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CEREBROVASCULAR ACCIDENT
• Medical term for a stroke, also called “brain attack”• The sudden death of some brain cells due to lack of
oxygen
•It occurs when blood flow to a part of your brain is stopped either by a blockage such as a floating clot or a stationary clot , or a rupture of a blood vessel, or compression.
CEREBROVASCULAR ACCIDENT
SYMPTOMS
• Symptoms of a stroke depend on the area of the brain affected.
• Stroke symptoms signify a medical emergency.
Definition of Stroke Severity
• MILD STROKE:– Alert patients with any or combinations of
symptoms such as: • mild motor weakness of one side of the body, • sensory deficit, • slurred speech, • vertigo with incoordination• visual field defects alone
– NIHSS score= 0-5
Definition of Stroke Severity
• MODERATE SROKE:– Awake patient with significant motor and /or
sensory and /or visual deficit, or– Disoriented, drowsy, or light stupor with purposeful
response to painful stimuli, or– NIHSS Score= 6-21
Definition of Stroke Severity
• SEVERE STROKE:– Deep stupor or comatose patient with non-
purposeful response, decorticate, or decerebrate posturing to painful stimuli, or
– Comatose patient with no response to painful stimuli , or
– NIHSS Score= >22
Stages of CVA
• Transient ischemic attack (TIA) – sudden and short-lived attack
• Reversible ischemic neurologic deficit (RIND) similar to TIA, but symptoms can last up to a week
• Stroke in evolution (SIE) - gradual worsening of symptoms of brain ischemia
• Completed stroke (CS) – symptoms of stroke stable over a period and rehab can begin
12
CLASSIFICATION OF STROKE
Stroke
Primary Hemorrhagic (20% of Strokes)
Primary Ischemic (80% of Strokes)
Thrombotic
50%
Embolic
30%
Intracerebral Hemorrhage 15%
Subarachnoid Hemorrhage 5%
Transient Ischemic Attack
• TIA was traditionally defined as a neurological deficit, the symptoms of which are defined CURED completely within 24 hours
• The current definition of TIA is
• Acute onset neurological dysfunction, due to focal brain ischemia, which completely resolves within 60 minutes
• No evidence of cerebral ischemia
ISCHEMIC STROKE PATHOPHYSIOLOGY: The First Few Hours
Penumbra
Core
Clot in Artery
“TIME IS BRAIN:SAVE THE PENUMBRA”
Penumbra is zone of reversible ischemia around core of irreversible infarction—salvageable in first few hours afterischemic stroke onset
Penumbra damaged by:• Hypoperfusion• Hyperglycemia• Fever• Seizure
What are the risks factors?
• Modifiable Risks– HTN– CAD/Carotid Disease/PVD– Atrial Fibrillation– Diabetes– Weight– High Cholesterol/Diet– Lack of exercise– ETOH/Drug abuse– Coagulopathy- Cancer,
Sickle Cell Anemia– PFO- Patent Foramen
Ovale
• Non-Modifiable Risks– Age->55– Race- African Americans
have 2x the risk of death and disability. Asians have 1.4x the risk of death and disability.
– Sex- 9% greater chance in men. (61% of stroke deaths occur in women)
– Previous Stroke or TIA– Family History of Stroke
Signs and Symptoms
In embolism Usually occurs without warning Client often with history of cardiovascular disease
In thrombosis Dizzy spells or sudden memory loss No pain, and client may ignore symptoms
In cerebral hemorrhage May have warning like dizziness and ringing in the
ears (tinnitus) Violent headache, with nausea and vomiting
Signs and Symptoms
• Sudden-onset CVA– Usually most severe– Loss of consciousness– Face becomes red– Breathing is noisy and strained– Pulse is slow but full and bounding– Elevated BP– May be in a deep coma
Time is Critical!
• The longer the time period that the person remains unresponsive, the less likely it is that the person will recover.
• The first few days after onset is critical.• The responsive person may:
– Show signs of memory loss or inconsistent behavior
– May be easily fatigued, lose bowel and bladder control, or have poor balance.
Stroke Awareness
The Cincinnati Prehospital Stroke Scale using the acronym "FAST"Facial Asymmetry Have the person smile or show his or her teeth. If one side doesn't
move as well as the other or it seems to droop, that could be sign of a stroke.
Arm Drift Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. Look for weakness or drift.
Slurred Speech Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be sign of stroke.
Time If any of the above 3 is present then patients are advised to seek immediate hospital consultation.
Stroke Test or FAST test
A local version of "FAST" is "KAMBIO -- Sambitin at Gawin Upang Stroke ay Alamin"KAmay Itaas ang kamay at obserbahan
kung may panghihina o "drift"Mukha Ipakita ang ngipin o mag-Smile.
Tingnan kung may kaibahan ang kaliwa sa kanang mukha.
Bigkas Bigkasin at ulitin "Kumukutikutitap ang lampara". Obserbahan kung may mali sa pananalita
Oras Kapag may nakitang mali, huwag magpatumpiktumpik at humarurot sa ospital.
INVESTIGATIONS
• full blood count, serum electrolytes, renal function tests, cardiac enzymes, and coagulation studies
• Blood sugar is mandatory to exclude hypoglycemia or diagnose diabetes mellitus
• Full blood count to detect Polycythaemia,ESR for endocarditis,
• clotting studies for Hypercoagulable States• An electrocardiogram (ECG) : arrhythmias and
myocardial infarction. Baseline ECG is recommended in all patients with stroke(AHA/ASA Guidelines)
• Echocardiography : valve disease and intra-cardiac clot
NEUROIMAGING
• Brain CT scan: CT is sensitive to the intracranial blood and is readily available.
Normal early CT therefore rules out haemorrhagic stroke. CT Scan changes in ischemic stroke may take several days to develop.• MRI: MRI is better at detecting posterior fossa
lesions especially in posterior circulation stroke such as Pons or cerebellum
• It is also recommended that all patients with transient neurologic symptoms have a neuroimaging within 24 hours or as soon as possible.(Class 1,LOE B)
MEDICAL MANAGEMENT
1. supportive management- airway, temperature, blood pressure, blood glucose,
cardiac assessement
2. thrombolysis – intravenous / intra arterial
3. antiplatelet drugs
4. anticoagulant drugs
5. hemodilution, vasodilators and induced hypertension
6. Neuroprotective agents
Stroke management algorithmSymptoms & signs suggestive of
StrokeSymptoms & signs persist > 1 hour
Acute CareUrgent Clinical Evaluation
Urgent brain CTBlood tests
ECG
Ischaemic StrokeBrain CT normal or shows
acute infarctionHaemorrhagic Stroke
( ICH / SAH )Brain CT shows haemorhage
Specific Stroke therapyThrombolytic therapy ( if no
contraindications , Antiplatelet therapy
Neurosurgical Evaluation & Treatment
Acute Stroke CareStroke Unit ( if available )
Airway , Breathing , Circulation Hydration.
Blood Pressure monitoringNeurological Status monitoringAnticipate & treat complications
Begin rehabilitation
NeurorehabilitationMultidisciplinary Team Approach
Proper PositioningEarly mobilization
PhysiotherapyOccupational therapy
Speech therapyTreat spasticity
Treat depression
Further InvestigationsEstablish Stroke
subtype and underlying cause
Cardio & Cerebrovascular Risk
Assessment
EducationPatient & Caregiver
Secondary PreventionAntiplatelet therapy
Treat risk factorsTreat specific underlying cause
Primary Prevention
Factors recommendation
Hypertension Treat medically if BP>140mmHg systolic and/or>90mmHg diastolic.Lifestyle changes if BP between 130-139mmHg systolic and/or 80-89mmHg diastolic.Target BP for diabetics is <130mmHg systolic and <80mmHg diastolic.Hypertension should be treated in the very elderly(age >70yrs) to reduce risk of stroke.
Diabetes mellitus Strict blood pressure control is important in diabetics.Maintain tight glycaemic control.
Hyperlipidaemia High risk group keep LDL<2.6mmol/l.1 or more risk factors: keep LDL<3.4mmol/l.No risk faktor: keep LDL<4.2mmol/l.
Smoking Cessation of smoking.
Aspirin therapy 100mg aspirin every other day may be useful in women above the age of 65
Post menopausal Hormone Replacement therapy
Oestrogen based HRT is not recommended for primary stroke prevention
Alcohol Avoid heavy alcohol consumption.
General Management of Acute Ischaemic Stroke
Factors Recommendation
Airway &Breathing Ensure clear airway and adequate oxygenation.Elective intubation may help some patients with severely increased ICP.
Mobilization Mobilize early to prevent complications
Blood Pressure Do not treat hypertension if<220mmHg systolic or<120mmHg diastolic. Mild hypertension is desirable at 160-180/90-100mmHg.Blood pressure reduction should not be drastic.Proposed substances: Labetolol 10-20 mg boluses at 10 minute intervals up to 150-300 mg or 1 mg/ml infusion, 1-3 mg/min or Captopril 6.25-12.25 mg orally.
Blood Glucose Treat hyperglycaemia (Random blood glucose>11mmol/l) with insulin.Treat hypoglycaemia (Random blood glucose<3mmol/l) with glucose infusion.
Nutrition Perform a water swallow test.Insert a nasogastric tube if the patient fails the swallow test.PEG is superior to nasogastric feeding only if prolonged enteral feeding is required.
Infection Search for infection if fever appears and treat with appropriate antibiotics early.
Fever Use anti-pyretics to control elevated temperatures.
Raised Intracranial Pressure
Hyperventilate to lower intracranial pressure.Mannitoll (0.25 to 0.5 g/kg) intravenously administered over 20 minutes lowers intracranial pressure and can be given every 6 hours.If hydrocephalus is present, drainage of cerebrospinal fluid via an intraventicular catheter can rapidly lower intracranial pressure.Hemicraniectomy and temporal lobe resection have been used to control intracranial pressure and prevent herniation among those patients with very large infarctions of cerebral hemisphere.Ventriculostomy and suboccipital craniectomy is effective in relieving hydrocephalus and brain stem compression caused large cerebellar infarctions.
Acute Stroke therapy
Treatment Recommendations
rt-Pa In selected patients presenting within 3 hours: IV rt-Pa (0.9mg/kg, maximum 90mg ) with 10% given as a bolus followed by an infusion over one hour.
Aspirin Start aspirin within 48 hours of stroke onset.Use of aspirin within 24 hours of rt-Pa is not recommended
Anticoagulants The use of heparins (unfractionated heparin, low molecular weight heparin or heparinoids) is not routinely recommended as it does not reduce the mortality in patients with acute ischaemic stroke.
Neuroprotective Agents
A large number of clinical trials testing a variety of neuroprotective agents have been completed. These trials have thus far produced negative results.To date, no agent with neuroprotective effects can be recommended for the treatment of patient with acute ischaemic stroke at this time.
Anti Coagulation following Acute Cardioembolic Stroke
Treatment Recommendations
Aspirin All patients should be commenced on aspirin within 48 hours of ischaemic stroke
Warfarin Adjusted-dose warfarin may be commenced within 2-4 days after the patient is both neurologically and medically stable.
Heparin (unfractionated)
Adjusted-dose unfractionated heparin may be sterted concurrently for patients at very high risk of embolism.
Anticoagulation Anticoagulation may be delayed for 1-2 weeks if there has been substantial haemorrhage.Urgent routine anticoagulation with the goal of improving neurological outcomes or preventing early recurrent stroke is not recommended.Urgent anticoagulation is not recommended for treatment of patients with moderate-to-large cerebral infarcts because of a high risk of intracranial bleeding complications
Secondary Prevention
FactorsTreatment
Recommendations
Antiplatelets Single agent
Aspirin
Alternatives:Clopidogrel Ticlopidine
Double therapyAspirin+clopidogrel
The recommended dose of aspirin is 75mg to 325mg daily.
The recommended dose is 75mg daily.The recommended dose is 250mg twice a day.
In selected high risk patients only when benefit outweighs risk
Anti-hypertensive treatment
ACE-inhibitor based therapy should be used to reduce recurrent stroke in normotensive and hypertensive patients.ARB-based therapy may benefit selected high risk populations.
Lipid lowering Lipid reduction should be considered in all subjects with previous ischaemic strokes.
Diabetic control All diabetic patients with previous stroke should improve glycaemic control.
Cigarette smoking
All smokers should stop smoking.
Stroke in special circumstances
Treatment Recommendations
Aspirin Young Ischaemic stroke If the cause is not identified, aspirin is usually given.There are currently no guidelines on the appropriate duration of treatment.
Heparin
Warfarin
Endovascular thrombolysis
Cerebral Venous thrombosis Anticoagulation appears to be safe, and cerebral haemoffhage is not a contra-indication for anticoagulation.
Simultaneous oral warfarin should be commenced.The appropriate length of treatment is unknown.
It is currently considered for patients with extensive disease and clinical deterioration
SURGICAL TREATMENT
• Surgical removal of hemorrhage with cerebellar decompression for patients with cerebellar hemorrhages, or with brainstem compression
• Standard Craniotomy for patients with supratentorial ICH,
PREVENTION AND MANAGEMENT OF COMPLICATIONS
• Management of complications improves both short-term and long-term prognosis.
• Complications of stroke can be divided into General medical and Neurological complications.
• They can also be divided into Acute(<7 days) or subacute(>7days) based on time of occurrence.
Key points
• Young stroke patients• Time is at premium• Early identification • Early institution of Rx• Good and very satisfying result• Drug available ,Neuro-imaging available • Previous cases encouraging result