Unit 3
Stroke Overview
OPTA 1331
CONDITIONS 2
Strokes: TIAs, Causes and
Vascular Supply
Learning Objectives
•Define terminology associated with stroke
•Differentiate between stroke and TIA
•Define the two different types of stroke: ischemic
and hemorrhagic
•Describe the general causes, risk factors, signs
and symptoms of the two types of stroke
•Explain the basic medical management post stroke
Global Stroke Facts
•15 million people suffer from a stroke worldwide per
year
•Stroke is the second leading cause of death globally
◦ From the World Health Organization (accessed from
www.physio-pedia.com)
Canadian Stroke Facts
•> 50,000 strokes in Canada each year
•Approx. 30,000 Canadians are living with the effects of a
stroke
•After age 55, the risk of stroke doubles every 10 years
•Stroke costs the Canadian economy $3.6 billion a year
◦ Physician services, hospital costs, lost wages, decreased
productivity
◦ From Heart & Stroke Foundation
What is a Stroke?
“ A stroke happens when blood stops flowing to
any part of your brain, damaging cells. The effects
of a stroke depend on the part of the brain that
was damaged and the amount of damage done.”
From the Heart and Stroke Foundation of Canada
What is a Stroke?
What is a Stroke?
What is a Stroke?
Stroke = Cerebral Vascular Accident (CVA)
•“Death of brain tissue (cerebral infarction)
resulting from lack of blood flow and insufficient
oxygen to the brain.” (The Merck Manual of Medical Information Home Edition)
•Results in a variety of neurological symptoms
•Due to disorder of cerebral blood vessels
What is a TIA?
TIA = Transient Ischemic Attack
•A mini stroke = a warning stroke
•An acute episode of temporary neurologic
dysfunction
•A warning that a more serious stroke may
occur…TIAs are a Medical Emergency
What is a TIA?
Characteristics:
-Symptoms lasts < an hour
-Due to focal ischemia (local decreased blood flow
in the brain)
•Partial, brief occlusion (block)
•No permanent neurological damage
•Once have a TIA, 5x more likely to have a stroke
than general population (Heart and Stroke
Foundation of Canada)
Transient Ischemic Attack
(TIA)
www.physio-pedia.com
Transient Ischemic Attack
(TIA)
Causes of Stroke
Due to circulatory problems in the brain
Either:
1) Blockage (occlusion) of blood vessels
decreased oxygenation cell death (infarct)
2) Bleeding into the brain
- due to rupture of cerebral blood vessel
Vascular System
Vascular Supply to Brain
Brain is supplied by the Vertebral A and
Internal Carotid A (one on each side)
Terminal branches of these arteries form a
circular blood vessel, called the Circle of
Willis
Vascular Supply to Brain
Terminal
branches
of Vertebral
A and
Internal
Carotid A
form a
circle
called:
Circle of
Willis
www.physio-pedia.com
Vascular Supply to Brain
Internal Carotid A gives rise to:
-Anterior Cerebral A (ACA)
Vertebral A gives rise to:
-Posterior Cerebral A (PCA)
Internal Carotid A continues and becomes the:
-Middle Cerebral A (MCA)
-*The MCA is the most commonly occluded
Cerebral A
Vascular Supply to Brain
Anterior Circulation (supplies cerebrum)
Anterior cerebral A (ACA)
Middle cerebral A (MCA)
Anterior circulation arteries supply:
-Frontal and parietal lobes
-Part of temporal lobe
Vascular Supply to Brain
Posterior Circulation
Vertebral A
Posterior cerebral A (PCA)
Basilar A
Posterior circulation arteries supply:
-Brainstem
-Cerebellum
-Parts of the occipital and temporal lobes
Vascular Supply to Brain
Circle of
Willis
Images from SMART Imagebase
Vascular Supply to Brain
Vascular Supply to Brain
Stroke Types
Stroke Types
1) Ischemic
◦ Loss of blood flow due to occlusion of artery (A)
◦ Blockage or clot in A
◦ 2 subtypes: thrombotic and embolic
2) Hemorrhagic
◦ Bleeding in the brain due to rupture of artery
◦ 2 subtypes: intracerebral and subarachnoid
Stroke Types
Ischemic Hemorrhagic
- Most common (80 %) - About 20% of all strokes
- Blood supply occluded to -Rupture of artery in brain
brain bleeding inside or outside of
- Results in cell death the brain
(infarct) beyond blockage
due to lack of oxygen -Common cause: high
-Common cause: blood pressure
atherosclerosis (plaque) or
blood clot
Ischemic Stroke
Hemorrhagic Stroke
Stroke Types: Ischemic
Thrombotic Embolic
Circulation decreased due to Blood clot occludes
narrowing of blood vessel circulation
walls from atherosclerosis - Thrombus (blood clot) often
or disease forms in heart; once it
- Occurs with large or dislodges, it becomes an
small A embolus which can lodge in
- Plague and artery wall brain and obstruct blood flow
degeneration blocks
blood flow occurs at area
of obstruction
Thrombotic Stroke: Disease Process
**Most common stroke**
Large Arteries: Plague forms at inner wall of arteries
(Atherosclerosis: plaque forms from cholesterol and
other lipid build up)
•Plague degenerates over time and pieces break off
•Chemical are released and blood clot forms
•Decreased blood flow
decreases or stops oxygen reaching cerebral
tissues – changes in brain cells after 2-3 h
•Complete occlusion
cerebral infarction – cell death after 6-24h
Thrombotic Stroke: Disease Process
Most common stroke
Small Arteries: smaller A in central brain that supply
brain stem and basal ganglia
•Prolonged HTN (hypertension) causes damage to inner
wall of artery
•Inner wall breaks down and creates debris
•Debris block blood flow
Decreased blood flow
decreases or stops oxygen reaching cerebral tissues
Complete occlusion
cerebral infarction (cell death)
Embolic Stroke: Disease Process
Ventricular contraction is impaired due to CHF (congestive
heart failure) or heart attack
Decreased contraction causes blood to pool in ventricle
Pooled blood thickens – becomes a thrombus
Thrombus forms, breaks off and becomes an embolus and
is now a travelling blood clot
Decreased blood flow occurs when embolus lodges in
smaller A in brain
Occlusion causes decreased oxygen and cell death
Embolic Stroke: Disease Process
Other causes of thrombus formation:
Atrial Fibrillation: impaired atrium causes thrombus
to form
Endocarditis: bacterial infection in blood (sepsis)
can cause thrombus to form
Ischemic Stroke: Disease Process
www.strokecenter.org/patients/sah.htm
www.strokecenter.org/patients/sah.htm
Stroke Types
Ischemic Haemorrhagic
- Most common (80 %) - About 20% of all strokes
- Blood supply occluded to -Rupture of artery in brain
brain bleeding inside or outside of
- Results in cell death the brain
(infarct) beyond blockage
due to lack of oxygen -Common cause: high
-Common cause: blood pressure
atherosclerosis or blood clot * 2 types: intracerebral and
subarachnoid
Stroke Types: Hemorrhagic
Intracerebral Subarachnoid
-Bleeding within the brain -Bleeding outside the brain
-In the subarachnoid space
-Due to rupture of small arteries -Commonly caused by rupture of a
Berry aneurysm
*Aneurysm = a sac formed by a
local dilation of the blood vessel
wall
-Other causes:
Serious head injury, drug use
(especially cocaine and
amphetamines), vascular
malformation
Intracerebral Stroke:
Disease Process
•Bleeding in the brain due to prolonged HTN, trauma, bleeding
disorders, vascular malformation, drug abuse
•Main cause = HTN
•Artery wall thickens and losses normal elasticity
•Rupture of A occurs when inelastic vessel wall unable to “cope”
with increased BP
•Hematoma forms and expands
•Leads to bleeding deep in brain where millions of neurons exist
•Cells die
Subarachnoid Stroke:
Disease Process
•Bleeding in the brain due to aneurysm rupture (85% occur at the
Circle of Willis)
•Weakness in A wall leads to a berry aneurysm that ruptures
•Hematoma forms
•Blood mixes with cerebral spinal fluid (CSF), travels through the
brain and enters the Subarachnoid Space
•Hematoma expands and compresses surrounding tissues
•Vasospasms of surrounding A occurs that can last up to a week
and can cause subsequent stroke
Subarachnoid Space
Hemorrhagic Stroke: Disease
Process
Intracerebral
Subarachnoid
Stroke: Risks, Signs and Symptoms
and Medical Management
Risk and Prevention
According to the Heart and Stroke Foundation
of Canada:
Prevention is key
9 in 10 Canadians have at least one risk factor
for stroke…almost 80% of premature strokes
can be prevented through healthy
behavior….eating healthy, being active and not
smoking..
Stroke Risk Factors
•Unhealthy diet
•Physical inactivity
•Unhealthy weight
•Smoking
•Stress
•Excessive alcohol and drug abuse
Stroke Risk Factors
•All of these factors can increase risk of HTN
and atherosclerosis thus indirectly increase
risk of stroke
•Other Risk Factors:
• Age, gender, family history, ethnicity,
previous history of stroke or TIA
Ischemic Stroke: Risk Factors
•Atherosclerosis
•HTN
•CHF and MI (impaired ventricle)
•Atrial Fibrillation (impaired atrium): over 60 years old, 1/3 of
all strokes are due to AF**
•Endocarditis: bacterial infection in blood (sepsis)
•Hemorrhagic Shock (leads to global loss of blood flow to
brain)
•Cardiac arrhythmias
Hemorrhagic Stroke: Risk Factors
•HTN
•Trauma
•Bleeding disorders
•Vascular malformation
•Estrogen deficiency
•Anticoagulation disorder
Stroke Signs and Symptoms
Depends on:
◦ Cause
◦ Severity
◦ Location of brain affected including which
hemisphere
Stroke Signs and Symptoms
www.physio-pedia.com
Functional areas of the cerebral cortex that can be affected by a stroke
Stroke Signs and Symptoms
Possible Acute Neurologic
Symptoms Symptoms
-Dizziness -Hemiplegia
-Headache -Sensory deficits
-Vomiting -Visual disturbances
-Altered level of -Speech deficits
consciousness (LOC) -Changes in reflexes
-Confusion -Muscle tone changes
-Respiratory symptoms -Cognitive deficits
-Perception deficits
Ischemic Stroke: Signs and
Symptoms
Focal neurologic signs
- Unilateral weakness
- Unilateral sensory deficits
- May also include speech problems
Hemorrhagic Stroke: Signs and Symptoms
Intracerebral Subarachnoid
-Neurologic focal signs -Headache +++
-May also see -Vomiting
headache, vomiting, -Altered LOC
seizures, decreased
LOC -Maybe no focal
-If large bleed, coma neurologic signs
poor prognosis
Vascular Supply to Brain
Circle of
Willis
Images from SMART Imagebase
Anterior Circulation Stroke Signs and Symptoms
Cerebral A supply different lobes therefore which A
is occluded will determine dysfunction
- Specific area affected is related to the
homunculus
- Depends on hemisphere affected
- Contralateral motor & sensory deficits of face, arm
& leg
Anterior Circulation Stroke Signs and Symptoms
Homonculus
MCA Stroke Signs and Symptoms
Left Hemisphere Right Hemisphere
Lesions Lesions
-Right sided weakness -Left sided weakness
-Right sided sensory -Left sided sensory
deficits deficits
-Language problems -Visual-spatial deficits
(Broca’s) -Impulsive
Posterior Circulation Stroke
Signs and Symptoms
•Approx. 20% of all strokes (Lewandowski.C)
•Due to occlusion of posterior cerebral arteries, vertebral
arteries and basilar artery
•Results in a wide variety of symptoms
• severity from hemiparesis to quadriplegia
•Complete occlusion usually fatal due to lack of O2 supply to
the brainstem
Posterior Circulation Stroke
Signs and Symptoms
Recall that the posterior circulation arteries
supply the cerebellum and the brainstem.
- Cranial Nerves emerge from the brainstem
and therefore can be affected
Posterior Circulation Stroke
Signs and Symptoms
The “5D’s”
Cerebellar involvement could involve:
◦ Dystaxia or ataxia
Cranial nerve involvement could involve:
◦ Double vision (diplopia)
◦ Difficulty swallowing (dysphagia)
◦ Difficulty forming words (dysarthria )
◦ Dizziness (vertigo )
Stroke: Medical Management
Need to treat quickly
First few hours = diagnose (type of stroke?)
and treat to prevent further brain damage
Then focus = preventing complications
Stroke: Medical Management
•Confirm Diagnosis
◦ Physical examination
◦ Subjective information
◦ Neuroimaging: computerized tomography (CT scan)
•Regulate blood pressure
◦ Maintain below 180/110
•Regulate Intracranial Pressure (ICP)
◦ If increased ICP a concern, maintain head of bed (HOB)
at 30 degrees (based on Dr’s Orders)
• Monitor neurological functioning
Stroke: Medical Management
•Medications:
•To improve blood flow: Thrombolytic drugs
•To prevent clotting: Anticoagulants
•To decrease high blood pressure: Antihypertensives
•To decrease cerebral edema: Anti-inflammatories
Stroke: Medical Management
Surgery:
•Craniotomy: surgical removal of part of skull to
access brain
•Intracranial Hemorrhage
◦ Remove blood clot (hematoma)
•Subarachnoid Hemorrhage
◦ Clip aneurysm
Medical Management - Comparison
Ischemic Hemorrhagic
-Improve blood flow: -Decrease cerebral
- thrombolytic drugs edema & ICP
-Decrease HTN: -Decrease HTN
- antihypertensives - antihypertensives
-Prevent clotting: -Maybe surgery
- anticoagulants
References
1) www.physio-pedia.com
2) Heart and Stroke Foundation of Canada
