ischemic and hemorrhagic stroke

54
CASE PRESENTATION Dr. Gauhar Mahmood Azeem House Officer, Medical Unit 4, Services Hospital Lahore.

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Page 1: Ischemic and hemorrhagic stroke

CASE PRESENTATIONDr. Gauhar Mahmood Azeem

House Officer,

Medical Unit 4, Services Hospital Lahore.

Page 2: Ischemic and hemorrhagic stroke

Clinical History

• Biodata:

• A 75 year old female resident of Lahore presented to

Medical Emergency Services Hospital on the 1st of

December 2014 with complaints of

• Presenting Complaints:

• Right sided body weakness 1 hour

• Inability to talk 1 hour

Page 3: Ischemic and hemorrhagic stroke

Clinical History

• History of present illness:

Patient is a known hypertensive (25 years) and known

patient of IHD (10 years) and was relatively well 2 hours

back when while walking to the bathroom the patient fell

suddenly and after receiving help could not talk or move

the right arm or leg, there was also deviation of face to the

left…

Page 4: Ischemic and hemorrhagic stroke

Clinical History

• History of present illness:

…The weakness was sudden in onset, was not associated

with fits, up rolling of eyes, tongue bite, or urination. The

patient was previously mobile and has no history of

preceding fever, there is no history of vomiting, headaches,

or any such events before.

Page 5: Ischemic and hemorrhagic stroke

Clinical History

• Past History

• Hypertension 15 years

• Low ejection fraction 40% known for 6 months

• No history of diabetes, hepatitis, tuberculosis is there.

Page 6: Ischemic and hemorrhagic stroke

Clinical History

• Treatment History:

• Patient treated for an episode of shortness of breath 6 months back.

• Drug History:

• Patient taking

• Norvasc 5mg

• Ascard 75mg

• Loprin 75mg

• Drug compliance recently not good

• Patient not known allergic to any medication

Page 7: Ischemic and hemorrhagic stroke

Clinical History

• SocioEconomic History

• Higher Middle Class family.

• Owns own home.

• Occupational History

• Retired Professional banker.

Page 8: Ischemic and hemorrhagic stroke

Clinical History

• Family History

• Was positive for Hypertension, Diabetes and Ischemic

Heart Disease.

Page 9: Ischemic and hemorrhagic stroke

Examination

• Vitals

• Pulse: 118/min rate and rhythm irregularly irregular

• Blood Pressure: 160/80 mmHg

• Respiratory Rate: 16/min

• Temperature: 98’F

• Blood Sugar Random: 249 mg/dl

Page 10: Ischemic and hemorrhagic stroke

Examination

• Central Nervous System Examination

• GCS: M6 V1 E4 11/15

• Sensory loss not present.

• Right sided facial weakness, deviation to the left side.

• Patient has aphasia, dysphagia.

• Eye movement normal

• Power:

Right Arm 0/5 Left Arm 5/5

Right Leg 0/5 Left Leg 5/5

Page 11: Ischemic and hemorrhagic stroke

Examination

• Tone

• Increased in Right arm and leg. Normal in left arm and

leg.

• Reflexes

• Reflexes on the right side were exaggerated. Those on

left side were normal.

• Planters

• Right Plantar was up going.

• Left Plantar down going.

Page 12: Ischemic and hemorrhagic stroke

Examination

• Respiratory System

• Air entry equal on both sides, mild bilateral inspiratory

crepts.

• Gastrointestinal System

• Abdomen looks normal, no visceromegaly, no area of

tenderness, percussion note resonant, no shifting

dullness, bowel sounds present.

Page 13: Ischemic and hemorrhagic stroke

Examination

• Cardiovascular System

• Pulse Rate 118/min

• Pulse was irregularly irregular

• Mitral area 2 cm lateral to the mid-clavicular line.

• There was no abnormal heart sound appreciated and

finding on auscultation was irregularly irregular rhythm.

Page 14: Ischemic and hemorrhagic stroke

Investigations

• CBC

• Hb 8.6

• TLC 14.8

• Hct 28

• Platelets 351

Page 15: Ischemic and hemorrhagic stroke

Investigations

• LFT

• ALT 23 AST 19

• RFT

• Creatinine 0.6

• Serum Electrolytes

• Na+ 148 K+ 5.0

• PT 15 APTT 35

Page 16: Ischemic and hemorrhagic stroke

Investigations

• UCE

• Pus Cells 3-6

• Epithelial cells 1-2

• Cardiac Enzymes

• CPK 99 LDH 382 CKMB 15

Page 17: Ischemic and hemorrhagic stroke

ECG

Page 18: Ischemic and hemorrhagic stroke

CT Brain

• No areas of abnormal attenuation seen on CT scan.

• Normal Senile atrophic changes seen.

• Calcified Choroid Plexus.

• (60% of infarcts are seen within 3-6 hours and virtually all

are seen in 24 hours)

Page 19: Ischemic and hemorrhagic stroke

Differential Diagnosis

• Ischemic Stroke

• Hemorrhagic Stroke (CT scan rules this out)

Page 20: Ischemic and hemorrhagic stroke

Diagnosis

• Ischemic Stroke most likely due to Embolus

Page 21: Ischemic and hemorrhagic stroke

Treatment Plan

• INJ N/S x 1000CC x IV x BD

• INJ HEPARIN 1cc x SC x OD

• Tab ATORVA x 40mg x PO x OD

• Tab HERBESSER x 30mg x PO x TDS (diltiazem)

• Tab LOPRIN 75mg x 2 x PO x OD

• INJ RISEK x 40mg x IV x OD

• Oxygen inhalation to keep saturation O2 to 94-96%

• Ted Stocking, Chest Physio, Limb Physio.

• Planned CXR, Echocardiography, Carotic Doppler,

Fasting Lipid Profile.

Page 22: Ischemic and hemorrhagic stroke

STROKE

Page 23: Ischemic and hemorrhagic stroke

Definitions

• Stroke

• Clinical syndrome of rapid onset of focal deficits of brain function

lasting more than 24 hours or leading to death

• Transient Ischemic attack (TIA)

• Clinical syndrome of rapid onset of focal deficits of brain function

which resolves within 24 hours

Page 24: Ischemic and hemorrhagic stroke

Definitions

• Progressive Stroke

• A stroke in which the focal neurological deficits worsen with time

• Also called stroke in evolution

• Completed Stroke

• A stroke in which the focal neurological deficits persist and do not

worsen with time

Page 25: Ischemic and hemorrhagic stroke

Types of Stroke

• Ischemic

• Hemorrhagic

Page 26: Ischemic and hemorrhagic stroke

Risk Factors

• Ischemic Stroke

• Nonmodifiable risk factors include the

• Age

• Race

• Sex

• Ethnicity

• History of migraine headaches[21]

• Fibromuscular dysplasia

• Heredity: Family history of stroke or transient ischemic

attacks (TIAs)

Page 27: Ischemic and hemorrhagic stroke

Risk Factors

• Ischemic Stroke

• Modifiable Risk Factors

• Hypertension (the most important)

• Diabetes mellitus

• Cardiac disease: Atrial fibrillation, valvular disease, heart failure, mitral stenosis, structural anomalies allowing right-to-left shunting (eg, patent foramen ovale), and atrial and ventricular enlargement

• Hypercholesterolemia

• TIAs

• Carotid stenosis

• Hyperhomocystinemia

• Lifestyle issues: Excessive alcohol intake, tobacco use, illicit drug use, physical inactivity[24]

• Obesity

• Oral contraceptive use/postmenopausal hormone use

• Sickle cell disease

Page 28: Ischemic and hemorrhagic stroke

Risk Factors

• Hemorrhagic Stroke

• Advanced age

• Hypertension (up to 60% of cases)

• Previous history of stroke

• Alcohol abuse

• Use of illicit drugs (eg, cocaine, other sympathomimetic

drugs)

Page 29: Ischemic and hemorrhagic stroke

Middle Cerebral Artery

Page 30: Ischemic and hemorrhagic stroke

Anterior Cerebral Artery

Page 31: Ischemic and hemorrhagic stroke

Posterior Cerebral Artery

Page 32: Ischemic and hemorrhagic stroke

Ischemic Stroke

• 80% of strokes

• Arterial occlusion of an intracranial vessel leads to

hypoperfusion of the brain region it supplies

Page 33: Ischemic and hemorrhagic stroke

Etiology

• Thrombotic

• Lacunar stroke

• Large vessel thrombosis

• Hypercoagulable

disorders

Systemic Hypoperfusion

Venous Thrombosis

• Embolic

• Artery to artery

• Carotid bifurcation

• Aortic arch

• Cardioembolic

• Atrial fibrillation

• Myocardial infarction

• Mural thrombus

• Bacterial endocarditis

• Mitral stenosis

• Paradoxical embolus

Page 34: Ischemic and hemorrhagic stroke

Thrombotic Stroke

• Atherosclerosis is the most common pathology leading

to thrombotic occlusion of blood vessels

• Hypercoagulable disorders – uncommon cause

• Antiphospholipid syndrome

• Sickle cell anemia

• Polycythemia vera

• Homocysteinemia

• Vasculitis: PAN, Wegener’s granulomatosis, giant cell

arteritis

Page 35: Ischemic and hemorrhagic stroke

Thrombotic Stroke

• Lacunar stroke

• Accounts for 20% of all strokes

• Results from occlusion of small deep penetrating arteries

of the brain

• Pathology: lipohyalinosis & microatheroma

• Thrombosis leads to small infarcts known as lacunes

• Clinically manifested as lacunar syndromes

Page 36: Ischemic and hemorrhagic stroke

Embolic Stroke

• Cardioembolic stroke

• Embolus from the heart gets lodged in intracranial vessels

• MCA most commonly affected

• Atrial fibrillation is the most common cause

• Others: MI, prosthetic valves, rheumatic heart disease

• Artery to artery embolism

• Thrombus formed on atherosclerotic plaques gets embolized to

intracranial vessels

• Carotid bifurcation atherosclerosis is the most comon source

• Others: aortic arch, vertebral arteries etc.

Page 37: Ischemic and hemorrhagic stroke
Page 38: Ischemic and hemorrhagic stroke

Pathophysiology of Ischemic Stroke

• Blood supply to the brain is auto-regulated

• Blood flow

• If zero leads to death of brain tissue within 4-10min

• <16-18ml/100g tissue/min infarction within an hour

• Ischemia leads to development of an ischemic core and

an ischemic penumbra

Page 39: Ischemic and hemorrhagic stroke

Ischemic Penumbra

• Tissue surrounding the core region of infarction which is

ischemic but reversibly dysfunctional

• Maintained by collaterals

• Can be salvaged if re-perfused in time

• Primary goal of revascularization therapies

Page 40: Ischemic and hemorrhagic stroke

Hemorrhagic Stroke

• Two types

• Intracerebral

hemorrhage(ICH)

• Subarachnoid

hemorrhage(SAH)

• Higher mortality rates

when compared to

ischemic stroke

Page 41: Ischemic and hemorrhagic stroke

Intracerebral Haemorrhage

• Result of chronic hypertension

• Small arteries are damaged due to hypertension

• In advanced stages vessel wall is disrupted and leads to

leakage

• Other causes: amyloid angiopathy, anticoagulant therapy,

cavernous hemangioma, cocaine, amphetamines

Page 42: Ischemic and hemorrhagic stroke

Subarachnoid Haemorrhage

• Most common cause is rupture of saccular or Berry

aneurysms

• Other causes include arteriovenous malformations,

angiomas, mycotic aneurysmal rupture etc.

• Associated with extremely severe headache

Page 43: Ischemic and hemorrhagic stroke

Pathophysiology of haemorrhagic stroke

• Explosive entry of blood into the brain parenchyma

structurally disrupts neurons

• White matter fibre tracts are split

• Immediate cessation of neuronal function

• Expanding hemorrhage can act as a mass lesion and

cause further progression of neurological deficits

• Large hemorrhages can cause transtentorial coning and

rapid death

Page 44: Ischemic and hemorrhagic stroke

Management

Page 45: Ischemic and hemorrhagic stroke

Management of Ischemic Stroke

• The central goal of therapy in acute ischemic stroke is to

preserve tissue in the ischemic penumbra, where

perfusion is decreased but sufficient to stave off infarction.

• ABC’s

• The goal for the emergent management of stroke is to

assess the patient’s airway, breathing, and circulation

(ABCs); stabilize the patient as necessary; and complete

initial evaluation and assessment, including imaging and

laboratory studies, within 60 minutes of patient arrival

Page 46: Ischemic and hemorrhagic stroke

Management of Ischemic Stroke

• Supplemental oxygen is recommended when the patient

has a documented oxygen requirement (ie, oxygen

saturation < 95%)

• In the small proportion of patients with stroke who are

relatively hypotensive, administration of IV fluid,

vasopressor therapy, or both may improve flow through

critical stenosis

• Hypoglycemia or hyperglycemia needs to be identified

and treated early in the evaluation.

Page 47: Ischemic and hemorrhagic stroke

Management of Ischemic Stroke

• Fibrinolytic Therapy

• With rtPA (alteplase) within 3-4.5 hours of symptoms

onset.

• Patient must meet the inclusion criteria and not have a

contraindication

Antiplatelet Therapy

• AHA/ASA guidelines recommend giving aspirin, 325 mg

orally, within 24-48 hours of ischemic stroke onset. The

benefit of aspirin is modest but statistically significant and

appears principally to involve the reduction of recurrent

stroke

Page 48: Ischemic and hemorrhagic stroke

Management of Ischemic Stroke

• Threshold for Blood Pressure lowering

Thresholds for antihypertensive treatment in acute

ischemic stroke patients who are not fibrinolysis

candidates, according to the 2013 ASA guidelines, are

systolic blood pressure higher than 220 mm Hg or diastolic

blood pressure above 120 mm Hg.

In those patients, a reasonable goal is to lower blood

pressure by 15% during the first 24 hours after onset of

stroke. Care must be taken to not lower blood pressure too

quickly or aggressively, since this could worsen perfusion in

the penumbra.

Page 49: Ischemic and hemorrhagic stroke

Management of Ischemic Stroke

• Fever Control

• Antipyretics are indicated for febrile stroke patients, since

hyperthermia accelerates ischemic neuronal injury.

Substantial experimental evidence suggests that mild

brain hypothermia is neuroprotective.

• Manage Cardiac Arrythmias eg in our case diltiazem was

given to manage AF

• In Cerebral Edema IV Mannitol can be given

• Pass NG tube if indicated, pass foleys.

Page 50: Ischemic and hemorrhagic stroke

Management of Ischemic Stroke

• Secondary prevention of stroke

• Platelet antiaggregants

• Antihypertensives

• Statins

• Lifestyle interventions

• Management of other conditions that may be contributing,

eg probable carotid endarterectomy for stenosis and

anticoagulation in valvular problems or AF

• Prevent pressure sores, aspirations, contractures, DVT

Page 51: Ischemic and hemorrhagic stroke

Management of Haemorrhagic Stroke

• The treatment and management of patients with acute

intracerebral hemorrhage depends on the cause and

severity of the bleeding. Basic life support, as well as

control of bleeding, seizures, blood pressure (BP), and

intracranial pressure, are critical.

• ICH is a neurological emergency and initial management

should be focused on assessing the patients airway,

breathing capability, blood pressure and signs of

increased intracranial pressure.

Page 52: Ischemic and hemorrhagic stroke

Management of Haemorrhagic Stroke

• The patient should be intubated based on risk of

aspiration, impending ventilatory failure (PaO2 < 60

mmHg or pCO2 > 50 mmHg), and signs of increased

intracranial pressure.

• Emergency measures for ICP control are appropriate for

stuporous or comatose patients, or those who present

acutely with clinical signs of brainstem herniation. The

head should be elevated to 30 degrees, 1.0–1.5 g/kg of

20% mannitol should be given by a rapid infusion, and the

patient should be hyperventilated to a pCO2 of 30–35

mmHg.

Page 53: Ischemic and hemorrhagic stroke

Management of Hemorrhagic Stroke

• In patients presenting with a systolic BP of 150 to 220 mm

Hg, acute lowering of systolic BP to 140 mm Hg is

probably safe.

• Management of seizures if any

• Acute management of seizures entail administering

intravenous lorazepam (0.05–0.10 mg/kg) followed by an

intravenous loading dose of phenytoin or fosphenytoin

(15–20 mg/kg), valproic acid (15–45 mg/kg), or

phenobarbital (15–20 mg/kg).

Page 54: Ischemic and hemorrhagic stroke

Management of Hemorrhagic Stroke

• If hemorrhage is due to anticoagulation, give Vitamin K,

FFP and PCC

• Fever should be treated aggressively because it is

independently associated with a poor outcome

• Neurosurgical Consultation