CEREBROVASCULAR ACCIDENT

MANAGEMENT AND PROGNOSIS

A.RASAGNA

MAJOR SUBTYPES OF STROKE

ISCHEMIC STROKE

MANAGEMENT

INVESTIGATIONS

IMAGING STUDIES:A CT scan of the head (without contrast) should be performed immediately, before the administration of aspirin or other antithrombotic agents, to exclude cerebral hemorrhage.CT is relatively insensitive to acute ischemic stroke, and subsequent MRI with diffusion-weighted sequences helps define the distribution and extent of infarction as well as to exclude tumor or other differential considerations.

Imaging of cervical vasculature, by CT angiography, MR angiography, or conventional catheter angiography, is indicated as part of a search to identify the source of the stroke.

CT SCAN

MRI SCAN

LABORATORY AND OTHER STUDIES:Complete blood count, ESR, blood glucose determination Antiphospholipid antibodiesAbnormalities of protein C, protein S, or antithrombin, or a prothrombin gene mutation - hypercoaguable disorderElevated serum cholesterol and lipids and serum homocysteine – thrombotic stroke

ECG or continuous cardiac monitoring- recent MI

Blood cultures- if endocarditis suspected CSF examination if infectious cause suspected

but should be delayed until after CT or MRI to exclude any risk for herniation

TREATMENT

• Management is aimed at minimizing the volume of brain that is irreversibly damaged, preventing complications, reducing the patient’s disability and handicap through rehabilitation and reducing the risk of recurrent stroke or other vascular events.

• Thrombolysis: i.v. thrombolytic therapy with recombinant tissue plasminogen activator (rtPA; 0.9 mg/kg to a maximum of 90 mg, with 10% given as a bolus over 1 minute and the remainder over 1 hour) is effective in reducing the neurologic deficit in selected patients without CT evidence of intracranial hemorrhage.

• Aspirin: in the absence of contraindication, aspirin (300 mg daily) should be started immediately after an ischemic stroke unless rtPA has been given, in which case it should be withheld for at least 24 hours

• Heparin: reduces the risk of early ischemic recurrence and venous thromboembolism but first intracranial haemorrhage must be excluded on brain imaging before considering anticoagulation

• Carotid endareterctomy: patients with carotid territory ischemic stroke will have a greater than 50% stenosis of the carotid artery on the side of brain lesion

• Removal of the stenosis has been shown to reduce the overall risk of recurrence

• Physical therapy• Early mobilization and active rehabilitation

PROGNOSIS

• The prognosis for survival after cerebral infarction is better than after cerebral or subarachnoid hemorrhage

• Only proved effective therapy- initiation of treatment within 3-4.5 hours after stroke onset

• Depends on time that elapses before arrival• rtPA- 30% more likely to have minimal or no

disability at 3 months• LOC after infarct- poorer prognosis• Extent of infarct governs the potential for rehab

HEMORRHAGIC STROKE

INTRACEREBRAL HEMORRHAGE

INVESTIGATIONS:

IMAGING:•CT scanning (without contrast)- to confirm hemorrhage and determining the size and site of the hematomas•It is superior to MRI for detecting intracranial hemorrhage of < 48 hours duration•CT angiography, MR angiography or cerebral angiography- aneurysm or AVM

LABORATORY AND OTHER STUDIES:•Complete blood count, platelet count, bleeding time, prothrombin, partial thromboplastin times •Liver and kidney function tests- predisposing cause•Lumbar puncture contraindicated- may precipitate herniation

TREATMENT

Conservative and supportive•Ventilatory support, blood pressure regulation, seizure prophylaxis, control of fever, osmotherapy, and nutritional supplementation•ICP monitoring•Ventricular drainage- intraventicular hemorrhage •Decompression- superficial hematoma in cerebral white matter exerting a mass effect and causing incipient herniation

• Cerebellar hemorrhage- prompt surgical evacuation of the hematoma because spontaneous unpredictable deterioration may lead to a fatal outcome and because operative treatment may lead to complete resolution of the clinical deficit

• Treatment of underlying lesions or bleeding disorderes

PROGNOSIS

SUBARACHNOID HEMORRHAGE

INVESTIGATIONS:

IMAGING:•CT scan (preferably with CT angiography) immediately to confirm hemorrhage and to search for clues regarding source•Preferable to MRI because it is faster and more sensitive in detecting hemorrhage in the first 24 hours

• Cerebral angiography- source of bleeding

• Bilateral carotid and vertebral angiography are necessary because aneurysms are multiple while AVMs may be supplied from several sources

LABORATORY AND OTHER STUDIES:• CSF is bloodstained • ECG evidence of arrhythmias or myocardial

ischemia has been well described • Peripheral leukocytosis and transient glycosuria

TREATMENT

• Nimodipine (30-60 mg iv for 5-14 days, followed by 360 mg orally for further 7 days) given to prevent delayed ischemia in acute phase

• Insertion of platinum coils into an aneurysm(via endovascular technique) or surgical clipping of the aneurysm neck reduces the risk of both early and late recurrence

• Coiling is associated with fewer complications and better outcomes than surgery, now the procedure of first choice

• Arteriovenous malformations can be managed either by surgical removal, by ligation of the blood vessels that feed or drain the lesion, or by injection of material to occlude the fistula or draining veins.

HEMORRHAGIC STROKE PROGNOSIS

• People who suffer ischemic strokes have a much better chance for survival than those who experience haemorrhagic strokes.

• Haemorrhagic stroke not only destroys brain cells but also poses other complications, including increased pressure on the brain or spasms in the blood vessels, both of which can be very dangerous.

• Studies suggest, however, that survivors of hemorrhagic stroke have a greater chance for recovering function than those who suffer ischemic stroke.

PRIMARY AND SECONDARY PREVENTION

OF STROKE

GENERAL PRINCIPLES

• Medical and surgical interventions, as well as lifestyle modifications, are available for preventing stroke.

• Identification and control of modifiable risk factors is the best strategy to reduce the burden of stroke, and the number of strokes could be reduced substantially by these means

ATHEROSCLEROTIC RISK FACTORS

• Older age, family history of thrombotic stroke, diabetes mellitus, hypertension, tobacco smoking, abnormal blood cholesterol

• hypertension should be controlled• Statins reduce the risk of stroke even in patients

without elevated LDL or low HDL• Tobacco smoking discouraged• Tight control of blood sugar

• ANTIPLATELET AGENTS: aspirin, clopidogrel and the combination of aspirin plus extended-release dipyridamole – commonly used

• ANTICOAGULATION THERAPY: with a VKA reduces the risk by 67%

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