Cerebrovascular Accident(STROKE)
Definition
• Stroke is a clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal, and at times global, loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin – WHO
• TIA (Transient Ischaemic Attack) recovery is complete within 24 hours.
Statistic
• 3rd most common cause of death in Malaysia NASAM 2013
• Incidence of Stroke in Malaysia increasing trend but inhospital mortality rate is in declining trend. Information and Documentation
Unit, Ministry Of health 1998
• The incidence of stroke has been reported to be more in men compared to women (Hu et al, 1992; al-Rajeh et al, 1993; Lopez et al, 1995; Korv et al, 1996; Rozenthul-Sorokin et al, 1996)
FACTZ
• Every two seconds, someone in the world suffers a stroke.
• Every six seconds, someone dies of a stroke.
• Every six seconds, someone’s quality of life will forever be changed – he will be physically disabled permanently due to a stroke.
REF : http://thestar.com.my/health/story.asp?file=/2011/10/30/health/9788575&sec=health
Recognize the Symptoms of a Stroke
• 3 Simple Questions
☺Ask the person to smile
☺Ask the person to raise both arms
☺Ask the person to say a simple sentence “The sky is blue in Johor”
The sky is blue in Johor
Stroke Symptoms
Sudden numbness or weakness of face, arm or
leg, especially on one side of the body
Sudden confusion, trouble speaking or
understanding
Sudden trouble seeing in one or
both eyes
Sudden trouble walking, dizziness, loss of balance or
coordination
Sudden severe headache with
no known cause
Risk FactorsNon-modifiable Modifiable
Age (uncommon below 40) High blood pressure (systolic & diastolic)
Sex M>F Cigarettes smoking
Ethnic/race Diabetes melitus
Family history of stroke Atrial fibrillation
Coronary heart disease
Hyperlipidemia
Obesity & physical inactivity
High dietary salt intake
Heavy alcohol consumption
Previous stroke
High homocystein level
Pathogenesis of StrokeAtherosclerosis,thrombosis,embolism,
arterial spasm,hypotension,Vasculitis cerebral venous infarction
infarction
Destruction of brain substance
Mark oedema of surrounding brain
Oedema of surrouding brain tissue
HPT, aneurysm, bleeding diathesis, arteriovenous malformation
neoplasm
Space occupying lessions
Expending mass from arterial haemorrhage
Destruction of brain substance
Increase intracranial pressureLocalizing sign
(due to destruction of brain tissue/Substance and oedema)
Loss of sensation
Slurred speech
Numbness and weakness ofLeft upper limb
Upper motor lession
Left upper limb-hypertonia-hyperreflexia
Types Of Stroke
ISCHAEMIC
HEMORRHAGIC
Occlusion in brain blood flow
♣ Thrombotic stroke: clot forms in an area of atherosclerosis. Plaques that completely clog or markedly narrow an artery also can cause ischemic stroke.
♣ Embolic stroke: clot, or piece of plaque formed in one of the arteries leading to the brain or in the heart, is brought by bloodstream to lodge in narrower brain arteries.
Ischemic Stroke
Causes of ischemic strokeThree main causes of ischemic stroke are:
1. Atherothromboembolism (50%)i. Large vessel occlusion or stenosis (e.g.: carotid artery)ii. Branch vessel occlusion or stenosis (e.g.: MCA)iii. Perforating vessel occlusion (lacunar infarction)
2. Intracranial small vessel disease (penetrating artery disease) (25%)
iv. Collagen disease e.g.: RA, SLEv. Vasculitis e.g.: PAN, temporal arteritisvi. Granulomatous vasculitis e.g.: Wegener’s
granulomatosisvii. Miscellaneous: syphilitic vasculitis, fibromuscular
dysplasia, sarcoidosis, trauma
3. Cardiogenic embolism (20%) – Valvular heart disease, arrhythmias, Ischemic heart disease, bacterial & non bacterial endocarditis, prosthetic valve, patent foramen ovale, cardiomyopathy
Other causes..
Disease of Blood• E.g.: Coagulopathies, Haemoglobinopathies
Venous Thrombosis• Venous Thrombosis may occur with infection
and dehydration or in a/w arterial occlusion when related to estrogen excess (pregnancy, oral contraceptives)
Decrease cerebral perfusion• Infarction between arterial territories may
result from impaired perfusion e.g.: cardiac dysrhythmia, GI blood loss
Artery occluded
Areas Infarcted Clinical Effect
Anterior Cerebral Artery
Frontal lobe Confusion, disorientated
Motor and sensory cortex (leg area)
C/lateral weakness, max in leg, cortical type sensory loss, max in leg
Middle cerebral artery
Lateral surface C/lateral hemiparesis, face>leg; c/lateral cortical type sensory loss
Speech area (dominant)
Expressive aphasia
Optic Radiation Hemianopia
Posterior cerebral artery
Occipital lobe Cortical type-visual loss
Vertebrobasilar arteries
Cerebellum Intention tremor, incoordination, hypotonia
Brain stem C/lateral hemiparesis and sensory loss; ipsilateral CN palsies
HEMORRHAGIC STROKE
• Hemorrhagic stroke occurs when a vessel in the brain suddenly ruptures and blood begins to leak directly into brain tissue and/or into the clear cerebrospinal fluid that surrounds the brain and fills its ventricles.
• Hemorrhagic strokes are less
common than ischemic strokes but cause a significant number of deaths worldwide.
• Approx. 70-80% of all strokes are ischemic,
20-30% are hemorrhagic (10-20%-intracerebral hemorrhage 5-10% -subarachnoid hemorrhage)
Kase et al., 2004
Haemorrhagic stroke
Haemorrhagic stroke • The fatality rate for hemorrhagic
strokes is higher than for ischemic strokes and the overall prognosis is poorer
• It is the location of the hemorrhage, rather than the amount of bleeding, that tends to be the bigger factor in influencing the severity of the stroke.
• For example, bleeds in the brainstem, though relatively tiny, can be quite lethal, whereas the same-sized bleed in the frontal lobe may not even be noticeable
A = Penetrating cortical branchesACA, MCA or PCAB = Basal gangliaC = ThalamusD = PonsE = Cerebellum
Most Common Locations Of ICB
By, Saravanan (MD USM)
Siriraj Stroke Score(to differentiate between cerebral haemorrhage and cerebral ischaemia)
1. Consciousness pointi. Alert 0ii. Drowsy and stupor 1iii. Semicoma and coma 2
2. Vomiting/ headache within 2 hrsi. No 0ii. Yes 1
3. Atheroma(diabetic history, angina,claudication)
i. None 0ii. ≥1 1
Formula:(2.5 x consciousness) + ( 2 x vomiting) + ( 2 x headache) + ( 0.1 x DBP)
– ( 3 x atheroma) – 12
Diagnosis>1 cerebral haemorrage90. 0%
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