Stroke CME

STROKE
MICHELLE KANISA
CONTENTS Ø Case scenario
Ø Definition
Ø Classification of stroke
Ø Risk factors
Ø Clinical features
Ø Causes
Ø Investigation
Ø Management
Ø Reperfusion of Ischemic Brain
Ø Cardioembolic stroke
Ø Prevention
Ø Revascularization procedures
Ø References
CASE • A 62 years old woman with a history of hypertension and
hyperlipidemia, presented to a ED with sudden onset of right-
SCENARIO sided body weakness.
QUESTIONS
• What are the further history you are going to ask?
• What are your differential diagnosis?
• On examination:
• she had a global aphasia
• left gaze preference
• right homonymous hemianopsia (field cut),
• right facial droop
• Dysarthria
• right hemiplegia – power 2/5
QUESTIONS
• What do you mean by power 2/5?
• What do you think her GCS level is?
• Why do you need to know all these?
RADIO MO ASK YOU:
• Can I know what is her NIHSS score?
• Can you tell me when is the onset?
• You replied,” Patient’s NIHSS score is 22.”

• What is this mean?
CT BRAIN
• Plain?
• Contrast?
• CTA?
• CTV?
• MRI Brain?
AS YOUR WISH
MANAGEMENT
• What is your plan?
• How are you going to manage this lady?
DEFINATION
• Stroke is defined as a clinical syndrome characterized by rapidly developing clinical symptoms
and/or signs of focal, and at times global, loss of cerebral function, with symptoms lasting more
than 24 hours or leading to death, with no apparent cause other than that of a vascular origin.
• Stroke is a major cause of mortality and disability in many countries, including Malaysia.
• Ischaemic stroke accounted for 79.4% of all stroke cases, followed by haemorrhagic stroke
(18.2%), transient ischaemic attack (2%) and unclassified stroke (0.4%).
CLASSIFICATION OF STROKE
Ischemic stroke-three subtypes:
• Thrombosis:in situ obstruction of an artery
• Embolism: particles of debris originating elsewhere that block arterial access to a
particular brain region
• Systemic hypoperfusion: more general circulatory problem,manifesting itself in the
brain and perhaps other organs
Hemorrhagic stroke due to intracerebral hemorrhage or subarachnoid hemorrhage

RISK FACTORS FOR STROKE
CLINICAL FEATURES OF STROKE
• The diagnosis of stroke is made by evaluating and analysing information derived from a good history,
physical examination and selected diagnostic tests.
• Anterior circulation stroke(carotid artery)
1.Middle cerebral artery
• Aphasia(dominant hemisphere)
• Hemiparesis/plegia
• Hemisensory loss/disturbance
• Homonymous hemianopia
• Parietal lobe dysfunction:sensory&visual inattention,acalculia
2.Anterior cerebral artery
• Weakness of lower limbs more than upper limbs
• Posterior(vertebrobasilar) artery circulation
• Homonymous hemianopia
• Cortical blindness
• Dysarthria
• Ataxia
• Dizziness or vertigo
• Cerebellar signs
• Diplopia
• Dysphagia
• Horner’s syndrome
• Hemiparesis or hemisensory loss contralateral to the cranial nerves palsy
CAUSES OF ISCHEMIC STROKE
• The three main causes of ischaemic stroke are:
• Atherothrombosis of large vessels (20-50%) :atherothrombotic plaque
can grow to obstruct a vessel with intraluminal propagation of the
thrombus to cause occlusion
• Intracranial small vessel disease (25%) : is due to lipohyalinosis,
microatheroma and fibrinoid necrosis.
• Embolism (20%) : most common causes are atrial fibrillation and
valvular heart disease
INVESTIGATION
ACUTE GENERAL MANAGEMENT
• ABC
• Oxygen and Airway Support: to prevent hypoxia and potential worsening of the
neurological injury.
• Observation: Regular observation is mandatory to recognise impaired pulmonary
function (pulse oximeter), circulatory function (pulse rate, blood pressure), NIHSS
score, head chart, GCS, and complications from mass effect.
• Mobilisation : Most patients are first treated with bed rest
• Blood Pressure: Lowering BP initially by 15% is probably safe. Very high
blood pressure should be reduced gradually.
• Blood Glucose: After an acute stroke, treat hyperglycaemia to keep the
blood glucose levels between 6.0-10.0 mmol/L and ensure that
hypoglycaemia is avoided
• Nutrition: Enteral feeding should be started within 7 days of admission
(oral or tube feeding). Do a water swallowing test ( and also SLP
assessment)
REPERFUSION OF ISCHAEMIC BRAIN
• Reperfusion therapy is the single most important and beneficial treatment for acute
ischaemic stroke
• Reperfusion therapy can be achieved via intravenous thrombolysis (IVT) or/and
endovascular thrombectomy (EVT).
• IVT is indicated for patients with onset of symptoms within 4.5 hours of
presentation, while EVT for large vessel occlusion (LVO) could be offered up to 24
hours using advanced imaging such as CT/MR perfusion scan.
REGIMEN FOR TREATMENT OF ACUTE ISCHAEMIC STROKE WITH
INTRAVENOUS THROMBOLYSIS
• Infuse 0.9mg/kg (maximum of 90 mg) Alteplase over 60 minutes with 10% of the dose
given as a bolus dose over 1 minute.
• Perform neurological assessments* every 15 minutes during the infusion of Alteplase
and 1-hour post IVT, and every 30 minutes for the next 4 hours and then every hour
until 24 hours lapses from the onset of treatment. (*GCS and Blood pressure)
• If the patient develops severe headache, acute hypertension, nausea or
vomiting or worsening neurological symptoms with an increase of the
NIHSS by 4 and reduction of the GCS by 2, discontinue the infusion and
obtain a CT scan of the brain.
• Avoid antiplatelet and anticoagulation drugs for the first 24 hours after
administration of Alteplase.
CARDIOEMBOLIC STROKE
• Cardioembolic stroke accounts for about 20% of all ischaemic strokes.
• Atrial fibrillation (AF) whether chronic or paroxysmal, is the most common cause of
cardioembolism and accounts for 50% of all cardiogenic emboli.
• Other high-risk conditions are prosthetic heart valves, rheumatic mitral valvular disease, acute
myocardial infarction, and severe left ventricular dysfunction.
• Oral anticoagulant (OAC) to prevent cardioembolic stroke is recommended for all NVAF patients
with CHA2DS2-VASc score of 2 or more.
• The choice of OAC for valvular AF (moderate-to-severe mitral stenosis) and mechanical heart
valves patients is a Vitamin K Antagonist (Warfarin).
PRIMARY PREVENTION
• Hypertension: treat if BP>140/90,target BP for diabetics patient <130/80

• DM:maintain tight glycemic control
• Hyperdyslipidemia:high risk group:keep LDL <2.6,if no risk factor LDL <4.2
• Smoking cessation
SECONDARY PREVENTION
• Aspirin: recommended: 75-150mg OD
• Clopidogrel : 75mg OD
• Ticlodipine : 250mg BD
• Double therapy (DAPT): combination of aspirin&clopidogrel
• Anti-hypertensive treatment: ACE-I is useful to reduce recurrent stroke in

normotensive and hypertensive pt
• Lipid-lowering agents: High dose statin
• Diabetic control: good glycemic control
REVASCULARIZATION
PROCEDURES
• Carotid endarterectomy (CEA)
• Angioplasty or Stenting - alternative to carotid endarterectomy for secondary stroke
prevention when surgery is undesirable, technically difficult, or inaccessible.
• Raised Intracranial Pressure - Mannitol (0.25 to 0.5g/kg) administered intravenously over 20
minutes lowers intracranial pressure and can be given every 6 hours. Maximum daily dose is
2g/kg.
• Hydrocephalus – EVD (external ventricular drain)
• Mass effect – Decompressive surgery (neurosurgical team)

REFERENCES
• https://www.cdc.gov/stroke/types_of_stroke.htm
• https://www.stroke.org/en/about-stroke
• https://specialty.mims.com/ischemic%20stroke/signs%20and%20symptoms?channel
=cardiology
• CPG Management of stroke Malaysia
• Sarawak Handbook of Medical emergencies
• https://www.msdmanuals.com/professional/neurologic-disorders/stroke/ischemic-
stroke
THANK YOU FOR YOUR
ATTENTION

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STROKE

• You replied,” Patient’s NIHSS score is 22.”

Hemorrhagic stroke due to intracerebral hemorrhage or subarachnoid hemorrhage

• Hypertension: treat if BP>140/90,target BP for diabetics patient <130/80

• Anti-hypertensive treatment: ACE-I is useful to reduce recurrent stroke in

• Hydrocephalus – EVD (external ventricular drain)

• Mass effect – Decompressive surgery (neurosurgical team)

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