Stroke by Dr Hari Om Chandrakar

8/8/2019 Stroke by Dr Hari Om Chandrakar

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Cerebrovascular Accident (CVA)Stroke

DrDr HariHari OmOm ChandrakarChandrakarMBBSMBBSBatchBatch --2006,2006, cimscims bilaspurbilaspur

Guided by

Dr Gopal Kanwar sir

MD Medicine


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Cerebrovascular Accident (CVA)

Other terms: stroke, brain attack, acuteischemic cerebrovascular syndrome

occurs when blood supply to part of the brainis disrupted, causing brain cells to die.

a "neurological deficit of cerebrovascularcause that persists beyond 24 hours or is

interrupted by death within 24 hours". -WHO


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CLASSIFICATION OFSTROKE


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Classification of Stroke

According to:

1. Etiology

a. Ischemic Stroke (80%)

a.1. Thrombotic

a.2. Embolic

a.3.hypoperfusionb. Hemorrhagic (20%)

b.1. Parenchymal

b.2. Subarachnoid

2. Onset and Duration

a. Transient Ischemic Attack / TIA (lasts less than 30

seconds but no more than 24 hours with completeresolution of symptoms)

b. Stroke in evolution (progressive development of stroke over

a period of hours to days)

c. Completed stroke (neurologic deficit remains unchanged for a 2-3

day period)


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Ischemic StrokeIschemic StrokeIn an ischemic stroke, blood supplyblood supply

to a part of the brain isto a part of the brain isdecreaseddecreased, leading todysfunction and necrosis of thebrain tissue in that area.

It may affect large vessel or smallervessels


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Types of ischemic stroke


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1.Thrombotic Stroke1.Thrombotic Stroke

Sickle cell anemia, which can cause blood cells to clump up and block blood

vessels, can also lead to stroke..


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2.Embolic stroke2.Embolic stroke


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3.Systemic3.Systemic HypoperfusionHypoperfusion


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Hemorrhagic StrokeHemorrhagic Stroke


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HEMORRHAGICSTROKE IS OF

THREE TYPES:

1. Primary intracerebral

hemorrhage ( intra

parenchymal hematoma

formation)2. Subarachnoid hemorrhage

3. Primary intraventricular

hemorrhage


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BLEEDING IN

PARENCHYMA OF

BRAIN


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Risk Factors

Nonmodifiable

a. Increasing age

b. Being male

c. Race

d. Prior (Stroke)/

transient ischemic

attackse. Heredity

Modifiable

a. Hypertension

b. Heart disease

c. Hyperlipidemia

d. Diabetes Mellitus

e. Cigarette smoking

f. Excessive alcoholintake

g. Drug abuse


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Sign and symptoms of stroke

Stroke symptoms typically start suddenly, over seconds to

minutes, and in most cases do not progress further.

The symptoms depend on the area of the brain affected as

per vascular supply hampered.

The more extensive the area of brain affected, the more

functions that are likely to be lost.

There is presence of focal neurological deficit accompanied by

headache and may be vomiting

The specific sign and symptoms present depends on which

artery is involved.


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Major Blood Vessels

Internal Carotid Artery

- supply blood to the anterior three-fifths of

cerebrum, except for parts of the temporal

and occipital lobes

Stroke in the internal carotid arteryresults in:

a. Contralateral hemiparesis

b. Global aphasia (dominant

side)

c. Visual disturbances

Vertebrobasilar Artery

- supplies the posterior two-fifths of the

cerebrum, part of the cerebellum, and the

brain stem.

Stroke in the vertebrobasilar artery resultsin:

a. Variable level of consciousness

b. Hemiparesis

c. Quadriplegia (possible depending

on collateral flow)

d. Cranial nerve paralysis (III, VI, VII,

XII)

e. Ataxia

f. Dysphagia

g.Mutism (locked in syndrome)

h. Visual disturbances


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Circle of Willis

At the base of the brain, the carotidand vertebrobasilar arteries form a

circle of communicating arteriesknown as the Circle of Willis.

From this circle other arteries ariseand travel to all parts of the brain:

1. AnteriorCerebralArtery

(ACA)2. Middle CerebralArtery

(MCA)

3. PosteriorCerebralArtery

(PCA)

Because the carotid andvertebrobasilar arteries form a circle,if one of the main arteries isoccluded, the distal smaller arteriesthat it supplies can receive bloodfrom the other arteries (collateralcirculation).


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Anterior Cerebral Artery (ACA)

The anterior cerebral

artery supplies thefrontal lobes, the partsof the brain that controllogical thought,personality, andvoluntary movement,especially the legs.

Stroke in the anterior

cerebral artery resultsin:

1. Contralateral leg

hemiparesis

2. Contralateral sensoryloss in leg

3. Bladder incontinence

4. Expressive aphasia(dominant

hemisphere)


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Middle Cerebral Artery (MCA) The middle cerebral

supplies a portion of thefrontal lobe and the lateral

surface of the temporal andparietal lobes, including theprimary motor and sensoryareas of the face, throat,hand and arm and in thedominant hemisphere, theareas for speech.

The middle cerebral arteryis the artery most oftenoccluded in stroke.

Stroke in the middlecerebral artery results in:

1. Receptive aphasia(dominant

hemisphere)2. Contralateralhemiparesis

3. Contralateral sensoryloss


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Posterior Cerebral Artery (PCA)

The posterior arteries supply thetemporal and occipital lobes of theleft cerebral hemisphere and theright hemisphere.

Stroke in the posterior cerebral artery

results in:1. Contralateral sensory loss

2. Contralateral hemiparesis

3. Contralateral homonymous

hemianopia

4. Ataxia


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enticulostriate Artery

Small, deep penetrating arteries,branch from the middle cerebralartery.

Occlusions of these vessels orpenetrating branches of the circle

of Willis or vertebral or basilararteries are referred to as lacunarstrokes.


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Difference between hemorrhagic,thrombotic and

embolic stroke

feature hemorrhagic thrombotic embolic

Time of onset During activity In sleep Any time

Progression Minutes and hours Over hours Within seconds

TIAs absent present present

vomiting present Absent or

occassional

Absent or

occassional

headache prominent Mild or absent Mild or absent

Early resolution unusual variable possible

Meningial irritn May be persnt absent absent

Valvular hrt dsz Not seen unusual Highly supportive

CT scan haemorrhage Pale infract Pale in early


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1. HISTORY :-

a. hx ofTIA or stroke.

b. hx of head injury.

c. hx of heart diseases.

d. hx of other chronic illness like

hypertension.

e. hx of clotting disorders or sickle cell.

2. LUMBARPUNCTURE:- invasive method, bloody tap is obtained

in case ofSAH, and also to differentiate from inflammation,

infection or tumor.

Investigations


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3. IMAGINGMODALITIESA. CTSCAN-

identify or exclude hemorrhage as a cause of

stroke and from other focal lesions like abscess or

tumor.

infraction may not be seen in ct in first several

hours .

midline shift is noted in case of severe

hemorrhage.B. CT angiography

can identify carotid or intracranial vascular

occlusions, aneurysm and av maformations.

Investigations


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C. MRIIMAGING- reliably documents extent and location of

infarction in brain but lacks sensitivity for detecting acute

blood as compared to CT.

D. x-ray cerebral angiography is gold standard

forathresclerotic stenosis of cerebral arteries.

Investigations


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Medical Management of stroke

General measures:- airway maintain, position changeto prevent bed sore, naso-gastric tube for vomiting,

bladder catheterisation if retention is present, water

restriction.

Specific measures :-

1. blood pressure reduction,urgent or gradual

reduction

2. anti-edema measures like mannitol 20

%

iv over 20min 3-4 times a day, frusemide 20mg iv 3 times a day


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Mgmt cont.

3. i.v. thrombolytic therapy :- rTPA has been shown

to be beneficial within 3 hrs of ischemic stroke,it is

contraindicated in hemorrhagic strokes, and

presence of av malformations 5. endovascular techniques:- thrombolysis and

thrombectomy

6. antithrombotic therapy:- aspirin is best drug for

acute ischemic stroke 300mg/day


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Surgical management

Craniectomy- surgical procedure wherein a portion of

the cranium is removed to relieve pressure on the

brain structures by providing space for expansion

Craniotomy- surgical procedure wherein the cranialvault is opened to visualize and relieve pressure on

the brain


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thanks

Stroke by Dr Hari Om Chandrakar

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