Stroke

Stroke (Cerebrovascular accident) 4.5 Ng Tsz Wing RysWong Pak Sing Benson IntroductionO2 deprivation after reduced blood supply to brain Necrosis of brain tissue FatalCan cause long-term disability (motor / speech/ cognition)PathophysiologyDue to interrupted blood supply to brain IschemicThrombosisEmoblihemorrhage

Risk factorsAtherosclerosis (prone to clot formation and / or rupture)Hypertension (damage arterial wall, promote atherosclerosis),Cardiac pathosis (MI, AF)SmokingDiabetes (AGE deposition makes vessel fragile & narrow), obesity, stressOld age TIA / previous strokeHigh dietary fat/ obesity/ Hypercholesterol levelPhysical inactivity

Type of stroke

Residual deficitUnilateral paralysisNumbnessSensory impairmentDysphasiaBlindnessDiplopiaDysarthria* Return of function is unpredictablesign

Transient ischemic attack (TIA) Temporary disturbance in blood supply to a localized area of brainNumbness of face/leg/arm on one side of bodyWeakness, tingling, weakness and speech disturbances last less than 10 mins warning signReversible ischemic neurologic deficit (RIND)Similar to TIA but does not clear within 24 hrsStroke-in-evolutionDeficit has been present for several hours and continue to worsenHemiplegia, temporary loss of speech, dimness of vision, unexplained dizzinessThe completed strokeMedical T(x)Stop dental T(x) immediate medical referral hospitalization to lyse any clot [esp. if ischemic] Drug early thrombolytic drug (tPA, tissue plasminogen activator) then antiplatelet / anticoagulant Surgery (thrombo-endarterectomy) remove hematoma / obstruction in vessels [if hemorrhage]

Dental T(x)Check medical history and identify the severity For TIA or stroke (within 6 months) defer dental T(x), consult physicians

Anxiety and stress control Short morning appointment and adequate pain control Oral sedative like benzodiazepine (1 hour pre-op) if necessaryOR inhalational sedation like nitrous oxide (~ 30%) and oxygen

Limit the use of LA (with Adr)Usually 2 cartridges is safe to use (no significant change in BP) Avoid use of retraction cord which soaked in adrenaline solution (Adr can diffuse via gingival sulcus)

Drug concern (bleeding control) Drug concern (bleeding control)For antiplatelets (aspirin) discontinuation of drug is unnecessaryFor anticoagulants (warfarin) consult physician first and monitor INR < 3Warfarin is good to prevent thrombus / emboli, thus to avoid strokeBut warfarin causes higher bleeding tendency must consult physician and alter drug therapy Adjunct with local homeostatic measures sponge with topical thrombin in socket, sutureSupportive dental care Aim at preventive and simplified treatment, with anxiety and stress controlAid in OHI electric toothbrush, learn to clean with one hand (e.g. patients with one side paralysis)Preventive treatment (topical fluoride and CHX), and use fixed instead of removable prosthesis