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%