In the name of god the most gracious the most merciful
Management of
stroke
Prof. kareem altameemi
Consultant physician and neurologist
College of medicine
Faculty of medicine
Kerbala universty
Stroke
Is the fifth leading cause of death in US( after heart
disease , cancer , chronic lung disease and injuries
and accident ) and the most common disabling
neurologic disorders. Approximately 800,000 new
strokes occur and approximately 130,000 new people
die from stroke in the US each year. The incidence of
stroke increase with age , approximately two thirds of
all stroke occur in those older than 65 years
Approach to diagnosis
Stroke is a symptom of 4 key features :
1. Sudden onset. Documented by history
2. Focal involvement of central nervous
system. Documented by history, neuro. exam,
and neuroimaging
3.Lack of rapid resolution
4. Vascular cause ..acute onset, age, risk
factors, anatomy, neuroimaging.
Acute onset
Stroke begin abruptly . Neurologic
deficits may be maximal at onset or may
progress over seconds to hours or
occasionally days.
Progressive stroke..?
Focal cerebral deficits .. that develope
slowly(over weeks or month) suggest a
cause other than stroke.
Focal involvement
Stroke produce focal symptoms and signs
that correlate with the area of brain
supplied by the affected blood vessels.
In ischemic stroke :produce more or less
sterotyped pattern of deficits
Hemorrhage: produce less predictable
patterns. Why?
Global cerebral ischemia. Is it stroke?
Subarachnoid hemorrhage.Is it stroke?
Anterior( carotid )circulation:
Supply cerebral cortex, subcortical white matter ,
basal ganglia & internal capsule.
Consist of anterior choroidal , anterior cerebral
&middle cerebral arteries
Posterior (vertebrobasillar) circulation :
Supply brainstem , cerebellum ,thalamus ,part of
occipital and temporal lobe .
Consist of paired vertebral arteries, basilar
artery : and their branches PICA , AICA ,superior
cerebellar& posterior cerebral arteries .TP,TG
Symptoms and signs of anterior
&posterior circulation ischemia
Symptom or sign Anterior posterior
Aphasia 20 % 0
Diplopia 0 7%
vertigo 0 48%
Drop attacks 0 16%
Hemi or 38% 12%
monopaesis
Visual field defect 14 % 22 %
Duration of deficits
TIA: Symptoms and signs resolved completely
usually within 1 hour + no evidence of infarction.
Stroke : persist focal neurological deficit , which may
be improving , stable , or worsening when the pt is
seen.
Stereotypic TIA: ONE SITE
Non stereotypic: Multiple sites or distant(cardiac
origin)
Vascular origin
The term stroke is used only when FND are
caused by vascular disease.
Ischemia 90%, hemorrhage 10%
Differentiation btw the two only feasible by ?
Among ischemic stroke:
1. Large artery occlusion 35%
2. Small artery occlusion 25%
3. Cardiac embolism 20%,
4. Cryptogenic 15%
5. Other processes 5%.
Clinical findings
History
Predisposing factors e.g TIA, HTN, DM
Onset & course …TIA, Stroke, progressive
stroke, thrombotic vs embolic
Associated symptoms .headache, seizures
Physical examination
General physical examination
Bd p, eye, neck, cardiac, temporal artery and
skin.
Neurological examination
Cognitive deficits
Visual fields abnormalities
Ocular palsy , nystagmus or internuclear
opthalmoplegia .
Hemiparesis
Cortical sensory deficits
Hemiataxia
RAPID ASSESSMENT OF SUSPECTED
STROKE
ROSIER SCALE
Unilateral facial weakness +1
Unilateral grip weakness +1
Unilateral arm weakness +1
Unilateral leg weakness +1
Speech loss +1
Visual field defect +1
Loss of consciousness -1
Seizure -1
Total(-2 to +6) ; score > zero indicate stroke is possible
cause
ROSIER SCALE Cont.
Exclusion of hypoglycemia bed side blood
glucose test
Language deficit comprehension , naming &
articulation .
Motor deficit pronator drift , clumsiness of fine
finger movement
Sensory and visual inattention
Investigation studies
Blood tests
Blood glucose
Complete blood counts
Coagulation studies
Inflammatory markers
Serologic assay for syphlis
Circulating troponin level
Electrocardiogram
Lumber puncture
Brain imaging
Non contras CT scan or MRI
diffusion weighted MRI perfusion weighted
MRI .
Vessel imaging
Doppler ultrasonography
Digital substraction x ray angiograpy
CT angiography and MRI Angiography.
Echocardiography
Differential diagnosis
Intracerebral hemorrhage
Subdural or epidural hematoma
SAH
SOL
SEZIURE
HYPOGLYCEMIA
Hyperosmollar Non Ketotic hyperglycemia .
Treatment
( pre stroke)
Primary prevention
TIA & Acute stroke treatment
Secondary prevention ( post
stroke )
Primary prevention
Lifestyle : exercise , diet , weight , quit smoking ,
moderation of alcohol & OSA.
Statin :
Recommended for pt with or without dyslipidemia .
Who are at high ( > 10 % ) 10 year risk for CVS events.
Blood pressure control: by life style modification or
antihypertensive drugs or both .for systolic >140 or
diastolic >90 .
Glycemic control.
Antiplatelets drugs: 81- 100 mg/d
Anticoagulantion
Asymptomatic carotid artery stenosis.
Anticoagulantion
1. Patient with valvular AF:
CHA2DS2-VASc >2 : long term warfarin INR target 2.5± 0.5.
CHA2DS2-VASc = 1 : options include warferrin or aspirin
or no treatment .
CHA2DS2-VASc = 0 : no treatment
2. Patient with non valvular AF+ CHA2DS2-VASc > 2:
Dabigatran ,rivaroxaban , apixaban or edoxaban.
3. Mitral stenosis with history of embolism or associated with
left atrial thrombus : warferrin .
Drugs for thromboembolic cerebrovascular
disease
Drug Route Dosage
Anticoagulants
Antithrombin activators
Heparin Iv To aPTT= 1.5 – 2.0 control
Vitamin k antagonists
War farin Po To INR = 2.5± 0.5
Direct thrombin inhibitors
Dabigatran Po 150 mg bid
Direct factor Xa inhibitors
Apixaban Po 5 mg bid
Edoxaban Po 60 mg qd
Rivaroxaban Po 20 mg qd
Drugs for thromboembolic
cerebrovascular disease Cont.
Antiplatelet agents
Aspirin Po 81 -325 mg/ d
Aspirin / dipyridamole Po 25/200 mg bid
Clopedogril Po 75 mg qd
Thrombolytics
Recombinant tissue IV 0.9 mg / kg once
plasminogen activator(r- IA Not established
Tpa)
Acute ischemic stroke & TIA
Medical treatment
Interventional treatment
Surgical treatment
Medical treatment
Blood pressure .
hyperthermia
hypoxia
hypoglycemia
anticoagulant or heparin
antiplatelets therapy
statins
Interventional treatment
Intravenous thrombolysis
Intraarterial thrombolysis
Clot retrieval
Intravenous thrombolysis
Alteplase (r-tPA) given within 4.5 hours can
reduce disability and mortality from AIS.
Treatment should be started within 60 minutes
of the patient arrival to hospital which provide
time for diagnosis and evaluation of possible
contraindications.
Contraindications designed to avoid
unnecessarily treating pt who are improving or
unlikely to benefit
Contraindications designed to avoid bleeding
complications
Intra-arterial thrombolysis
Indicated for:
those who reach after the widow
time from 4.5-6 hours
Recent history of major surgery
IV thrombolysis is unsuccessful
Clot retrieval
Mechanical thromboectomy with a stent retrieval ,
typically in combination with IV r-tPA, can
improve functional outcome for pt with stenosis
or occlusion of proximal (internal carotid or
proximal MCA) intracranial arteries in the ACC.
Those who fail IV thrombolysis or not candidate
for, but should started 6 hours after starting of
symptoms
Surgical treatments
1. Carotid endarterectomy :
TIA and high grade( 70-90%) extracranial ICA
stenosis
Selected patient with moderate (50-70) stenosis.
2. Carotid artery stenting . As effective as EA
3. Decompressive craniectomy with dural expansion
Cerebellar infarction
Large hemispheric stroke. If occur in less than 60
years and deteriorate within 48 hours
Secondary prevention
Statins: Atorvastatin 80 mg po /d
Blood pressure control: Diuretic & ACI
Antiplatelet drugs: Non cardiogenic?
If occur while taking aspirin?
Anti coagulation
Indicaations and INR target?
Surgical treatments: the same
