Dr Farzadfard. Stroke types Infarcts Artery Vein Hemorrhages ICH IVH SAH.
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Transcript of Dr Farzadfard. Stroke types Infarcts Artery Vein Hemorrhages ICH IVH SAH.
Dr Farzadfard
Stroke types
Infarcts Artery Vein
Hemorrhages ICH IVH SAH
Presentation
• Abrupt Onset• Fit the distribution of a single vascular territory• early decrease in level of consciousness, nausea
and vomiting, headache, and accelerated hypertension are more common with hemorrhages.
• Subarachnoid hemorrhages classically present as a bursting very severe headache (‘‘the worst headache of my life’’), and are often accompanied by stiff neck, decreased consciousness, nausea and vomiting
Signs and symptoms characteristic of the various arterial territories • Middle cerebral – contralateral loss of strength and
sensation in the face, arm, and to a lesser extent leg. Aphasia if domi nant hemisphere, neglect if non-dominant.
• Anterior cerebral – contralateral loss of strength and sensation in the leg and to a lesser extent arm.
• Posterior cerebral – contralateral visual field deficit. Possibly confusion and aphasia if dominant hemisphere.
• Penetrating (lacunar syndrome) – contralateral weakness or sensory loss (usually not both) in face, arm, and leg. No aphasia, neglect, or visual loss. Possibly ataxia, dysarthria.
• Vertebral (or posterior inferior cerebellar) – truncal ataxia, dysarthria, dysphagia, ipsilateral sensory loss on the face, and contralateral sensory loss below the neck.
• Basilar – various combinations of limb ataxia, dysarthria, dysphagia, facial and limb weakness and sensory loss (may be bilateral), pupillary asymmetry, disconjugate gaze, visual field loss, decreased responsiveness
DIAGNOSIS
• History• Exam• presence of comorbidities• Absence of seizures or other stroke
mimics• Imaging
Differential diagnosis
Seizures Migraine Syncope Hypoglycemia Metabolic encephalopathy Drug overdose Central nervous system tumor Herpes simplex encephalitis (HSE) Subdural hematoma
Peripheral compression neuropathy Bell’s palsy (peripheral seventh
nerve palsy) Benign paroxysmal positional vertigo
(BPPV) Conversion disorder
What to do first
O2 via nasal cannula Intubation may be necessary Consider putting the head of the bed
flat Consider normal saline bolus
All patients brain CT (brain MRI could be
considered at qualified centers) electrocardiogram blood glucose serum electrolytes renal function tests complete blood count, including
platelet count PT, INR,PTT
Selected patients hepatic function tests toxicology screen blood alcohol determination pregnancy test oxygen saturation or arterial blood gas tests
(if hypoxia is suspected) chest radiography (if lung disease or aortic
dissection are suspected) lumbar puncture (if subarachnoid hemorrhage
is suspected and CT is negative for blood) electroencephalogram (if seizures are
suspected)
Do not treat hypertension acutely unless:
(1) the patient was treated with TPA (2) the patient has acute hypertensive end
organ damage (congestive heart failure, myocardial infarction, hyperten sive encephalopathy, dissecting aortic aneurysm, etc.)
(3) systolic or diastolic pressures are above 220 or 120 mm Hg
Proven acute medical treatment for ischemic stroke tissue plasminogen activator (rt-PA)
Age 18 or older Clinical diagnosis of ischemic stroke causing a measurable
neurological deficit Onset of stroke symptoms well established to be less than 180
minutes (3 hours) before treatment would begin
aspirin with 48 hours of stroke onset Clopidogrel (Plavix) 375 mg, and then aspirin 81mg and
clopidogrel 75mg once daily for the first few days In patients who :
while already on antiplatelet therapy have a fluctuating neurological course have a heavy burden of atherosclerotic risk factors
or atherosclerotic lesions
Based on the NINDS rt-PA study, the requirements for administering rt-PA include a CT scan of the head, which is negative for
hemorrhage a serum glucose level between 50 and 400
mg/dL INR less than 1.7 platelet count more than 100,000 per cubic mL systolic blood pressure less than 185 mmHg
systolic no recent major procedures, traumas, or stroke
Later head CT (day 2) revealing hypodensity within the left MCA distribution
Acute anticoagulant therapy
patients with a cardioembolic condition at high risk for recurrence (thrombus on valves, or mural thrombus),
documented large-artery (ICA, MCA, or basilar artery ) occlusive clot at risk for distal embolism
arterial dissection venous thrombosis
Treat
HYPERGLYCEMIA HYPERTHERMIA
DVT prophylaxis
Heparin 5000 units SC every 12 hours
Enoxaparin (Lovenox, Clexane) 40 mg SC once daily
Dalteparin (Fragmin) 5000 units SC once daily
Sequential compression devices (non-drug)
Compression (TED) stockings
TIA brief episode of neurologic dysfunction
caused by focal brain or retinal ischemia The causes are the same as for ischemic
stroke the management is similar to that for
acute ischemic stroke Observe the patient for 24 hours Start daily antiplatelets EKG Cardiovascular risk-factor evaluation of
blood pressure, lipids, and fasting glucose
Intracerebral hemorrhage
Spontaneous bleeding into the brain parenchyma or ventricles from a ruptured artery, vein, or other vascular structure
Etiology
Hypertension (most common) Amyloid angiopathy Drugs Vascular malformation Cerebral vein thrombosis Tumor Trauma
Initial assesment of ICH
History and physical exam Glasgow coma scale (GCS) and brainstem
reflexes if comatose, NIHSS score if awake. Measure blood pressure Oxygen saturation Brain CT Check platelet count, INR, and PTT, and urine
drug screen EKG
HEMATOMA ENLARGEMENT blood pressure levels be maintained below a
mean arterial pressure of 130 mm Hg WARFARIN (COUMADIN)-RELATED
INTRACEREBRAL HEMORRHAGE Goal: normal INR using fresh frozen plasma (FFP) 20 mL/kg and
vitamin K Activated factor VII
HEPARIN-RELATED INTRACEREBRAL HEMORRHAGE Stop heparin CT brain immediately INR, PTT, platelets, CBC, fibrinogen, thrombin time, D-dimers Type and cross Give protamine: 25mg initial dose; check stat PTT 10 minutes later
and if increased give 10mg additionally; repeat until PTT normal
Subarachnoid hemorrhage
The worst headache of my life ‘‘Thunder-clap headache Headache is sometimes associated
with focal neurologic symptoms
DIAGNOSIS OF SUBARACHNOID HEMORRHAGE
CT of the head without contrast If head CT is normal, but you have a high clinical
suspicion for SAH, you must do a lumbar puncture, because CT can miss small or subtle SAHs, especially if more than 72 hours has passed since the ictus
DIAGNOSIS OF INTRACRANIAL ANEURYSMS Digital subtraction angiography
(DSA) CT angiography MRA
CAUSES OF SAH OTHER THAN INTRACRANIAL ANEURYSM Perimesencephalic SAH Arteriovenous malformation (AVM) Arterial dissection (vertebral artery
usually) Arteriovenous fistula Pituitary apoplexy Cocaine Trauma Vasculitis
GOALS
Prevention of rebleeding Blood pressure control may be important before
definitive treatment to reduce rebleeding Bed rest in ICU with monitoring
Treatment of the aneurysm itself: clip or coil
Prevention and treatment of complications: hydrocephalus, seizure, vasospasm, hyponatremia, infections, and DVTs.