CEREBROVASCULAR ACCIDENT

By:

Brigitte Tabaranza MD

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

CEREBROVASCULAR ACCIDENT

SYMPTOMS

• Symptoms of a stroke depend on the area of the brain affected.

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

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CLASSIFICATION OF STROKE

Stroke

Primary Hemorrhagic (20% of Strokes)

Primary Ischemic (80% of Strokes)

Thrombotic

50%

Embolic

30%

Intracerebral Hemorrhage 15%

Subarachnoid Hemorrhage 5%

Types of Stroke

85% Ischemic

15 % hemorrhagic

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.

Immediate Diagnostic Studies: Evaluation of aPatient With Suspected Acute Ischemic Stroke

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.

Stroke Scales• Glasgow Coma Scale

Stroke ScalesNational Institutes of Health (NIH) Stroke Scale

Stroke ScalesAphasia and Dysarthria Test

Stroke ScalesModified Rankin Scale

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.

PREVENTION

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

TIME is BRAINRemember:

Thank you!!!