Stroke

Definition

Ø  Stroke (WHO definition)

§  Rapidly developing clinical signs of focal/global cerebral dysfunction

§  Lasting >24hours or leading to death

§  With no apparent cause other than of vascular origin

ü  ischaemia (85%) /haemorrhage (15%)

Ø  Transient ischaemic attack (TIA)

§  Sudden onset of transient focal neurological deficit

§  lasting < 24h (however, usually lasting < 24 hours)

Classification

1.       Pathogenesis

a.       Ischaemia (thrombosis, embolism, hypoperfusion)

b.      Hemorrhage (ICH, SAH)

2.      Arterial vs Venous vs Watershed

(Boundary zone infarcts)

3.      Arterial Territory

a.       Anterior Circulation (ACA, MCA)

b.      Posterior Circulation (VBA, PCA)

(source: http://rad.usuhs.mil/rad/stroke/)

ACA – Gold

MCA – Pink

PCA – blue

4. Age of onset

a.       Children

b.      Young adult

c.       Older adult

Classification of ischaemic stroke by TOAST classification (Trial of Org 10172 in Acute Stroke Treatment)

Atherosclerosis – thrombosis or embolism	Lacunar - Occlusion of small blood vessel	Cardiogenic embolism	Other determined causes	Cryptogenic
20%	25%	20%	5%	30%
§  Large artery, >50% occlusion §  Size of infarct >1.5cm	§  a/w diabetes and hypertension §  infarct < 1.5cm	§  AF §  valve disease §  Ventricular thrombi §  cardiomyopathy	§  Arteritis §  Thrombophilia §  Arterial dissection §  drugs

Haemorrhagic classification

1.       Intracerebral

a.       RF - hpt, bleeding into tumor

2.       Subarachnoid – crescentric

a.       RF – berry aneurysm, AV malform, coagulopathy, drugs

DDx of stroke

1.       Post-ictal Todd’s paralysis

2.       Subdural haematoma

3.       Brain abscess

4.       Brain tumor

5.       Hypoglycaemia

RF for stroke

Ø  Non-Modifiable

1.       Age

2.       Gender

3.       Race

4.       Hereditary

Ø  Modifiable

1.       DM

2.       Dyslipidaemia

3.       HTN

4.       Smoking

5.       Alcohol

6.       Obesity

Additional risks in young patient with stroke

1.       Cardioembolic

a.       Atrial fibrillation

b.      Prostatic valve

c.       Patent foramen ovale

2.       Carotid/vertebral dissection

3.       Anti-phospholipid syndrome, thrombophilia

4.       Drugs – OCP, MAO inhibitor, mainliner

5.       Vasculitis

Warning signs of stroke

1.       Sudden onset of numbness / weakness of face, leg, arm

2.       Difficult to speak

3.       Visual field loss

4.       Loss of balance

How to diagnose?

·         History – sudden focal neurological sign + RF

·         Neurological evidence of infarction / haemorrhage

Neurologic Diagnostic Formulation

1. Summarise deficit

2. Localise lesion

3. Postulate pathogenesis /aetiology.

Where is the lesion?

Anterior circulation	Posterior circulation
ACA/MCA territory	Brainstem/cerebellar
Transient monocular blindness Hemisensory loss Hemiparesis/hemiplegia Speech disorder Spatial neglect (sensory inattention, visual field defect)	Diplopia Vertigo Dysphagia Dysarthria Ataxia Cross paralysis Altered consciousness

Localisation of lesion and CF

L gaze preference with R hemiparesis	L cortical infarct
R gaze preferecene with R hemiparesis	L pons lesion
Weakness : R arm > R leg Aphasia Hemisensory loss L gaze preference Homonymous hemianopia	L MCA territory
Weakness: R leg > R arm	L ACA territory
Acalculia Agraphia Left right disorientation Finger agnosia	Gerstmann’s syndrome Dominant Parietal lobe lesion
R hemiplegia + R facial nerve palsy	L internal capsule, basal ganglia (lacunar stroke, intracerebral haemorrhage)
R hemiplegia + L facial nerve palsy	L pontine lesion

NB:-

1.       Corticospinal tract decussates at lower medulla

2.       Corticobulbar tract decussates at midbrain

3.       Gaze preference towards lesion in cortical infarct

Oxfordshire Community Stroke Project Classification (OCSP)

Routine I(x) 

1.       FBC                                                       Anaemia, thrombocytosis, thrombocytopenia

2.       RFT                                                       Hydration status, electrolyte imbalance

3.       PT/APTT                                             Baseline (if thrombolysis indicated)

4.       FBS                                                       Hypo/hyperglycaemia

5.       Lipid profile                                       Athrosclerosis

6.       ECG                                                      A. fib, IHD

7.       CXR                                                      Baseline, enlarged in HTN patient

8.       CT                                                         Ischaemia vs. haemorrhage, site of lesion, extent of lesion

9.       MRI                                                      DWI (diffusion weighted), T2W

I(x) in young stroke

1.       Echo                                                     Cardioembolism, assess cardiac function

2.       ANA, Anti-dsDNA                           Auto-immune

3.       Thrombophilia screen, APS       

4.       Droppler US                                      KIV if anterior circulation involvement

5.       CTA/MRA                                          If planned for thrombolysis

Acute management

Quick history and exam

Call for help

Urgent CT scan

Monitoring esp ECG

IV line

Baseline I(x) – FBC, U&E, LFT, coag profile, RBS, lipid profile

Ø  Ischaemic stroke

1.       Thrombolysis if <3h – if no contra-indication – start on alteplase

a.       Rule out CI

b.      Suitability for thrombolysis

                                                                           i.      NIHSS – National Institute of Health Stroke Scale

                                                                                     Start if score between 6-21/42

                                                                        iii.      BP<185/110

                                                                       iv.      No contraindication for thrombolytic

                                                                         v.      Normal/ischaemic CT scan

2.       T. aspirin 300mg if CI or

3.       T. statin

Ø  Haemorrhagic stroke

Monitor

Refer to neurosurgeon

Stroke rehab unit 

Long term – multi disciplinary

– OT, physiotherapy, speech therapy, dietician, physician

Life style changes

Tackle morbidity – DM, Hpt, dyslipidaemia

High dose statin

Study shows ischaemic stroke improvement if on statin

ALGORITHM OF MANAGEMENT OF STROKE

Source:

CPG MOH, Management of Stroke, Jun 2006 MOH/P/PAK/113.06(GU)

What happen to a person after having stroke?

1.       Initial phase of cerebral shock (1^st 2 weeks)

a.       Immediately after cerebral infarct

b.      Muscle tone is flaccid (hypotonic)

2.       Recovery phase (2^nd -6^th week)

a.       Persistence of hypotonicity (flaccid stage)

                                                               i.      Motor loss is usually accompanied by severe sensory loss

                                                             ii.      Most disabling stage

b.      Evolution towards normal tone (recovery stage)

                                                               i.      Movements start in the limp, distil first

                                                             ii.      UL first

                                                            iii.      Slight disability usually remain

c.       Evolution towards hypertonicity (spastic stage)

                                                               i.      Most frequent occurrence

                                                             ii.      Initial recovery of proximal movement (hip & shoulder)

                                                            iii.      Earlier in lower limp, typical spasm for hypertonicityàspacticity

                                                           iv.      Spasticity > at anti-gravity muscle

                                                             v.      UL: flexor>extensor

                                                           vi.      LL: extensor>flexor

Complications of stroke

Acute	Chonic
Aspiration pneumonia DVT Bedsore UTI Septicaemia Depression Death	Seizure Physical disability Dependance Contracture, disuse atrophy Psychological