Stroke

1st common cause of death-IHD

2nd-Cancer

3rd-Stroke(CI/Ischemic stroke is commonest due to thromboembolic disease secondary to atherosclerosis in the major extracranial arteries (carotid artery and aortic arch)

Cerebrovascular accidents

               Cerebral hemorrhage

               Cerebral thrombosis

               Cerebral embolism

               Sub arachnoid hemorrhage

               Hypertensive encephalopathy

               Cerebellar hemorrhage

               Cerebral infarction

Stroke

       Acute cerebral dysfunction due to vascular cause presented with haemorrhage ,thromboembolism

       Stroke describes those events in which symptoms last more than 24 hours

*Remember the followings-

*Haemorrhage-Intracerebral , Subarachnoid

*Intracerebral haemorrhage-With/without communication ,within ventricle

*SAH-Neck rigidity ,kernig  sign ,fundoscopy(sub hyaloid hge/boot shaped concavity)

*Thrombosis-Slow onset ,no history of  vomiting ,convulsion ,unconsciousness

*Embolism-Stormy onset within seconds to minutes

*Source of thromboembolism-Great artery of neck ,left atrium ,thrombus in situ

*Examine heart-For arrhythmia

*Examine neck-For carotid bruit(Thrombus source)

Cerebral ischemia is caused by a reduction in blood flow that lasts longer than several seconds. 

Neurologic symptoms are manifest within seconds because neurons lack glycogen, so energy failure

is rapid

More than a few minutes of infarction or death of brain tissue results

Risk factor

               Systemichypertension

               Smoking

               Hyperlipidemia

               Diabetes

               Arterial aneurysm

               Increased salt intake(Salty biscuits ,sea foods)

Types

TIA(Transient ischemic attack)>Stroke>Stroke in evolution>Completed stroke

 

            TIA-Focal neurologic sign that resolve  within 24 hrs completely ,

                    Regardless of whether there is imaging evidence of new permanent brain injury;

                    Mechanism-Small embolism

                    e.g.50 yrs ,morning body weakness at one side>Next day no S/S

      Completed stroke-Focal neurologic sign that persist >24 hrs

                                      One time attack ,not gradually progress

            Stroke in evolution-

• Gradually progressive
• e.g.Right hand paralysis>Mouth paralysis>Then leg>Whole body of one side>More and more parts are being involved progressively

            Subarachnoid hemorrhage

Clinical fetaures

Mode of presentation-

• Unconsciousness/coma
• Weakness of 1/more limb(Never paraplegia)-Monoplegia ,monoparesis ,hemiplegia ,hemiparesis ,only aphasia
• Sudden severe headache  with disturbed consciousness with/without convulsion/vomiting(Subarachnoid hemorrhage and neck rigidity)
• Visual deficit-

                            Amaurosis fugas(Mononuclear blindness)-Transient ischemic attack

                            Occipital lobe-Contralateral hemianopia

• Speech deficit-Dysarthria ,dysphasia

• Young stroke(Thrombus from heart; Mitral stenosis with atrial fibrillation)

Mode of presentation according to site of lesion

• Cortical-Monoplegia ,contralateral hemiplegia ,jacksonian convulsion
• Subcortical-Monoplegia ,contralateral hemiplegia ,tactile discrimination and speech disturbance
• Internal capsule-Contralateral hemiplegia ,global aphasia
• Brainstem-Vertigo ,nausea ,vomiting ,pinpoint pupil ,hyperpyrexia ,coma

CNS examination

• Higher psychic function
• Slurred speech
• Cranial .nerves-Upper motor neuron lesion
• Muscle bulk-Normal
• Tone-Increased usually(1hour within stroke-decreased ,but after recover increases)
• Power-Decreased(0-5)
• Plantar response-Extensor on affected side
• Flexor on unaffected side(If conscious)
• Bilateral extensor if deep unconscious
• All jerk increases on affected side and normal on unaffected side
• Co-ordination test
• Muscle fasciculation-Absent
• Convulsion-May be present
• Hemiplegic gait if can walk
• Sensory-Intact

CVS-Evidence of Mitral stenosis/cardiomyopathy

Abdpmen-Full bladder

Investigation

• CT scan  ,MRI of brain-Tissue surrounding the core region of infarction is ischemic but reversibly dysfunctional and is referred to as the ischemic penumbra . The penumbra may be imaged by using perfusion-diffusion imaging with it
• CBC-Routine(Exclude polycythemia)
• Urine for RME(Exclude renal cause)
• Blood Sugar-(Exclude diabetes)
• CXR-(Exclude cardiomegaly)
• ECG-(Exclude ischemic heart disease)
• Serum creatinine
• Serum electrolyte(SIADH/not)

In stroke  hyponatremia occurs ,so give normal saline ,and never give glucose

Recurrent hemiplegia

• Cerebrovascular disease
• Other-Hemiplegic migraine ,hysteric hemiplegia ,todd palsy(Epilepsy)

Causes of young stroke

• Mitral stenosis withatrial fibrillation
• TOF
• Antiphospholipid syndrome
• SLE
• Polycythemia rubra vera
• Dissecting aneurysm
• Sudden onset neurologic s/s that mimic stroke
• Seizures-(Tonic/clonic/tongue bit)
• Intracranial tumor-(Hydrocephalus)
• Migraine-(Acephalgic migraine occurs without headache ,history of migraine )
• Metabolic encephalopathy

Treatment of stroke

• Supportive-Nutrition ,fluid ,catheter
• 1st 48 hours-No antihypertensive  drugs 
•  If mean pressure  is more than 130mmHg , give antihypertensive drugs within 48 hours(Esmolol/beta 1 blocker)
• If haemorrhage>Resolves by itself
• If cerebral edema-Increased intracranial pressure(Irregular response/pupil) ; give mannitol by checking renal function
• If emboli>Aspirin/clopidogrel/combined
• If emboli in heart>Heparin followed by warfarin
• If Subarachnoid hemorrhage>Nimodipin
• Physiotherapy/speech therapy
• Post stroke contracture-Physiotherapy
• Depression/anxiety-Rehabilitation