SITI MARIAM BINTI MOHD HAMZAH

STROKE Investigations and

Management

aims of investigation is to confirm the vascular nature of the lesion, distinguish cerebral infarction from

hemorrhage and identify the underlying vascular disease and risk factors.

INVESTIGATIONS

Risk Factors Analysis Initial investigation of all patients with stroke includes a range

of simple blood tests to detect common vascular risk factors and markers of rarer causes, an ECG and brain imaging.

Neuroimaging Either CT or MRI should be performed in all patients with acute

stroke CT is the most practical and widely available method of imaging the brain

It will usually exclude non-stroke lesions, including subdural haematomas and brain tumours, and will demonstrate intracerebral hemorrhage within minutes of stroke onset

However, especially within the first few hours after symptom onset, CT changes in cerebral infarction may be completely absent or only very subtle.

Changes often develop over time, but small cerebral infarcts may never show up on CT scans.

Even in the absence of changes suggesting infarction, abnormal perfusion of brain tissue can be imaged with CT after injection of contrast media

MRI is more sensitive than CT in detecting strokes affecting the brain stem and cerebellum, and unlike CT, can reliably distinguish haemorrhagic from ischemic stroke even several weeks after the onset

MRI is not widely available because scanning time are longer and it cannot be used in some individuals with contraindications; pacemakers

Vascular Imaging Many ischaemic strokes are caused by atherosclerotic

thromboembolic disease of the major extracranial vessels. Detection of extracranial vascular disease can help establish

why the patient has had an ischaemic stroke and may, in highly selected patients, lead on to specific treatments including carotid endarterectomy to reduce the risk of further stroke

Cardiac Investigations app. 20% of ischemic strokes are due to embolism from the

heart. Atrial fibrillation, prosthetic heart valves, other valvular abnormalities

and recent MI Transthoracic or transoesophageal echocardiogram can be

useful To confirm the presence of a clinically apparent cardiac source To identify an unsuspected source such endocarditis, atrial myxoma

and intracardiac thrombus Such findings may lead on to specific treatment

is aimed at minimizing the vol. of brain that is irreversibly damaged, preventing complications, reducing the patient’s disability and handicap through rehabilitation, and reducing

the risk of recurrent episodes.

Primary prevention and secondary prevention Primary prevention is to treat the factors

Secondary prevention is to avoid the reoccurrences of the stroke

MANAGEMENT (ischemic stroke)

Early admission of patients has been shown to reduce both mortality and residual disability amongst survivors.

Consideration of a patient’s rehabilitation needs should commence at the same time as acute medical management.

SUPPORTIVE CARE

Intravenous thrombolysis with recombinant tissue plasminogen activator(rt-PA) increases the risk of hemorrhagic transformation of the cerebral infarct with potentially fatal results.

However if given within 3 hours of symptom onset to highly selected patients, the hemorrhagic risk is offset by an improvement in overall outcome

THROMBOLYSIS

In the absence of contraindications, aspirin (300mg daily) should be started immediately after

ischaemic stroke unless rt-PA has been given, in which case

it should be withheld for at least 24 hours.

Aspirin reduces the risk of early recurrence; it may be given by rectal suppository or by nasogastric tube in dysphagic patients

ASPIRIN

A small proportion of patients with a TIA will have a greater than 50% stenosis of the carotid artery on the side of the brain lesion.

Such patients have a greater than average risk of stroke recurrence.

The effectiveness of surgery is greatest for those with severe stenoses (70-90%) and in those in whom surgery can be performed within the first couple of weeks after TIA or ischemic stroke.

CAROTID ENDARTERECTOMY & ANGIOPLASTY

For patient taking VKAs, rapid reversal of coagulopathy can be achieved by infusing prothrombin complex concentrates which can be administered quickly, followed by fresh-frozen plasma and vitamin K

If ICH is ass. with thrombocytopenia, transfusion of fresh platelets is indicated.

Tissue surrounding hematomas is displaced and compressed but not necessarily infarcted. Major improvement commonly occurs as the hematoma is reabsorbed and the adjacent tissue regains its function.

Surgical evacuation may be undertaken for cerebellar hemisphere hematomas >3cm diameter in selected patients

ACUTE MANAGEMENT-INTRACEREBRAL HEMORRHAGE

If ICP is low, place a ICP monitor. Further hyperventilation and osmotic therapy can be tailored to the patient to keep cerebral perfusion pressure above 60 mmHg.

If ICP is found to be high, CSF can be drained from the ventricular space and osmotic therapy continued

Persistent or progressive elevation in ICP may prompt surgical evacuation of the clot

Alternately if ICP become normal or mildly elevated, induced hyperventilation can be reversed and osmotic therapy tapered.

ICP is often normal even with large intraparenchymal hemorrhages

Rehabilitation should be structured to provide as much practice as possible within the first six months after stroke

For patients undergoing active rehabilitation, as much physical therapy should be provided as possible with

a minimum of one hour active practice per day at least five days a week

As much therapy for dysphagia or communication difficulties should be provided as they can tolerate

Patients should be mobilized as early and as frequently as possible

REHABILITATION

• Davidson’s principles & practice of medicine 21st ed• Harrison’s principle of internal medicine 18th ed

• Clinical Practice Guidelines; Management of Ischaemic Stroke 2nd ed 2012

• Clinical Guidelines for Stroke Management 2010; stroke foundation

THANK YOU