or paralysis of the face, leg or arm most likely affecting just one side of
the body.
 Blurred or dark vission
 Sudden headache especially when accompanied by nausea, vomiting and dizzyness
as in hemorrhagic stroke.
Major signs include:
 Loss of balance and coordination
 Difficulties speaking or understanding others speaking
 Altered breathing and heart rate
 Drooping of the eyelid (ptosis) and weakness of occular muscles.

For the most common stroke symptoms, remember FAST.

Face: does one side of the face drop?
Arm: if the patient holds both arms out, does one drift downwards?
Speach: is patient’s speach abnormal or slurred?
Time: it is time to call for emergency to get to the hospital if any of these three symptoms
are present.

DIAGNOSIS OF STROKE
1. Good history taking, physical exam and neurological status assessement can help
evaluate the location and severity of the the stroke.
2. Imaging techniques and other studies can be done to determine the underlying
cause such as:
 Ultrasound/dopler study of carotid artery to detect caritid stenosis

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  Electrocardiogram and echocardiogram to identify arrythmias and resultant
clots in the heart ahich may spread to the brain vessels
 Blood tests to check blood cholesterol level
 Echocardiogram may help determine source of blood clot.

MAMAGEMENT OF SHOCK
Objectives:
1. To remove blockage within the first few hours by thrombolisis or mechanically
(thrombectomy)
2. To stop or rrduce cerebral hemmorhage as early as possible

The management for ischemic stroke

1. Clinical monitoring of v/s ie BP, P, R, T and pain
 BP should be lowered to<185/100mmHg before thrombolytic therapy.
Elevated temp T, hypoxia and hypoglycemia should be agressively treated
 Blood: SPO2, RBS urine output, fluid input and output should be controlled
2. Paraclinical monitoring: lab and radiologic test control
3. Ventillation and oxygenation to maintain PaO2 at 90mmhg and PaCO2 at 40mmHg.
4. Nutrition: oral feeding dellayed untill swallowing evaluation is done.
5. Physioltherapy necssary for mottor and respiratory functions
6. Fluid therapy: NS preferred.
7. Thrombolitic therapy: using eg Streptokinase that destroy blood clots
8. Anticoagulants: Lmw heparine (lovenox should be considered in immobilised pts.
9. Diuretics: to manage ICP
10. Antiplatelets therapy should be considered in patients zho do not have a clear
embolic source

Management of hemorrhagic stroke

1. Drugs that lower BP in the brain
2. Fluid of choice is glucose
3. In svere bleeding, surgery may be considered
There is a recovery period after having any kind of stroke. The length of recovery varries
depending on the type and severity of the stroke.

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