ISCHEMIC STROKE PROF.SHKROBOT. Stroke morbidity in different countries 1:3,6 1:7 Hemorrhagic stroke...

ISCHEMIC STROKEISCHEMIC STROKE

PROF.SHKROBOTPROF.SHKROBOT

Stroke morbidity in Stroke morbidity in different countriesdifferent countries

269,8

200

0

50

100

150

200

250

300

Ukraine Europe

1:3,61:7

Hemorrhagic Hemorrhagic stroke stroke

Ischemic Ischemic strokestroke

per

100

OO

O o

f p

op

ula

tio

n

Stroke morbidity Stroke morbidity

266,3

253,9

247,2

260,7

256,6

269,8

235

240

245

250

255

260

265

270

2000 2001 2002 2003 2004 2005

per

100

000

of

po

pu

lati

on

Stroke mortality in different Stroke mortality in different countries countries

72,4

0

10

20

30

40

50

60

70

80

Ukraine Developed countries

per

100

000

of p

opul

atio

n

Mortality from different types Mortality from different types of stroke in Ukraineof stroke in Ukraine

19,7

39,8

30,7

3,2

0 20 40 60

SH

IH

IS

nonspecified

per 100 000 of population

Nowadays Nowadays

... ... Every fifth Ukrainian resident will die Every fifth Ukrainian resident will die of strokeof stroke ... ...

Every fifth one will finish his life as Every fifth one will finish his life as depending from others disabled person depending from others disabled person

DEFINITIONDEFINITION

• STROKE IS RAPIDLY DEVELOPING CLINICAL SIGNS OF FOCAL DISTURBANCE OF CEREBRAL FUNCTION,LASTING MORE THEN 24 HOURS OR LEADING TO DEATH

ClassificationClassification

• 1. Atherothrombotic

• 2. Cardioembolic

• 3. Haemodynamic

• 4. Rheologic

• 5. Lacuna


1. Atherothrombotic - occurs in case of plugging of extracranial or intracranial vessel by atherosclerotic plague

2. Cardioembolic - occurs in case of plugging of extracranial or intracranial vessel by thrombus or embolus from the heart


3. Hemodynamic - one occurs at angiospasm in case of atherosclerosis, vascular insufficiency, central hemodynamics disorders.

4. Rheologic – occurs in case of disturbance of rheologic blood properties

5. Lacuna-focus of iscemia without meningeal,cortical symptoms

Subtypes of ischemic stroke Subtypes of ischemic stroke

Atherotrombotic (36%)

Lacunar (29%)

?

Others and non specified (8%)

Cardioembolic (27%)

The most common causes of brain The most common causes of brain infarctioninfarction

• Atherosclerotic lesion of MAH

• Combination of atherosclerosis with hypertension

• Chronic ischemic heart disease with rhythm disorders

The most common causes of brain The most common causes of brain infarctioninfarction

• Combination of atherosclerosis with diabetes

• Rheumatism, heart abnormalities (inborn and acquired)

• Vasculitis

PathophysiologyPathophysiology

• As a result of brain infarction in case of blood circulation less than 10 ml per 100 g of brain tissue in 1 min zone of focal necrosis is formed.


• Penumbra - during the first 6 hours this zone is surrounded by region with borderline blood circulation (18 – 20 ml per 100 g in 1 min). The neurons within this region are preserved structurally but their function suffers.


• During first 3 – 6 hours we can renew their function, that’s why this period is known as “therapeutic window


• After 6 hours zone of brain infarction is formed completely. Pathobiochemical and pathophysiological changes are observed in penumbra region:

Pathobiochemical and Pathobiochemical and pathophysiological changespathophysiological changes

• One of the main reason of neurons death is accumulation of glutamat

• brain edema

• disturbance of synaptic transference

Pathobiochemical and Pathobiochemical and pathophysiological changespathophysiological changes

• the number of intracellular enzymes is increased

• activation of thrombocytes, microcirculation disorders, ischemia.

• As a result ruination of neurons occurs.

• penumbra

Clinical features of ischemic Clinical features of ischemic strokestroke

Acute period of brain infarction is divided into three stages:

• Precursors

• Apoplectic stroke

• Focal signs


1. Precursors - transient ischemic attacks in the same region where brain infarction is developed

2. Onset is gradually

3. During several hours focal neurologic symptoms are developed.

4. The prevalence of focal symptoms over the general cerebral ones.


• General cerebral symptoms manifest as:

- Headache- Vomiting- Consciousness disorders

Focal symptoms depend of localization of the infarction, damaged vessel and state of collateral blood circulation.

Clinical features Clinical features AtherothromboticAtherothrombotic stroke stroke

• Occur at older age• Develop during some ours and

days• TIA present in anamnesis• Developed at night or in the

morning time• Stenosis and occlusion of MAH at

ultrasound examination• Decreased of Internal Carotid

artery pulsation on the neck

Ischemic strokeIschemic stroke

Lacunar

Extensive

Clinical features of Clinical features of cardioemboliccardioembolic stroke stroke

1. Precursors are absent

2. Acute onset at emotional and physician activity

3. General cerebral signs are very intensive:

Loss of consciousness,

Seizures and psychomotor agitation

Severe headache

Clinical features of Clinical features of cardioembolic strokecardioembolic stroke

4. Embolism of vessels of retina, extremities, other inner organs

5. Embolism of different arteries of the brain

6. Embolism of cortical branches of the brain arteries

7. Maximal neurological deficit at the begining of stroke

8. More often medial cerebral arteries are involved

The reasones of The reasones of embolismembolism

• aortal or arterial thrombus• thrombus in case of heart

abnormalities, such as mitral stenosis, aortal abnormality, rheumatic or bacterial endocarditis, myocardial infarctions, cardiosclerosis, cardiomyopathy.

The reasones of The reasones of embolismembolism

• Embolism can occur at thrombophlebitis, lung abscess, malignant tumors, sepsis

• Fat embolism occurs at bone fractures, after surgery associated with trauma of subcutaneous tissue

• Gas embolism occurs at surgery on lungs, at pneumothorax

Lacunar stroke Lacunar stroke

Lacunar strokeLacunar stroke

Blood supplying of brain Blood supplying of brain hemispheres hemispheres

• А - convex,• Б – medial surface,• В – frontal section

(pink – blood supplying by anterior cerebral artery, blue - middle, yellow – posterior cerebral artery)

А Б

В

Blood supplying of brainBlood supplying of brain

Territory of Middle cerebral arteryTerritory of Middle cerebral artery

Scheme of middle cerebral Scheme of middle cerebral artery basin artery basin

• А – cortical branches on convex surface of hemispheres;– 1 – middle cerebral artery;– 2 – branches to eye - socket;– 3 – frontal branches;– 4 – parietal branches;– 5 – occipital branches;– 6 – temporal branches;

• Б – central branches. – 7 – internal carotid artery;– 8 – anterior cerebral artery;– 9 – middle cerebral artery;

А

Б

2 3 1 6 4 5

78

10 9

Middle cerebral arteryMiddle cerebral arterydistributiondistribution

• basal nuclei

• internal capsule

• part of temporal lobe

• middle and lower parts or anterior and posterior central gyruses

• opercular region

• part of parietal lobe

• gyrus angularis

• posterior parts of upper and middle frontal gyruses

Focal symptomes of infarction in Focal symptomes of infarction in middle cerebral arterymiddle cerebral artery (MCA)(MCA)

1. Motor disorders – Hemiplegia

2. Sensory disorders - Hemianesthesia

3. Gaze paresis

4. Visual disorders - Hemianopsia

The lesion of the left MCAThe lesion of the left MCA

1. Aphasia

2. Alexia

3. Acalculia

4. Agraphia

The lesion of the right MCAThe lesion of the right MCA

Apracto – agnostic syndrome

• Anozognosia

• Astereognosis• Autotopognosia

• Apraxia

Postischemic cistPostischemic cist

Anterior cerebral arteryAnterior cerebral arterydistributiondistribution

• the cortex of frontal lobe ( superior frontal gyrus )

• superior part of anterior central gyrus• superior part of posterior central gyrus• corpus callosum• part of superior parietal lobulus• orbital part of frontal lobe• lobulus paracentralis

Scheme of anterior cerebral artery Scheme of anterior cerebral artery basinbasin

1 – posterior communicant artery; 2 – internal carotid artery; 3 – central branch of anterior cerebral artery; 4 – middle cerebral artery; 5 – anterior cerebral artery; 6 – branch of internal carotid artery; 7 – ophthalmic branches; 8 – corpus callosum arteries with cortical branches; 9 – frontal arteries; 10 – parietal branches

Focal symptomes of infarction in Focal symptomes of infarction in anterior cerebral arteryanterior cerebral artery (ACA)(ACA)

• Spastic hemiparesis with the prevalence in proximal part of upper extremity and distal part of lower extremity

• Symptoms of oral automatism • Psychiatric disorders – frontal mental

disorders

Focal symptomes of infarction in Focal symptomes of infarction in anterior cerebral arteryanterior cerebral artery (ACA(ACA

• Dysphagia

• Dysphonia

• Astasia, abasia

• Motor aphasia

• Retention of urine

Posterior cerebral arteryPosterior cerebral arterydistributiondistribution

• occipital lobe

• posterior part of lower and middle temporal gyruses

• basal and mediobasal part of temporal lobe

• deep thalamocollicular branches blood supply thalamus

• hypothalamus

• posterior – lower parts of cortex of parietal lobe

Posterior cerebral artery Posterior cerebral artery distributiondistribution

• 1.Occipital lobe

• 2.Posterior part of lower and middle temporal gyruses

• 3. Posterior –lower part of parietal lobe

• 4.Thalamus

• 5.Hypothalamus

Focal symptomes of infarction in Focal symptomes of infarction in posterior cerebral arteryposterior cerebral artery (PCA)(PCA)

• Hemianopsia

• Visual agnosia

• Hemianesthesia

• Hyperpathia

• Desorientation in space and time

Postischemic cistPostischemic cist

Territory of Vertebral arteryTerritory of Vertebral artery

Scheme of vertebral artery Scheme of vertebral artery basinbasin

1 – internal carotid artery; 2 – anterior artery of choroid plexus; 3 – posterior communicant artery; 4 – posterior cerebral artery; 5 – upper cerebellar artery; 6 – basal artery; 7 – anterior lower cerebellar artery; 8 – posterior lower cerebellar artery; 9 – vertebral artery

Region of vertebral arteryRegion of vertebral artery

• Brain stem

• Oblongate brain

• Cerebellum

• Cortex of occipital lobe

• Part of cervical part of the spinal cord.

• It can be damaged extra – or intracranialy

Focal symptoms of infarction in Focal symptoms of infarction in vertebral arteryvertebral artery

In case of extracranial lesion:• systemic dizziness• Hearing disorders• Visual disorders• eye movements disorders• Vestibular and equilibrium disorders • paresis with sensory disturbances in

extremities• some patients have “ drop- attacks “.

Focal symptoms of infarction in Focal symptoms of infarction in basilar arterybasilar artery

• loss of consciousness• eye movements disorders• pseudobulbar syndrome • tetraplegia • muscle tone disturbance• cerebellar symptoms • cortical blindness • vital functions disorders.

Vertebro – basilar basin Vertebro – basilar basin infarctioninfarction

• Lesion of vertebro – basilar basin arteries cause development of brain stem and occipital lobes infarction

CT - scanCT - scan

• Focus of ischemia in right occipital lobe (posterior cerebral artery basin)

Blood supplying of the base of the Blood supplying of the base of the brainbrain

Diagnostics of Brain InfarctionDiagnostics of Brain Infarction

The main peculiarities are:

• Before stroke period in the previous history ( TIA in anamnesis )

• The beginning of the stroke is gradual

• Data of somatic and neurological status

• Additional methods of diagnostics

Diagnostics of Brain InfarctionDiagnostics of Brain Infarction

• Rheologic disturbances• Liquor is pellucid, without significant

changes. • EEG - There is focus of pathologic activity• USD finds out occlusion, stenosis of

carotid and vertebral arteries• CT reveals hypodensive focus on the

second day • MRI helps to find out small focuses and

those, located in the brain stem

Differential diagnosisDifferential diagnosis

– Traumatic hemorrhage, trauma of brain– Myocardial infarction– Epilepsy– Uremic coma– Hyperglycemic coma– Hypoglycemic coma– Brain tumor with inside hemorrhage

Strokes treatmentStrokes treatment

Nondifferential treatment includes:

• Prevention and treatment of pulmonary insufficiency

• Liquidation of heart – vascular disorders

• Brain edema treatment

Strokes treatmentStrokes treatment

• Normalization of water – electrolytes balance and acid – alkali balance

• Osmosis correction

• Improving of brain metabolism

• Liquidation of hyperthermia and other autonomic disorders

Prevention and treatment of Prevention and treatment of pulmonary insufficiencypulmonary insufficiency

– the patient is lying on the bed with his head elevated

– cleaning of patient’s oral cavity– tracheostomia ( at inspiratory muscles

paralysis )– in lung edema - oxygen; narcosis, Bobrov’s

apparatus, 2 ml 1 % lazix, 2 ml 1 % dimedroli, 2 ml 0.1 % atropini I/m

– antibiotics are used in order to prevent pneumonia

Elimination of heart – vascular Elimination of heart – vascular disordersdisorders

In increased blood pressure we use• Clofelini 1 – 3 ml 0.01 % solution i/m, i/v.• Dibasoli 3 – 4 ml 1 % solution i/v• Droperidoli 1 ml 0.25 % solution i/v• Rasedili 1 – 2 ml 0.1 % i/v, I / m, - adrenoblockers ( anaprilini, obzidani,

inderali )• peripheral vasodilatators ( Natrii

nytroprussidi , appresini ) in combination with euphyllini

In low blood pressure we prescribeIn low blood pressure we prescribe

• Dexamethazoni 4 – 8 mg i/v by drops in physiological solution

• Prednizoloni 60 – 120 mg i/v by drops in physiological solution

• In order to improve heart activity we use strofantini, corgliconi, cordiamini

Brain edema treatmentBrain edema treatment

• Diuretics• Corticosteroids• Albumini• Ganglioblockers• 20 % Mannit• Manitoli• Glycerini• Lazix• Diakarbi

Normalization of water – electrolytes Normalization of water – electrolytes balance and acid – alkali balancebalance and acid – alkali balance

• We should estimate patient’s necessity in water according to his secretion, the level of Na in blood, hematocritis

• An average water necessity is 35 ml per kg, in patients with loss of consciousness it is 50 ml per kg

• We should correct patient’s hyper- or hyponatriemia, hyper- or hypokaliemia

• 4 % solution of Na bicarbonates i/v, trisaminum is used at metabolic acidosis.

• KCl i/v is used at metabolic alkalosis

Osmosis correctionOsmosis correction

• Normally blood osmose is within 280 – 295, urine osmose is 600 – 900 moms per liter

• At stroke usually we have hyperosmose, which manifests as increased hematocritis, hyperagrigation

Improving of brain metabolismImproving of brain metabolism

• Vit E

• Piracetam

• Instenon

• cerebrolysin

• Nootropil

• Citikolin

• Cortexin

Liquidation of hyperthermia Liquidation of hyperthermia and autonomic disorders.and autonomic disorders.

• analgini 50 % 2.0

• aspizoli 0.5 g

• sibazoni 0.5 % 1 ml

• haloperidoli 0.5 % 1 ml

• dimedroli 1 % 2 ml

• natrii oxybutiras 20 % 10 ml

Differential treatment of brain Differential treatment of brain infarctioninfarction

• To renew blood circulation in zone of ischemia

• To correct rheologic and coagulative properties of blood, to improve microcirculation

• To prevent disorders of cerebral metabolism

• To decrease brain edema• To treat brain hypoxia

To renew blood circulation in To renew blood circulation in zone of ischemiazone of ischemia

– Actilaza 100 mg I / v by drops every 2 – 3 hours.

– Inhibitors of glutamat excretion ( difenin, nimotop, MgSO4) are used. Nimotop is used 15 mg in 1500 ml of physiologic solution i/v by drops, or in tablets 30 – 60 mg 4 times per day.

• In order to improve perfusion we use cavinton 20 mg I /v by drops

To renew blood circulation in To renew blood circulation in zone of ischemiazone of ischemia

• At hyperperfussion we use

• euphyllini 10 ml 2.4 % solution

• penthoxiphyllini

• diuretics (manitol 15 % 100 – 200 ml )

• albumini 100 ml I / v

To improve microcirculationTo improve microcirculation

Anticoagulative therapy :• heparini 5 000 U 4 times per day

during 5 – 7 days, the 2 500 U during next 3 –4 days.

• Fraxiparini is considered to be even more effective

• Clexane-0.3 twice a day

AntiagregantsAntiagregants• Penthoxiphyllini 5 – 10 ml 2 % solution I /v

by drops during 10 days, then 200 mg 3 –4 times per day up to 1 month.

• Sermioni 4 mg I / v by drops during 10 days , then 1 tablet 3 times per day up to 1 month.

• Ticlid 250 mg twice a day.

• Aspirini 250 mg once a day.

• Dipiridamoli 1 – 2 ml i/v by drops during 10 days, then 25 mg 2 –3 times per day

Organization of assistance

to patients with stroke

Secondary prevention

Primary prevention

First aidRehabilitation

SmokingSmoking

• Risk of recurring stroke in smokers increases in 1.5 times

WeightWeight

• For all over weighted people is recommended to keep weight index between 18,5 and 24,9 kg/m2 and size of waist not more than 88 sm in women and not more than 102 sm in men (Northern Manhattan Study)

Physical activityPhysical activity

• Physical exercises for not less than 30min a day are recommended for patients

ISCHEMIC STROKE PROF.SHKROBOT. Stroke morbidity in different countries 1:3,6 1:7 Hemorrhagic stroke...

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Transcript of ISCHEMIC STROKE PROF.SHKROBOT. Stroke morbidity in different countries 1:3,6 1:7 Hemorrhagic stroke...