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Dr Aaron de Souza MD, DM, DNB, MNAMS
Consultant Neurologist, Manipal Goa Hospital
STROKE: AN OVERVIEW
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Stroke: Brain Attack
Sudden loss of function
of a part of the brain
Due to a problem with
blood supply
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Types of Stroke Loss of blood supply to a part of the
brain: Ischaemic (85%)
Bleeding within brain matter: Haemorrhagic (15%)
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Types of Stroke
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Not a Single Disease: Stroke Subtypes and Incidence
Albers G et al. Chest. 2001; 119 (suppl): 300S.
Ischaemic stroke85%
Hemorrhagic stroke15%
Other5%
Unknown cause30%
Cardiac disease20%
Small vesseldisease
“lacunes”25%
Atheroscleroticcerebrovascular
disease20%
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Thrombosis
Embolism
Haemorrhage
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Atherosclerosis and stroke
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Cardiac Embolism
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Arterial Embolism
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Aneurysms and cerebral haemorrhage
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Why is Stroke Important?
Third leading cause of death
Heart disease
Cancer
Stroke
700, 000 strokes per year in USA;
450, 000 in Europe
Almost 8% of ischaemic and 40% of
haemorrhagic strokes die in 30 days
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Indian Scenario
Incidence: 150 per lakh
(150 persons out of every lakh,
or 3 in each 2 000)
Most common neurologic disease after
migraine and epilepsy
Of stroke patients still alive at 6months,
over 30% are dependent on others for even
basic functions
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A Deadly Disease,Becoming More Frequent
Increased incidence of stroke
As the population grows older due to
longer life expectancy,
Lifestyle changes in India
High incidence of diabetes
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Blood supply to the brain
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Risk Factors for Stroke
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Cigarettes: potent risk factor
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Myocardial Infarction
(Heart Attack)
Per
cent
of s
trok
e pa
tient
sw
ith s
ubse
quen
t eve
nts
Stroke Begets Stroke
Albers G. Neurology. 2000; 14(5):1022-8.
CATS0
2
4
6
8
10
12
14
16
TASS CAPRIE* ESPS 2
Stroke
14%
3%
13%
7%
10%
2%
13%
3%
Stroke patients are most at risk of another stroke
Trials
Previous stroke is the single most important risk factor
for stroke
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Facial Weakness
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Brainstem Strokes Motor & sensory deficits
Change in voice
Swallowing problems
Eye deviation, eye paralysis
Loss of consciousness
Gait change (“drunken” gait)
Vertigo / dizziness
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Investigations / Lab Tests CT scan head ECG, Echocardiogram Hemogram Blood Glucose, Lipid profile Carotid doppler. MRI Diffusion Weighted MRI (DWI), Perfusion-CT and MRI(PWI)
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Uses of CT
Usual first investigation
Plain & Contrast
Exclude intracranial haemorrhage
Exclusion of extensive ischemic
infarctions.
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CT scan in stroke
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CT scan in intracerebral haemorrhage
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MRI in stroke
T2 weighted / Diffusion
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CT vs MRI / MRA
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Doppler Studies
Special ultrasound
examination for arteries in the neck
Detects clot or narrowing
Helps plan treatment to prevent
recurrent stroke.
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Treatment
Primary Prevention
Persons who have never had a stroke
Secondary Prevention
Persons with stroke, to prevent another
Treatment of acute stroke
Treatment of chronic stroke
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Primary Prevention
Modify stroke risk factors (BP,
diabetes, cholesterol)
Stop smoking
Exercise
Tablets for BP or cholesterol
Anticoagulation for heart disease
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Secondary Prevention
Aspirin
Other meds (clopidogrel)
Carotid artery surgery if block found
Treat heart disease if present
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Treatment of acute stroke
Within 3 hours of onset: IV Alteplase/tPA
Many conditions to be fulfiled before use
Treat brain swelling
Treat complications of unconsciousness /
immobility
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Intravenous Thrombolysis
Uses tPA/alteplase
Reduces risk of long-term deficits due to
stroke, speeds up recovery
Risky: can cause severe bleeding
Strict conditions for use
Patient must reach hospital <3hours
after onset
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“Brain Attack”
As much of an emergency as heart
attack
A few minutes can make lots of
difference to outcome
Get the patient to hospital FAST
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Treatment of Chronic Deficits Neurological rehabilitation
Physiotherapy
Medicines to relieve stiffness
Surgery for limb deformities
Botox injections
Newer machines developed for faster
recovery
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Social Rehabilitation
Prolonged recovery after stroke
Many patients with severe deficits in
the community
Need vocational training
Family needs counselling
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TIA
Transient: short lived (<1 day)
Ischaemic: lack of blood flow
Attack: weakness, numbness, speech,
blindness
Warning sign of future stroke risk
Should NEVER be ignored
Treatment with aspirin
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Stroke Services at Manipal Hospital
Department of Neurology
Backed up by 24hr CT, MRI services
Intravenous thrombolysis
Facilities for rehabilitation
Research into strokes in Goa.
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Take Home Points
Stroke is a common disease
Warning signs of stroke should always be treated
Lifestyle modifications and control of risk factors
Acute stroke: IMMEDIATE transfer to hospital
Chronic stroke: needs long term rehabilitation
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