1

Stroke: Diagnosis and Management��.��.�������� �� !���"#

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e-mail:somtia@kku.ac.th

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1. Sudden onset

2. Risk factors

3. Neuro-vascular

Risk Factors for Cerebral Infarction

Mechanism EtiologyHypertension

Aging

Hyperlipidemia

Diabetes and so on

Hypertension

Hyperlipidemia

Others

Cardiac

disease

Hypertension

Aging

Others

Cerebral

thrombosis

Cerebral

embolism

Hemodyna-mic

Athero-

thrombotic

Cardio-

embolic

Lacunar

Stroke Risk FactorsNon-modifiable Modifiable• Older age • HT• Male sex • Smoking• Race • Carotid stenosis• Genetic • Exercise

• DM• TIA• Hyperlipidemia• Cardiac disease

Classification IschemicIschemic--occlusiveocclusive

�� ThrombosisThrombosis

�� major major vvvv

�� minor minor vvvv

�� EmbolismEmbolism

�� cardiogeniccardiogenic

�� arteryartery--toto--arteryartery

�� cryptogeniccryptogenic

HemorrhagicHemorrhagic

�� IntraparenchymalIntraparenchymal

�� SubduralSubdural

�� EpiduralEpidural

�� SubarachnoidSubarachnoid

2

Circle of Willis�� Anterior circulationAnterior circulation

ICA ( internal carotid a.)ICA ( internal carotid a.)

MCA ( middle cerebral a.)MCA ( middle cerebral a.)

ACA ( anterior cerebral a.)ACA ( anterior cerebral a.)

Anterior Anterior choroidalchoroidal a.a.

�� Posterior circulationPosterior circulation

VA ( vertebral a. )VA ( vertebral a. )

BA ( basilar a. )BA ( basilar a. )

PCA ( posterior cerebral a.)PCA ( posterior cerebral a.)

SCA ( superior cerebellar a.)SCA ( superior cerebellar a.)

PICAPICA

AICAAICA

Acute memory loss

3

Global aphasia

Sudden right hemiplegia

Parietal lobe sign

�� AstereognosiaAstereognosia

�� Dressing Dressing apraxiaapraxia

�� Homonymous inferior quadrant Homonymous inferior quadrant anopiaanopia

�� GertmannGertmann’’ss syndromesyndrome

�� Sensory inattentionSensory inattention

Dressing apraxiaAcute cortical blindness

Sudden vertigo

4

Lacunar Syndrome

1.1. Pure motor Pure motor hemiparesishemiparesis

2.2. Pure sensory strokePure sensory stroke

3.3. Ataxic Ataxic hemiparesishemiparesis

4.4. DysarthriaDysarthria--clumsy hand clumsy hand

syndromesyndrome

5.5. Pure motor Pure motor hemiparesishemiparesis

with motor aphasiawith motor aphasia

Business man, coma during meetingRight side weakness on awakening

CEREBRAL INFARCTION

HT,RHD,dyslipid,DM

Smoking,obesity

Acute, awakening

Progressive

No

Underlying

Onset

ICP

HEMORRHAGE

HT, coagulopathy

Amphetamine

Sudden

Activity

Yes

5

Acute Treatment• Aspirin gr V

– R#��#��h�V# International Stroke Trial 02( Chinese Acute Stroke Trial

–� GHI'J%!�%� 40,000 *�

–�T%"#�#�#�j2� +�-�#�#�-#!02( dependency R#� 47.1% �'N� 45.8% absolute risk reduction 1.2%

ASA in Acute Stroke

Thrombolytic Therapy : Benefit

IMPOSSIBLE

6

Anticoagulant in Stroke

NO BENEFIT

Acute Treatment• Outcome �#����V#� X2��#�-#!02(�#� dependents 1 �#!• Aspirin

– -�%+!"#<�#�*Q#�%�• Death or dependency 47.0%• ASA 45.8%• Absolute risk reduction (ARR) 1.2%• Number needed to treat (NNT) 100/1.2 = 83 �#! • *"#D&IR"#! 83 x 0.5 x 28 = 1, 160 T#�

• Thrombolytic therapy – ARR 6.3% NNT 16 *"#D&IR"#! 800,000 T#�

Ref : Hankey GJ and Warlow CP, 1999

Male, 70 years, DM, HT, IHD, dyslipidemiaDysphagia, dysarthia

What to do about BP in

acute ischemic stroke is

unclear: raise it, lower it or

leave it alone? We trend to

leave it alone unless there is

evidence of end-organ

damage.

Indication to Reduction BP• Before and post rt-PA ( 24 hr )

• Hypertensive encephalopathy

• AMI

• Aortic dissection

• Hemorrhagic transformation

Drug : Nitroglycerine , Nitroprusside ,Nicardipine , Labetarol ,Captopril

NO ADALAT SUBLINGUAL

7

Stroke Risk FactorsNon-modifiable Modifiable• Older age • HT• Male sex • Smoking• Race • Carotid stenosis• Genetic • Exercise

• DM• TIA• Hyperlipidemia• Cardiac disease

Gold Standard: European Stroke

Committee 1. BP should be lowered to normal 140/85 mmHg

2. Strict control BS, cholesterol (statin)

3. Stop cigarette smoking

4. Regular physical activity

5. Heavy alcohol drinking should be avoided

6. Long term anticoagulant in AF patients

No role of ASANo role of ASANo role of ASANo role of ASA

Secondary Prevention

1. Anti hypertensive drugs

2. Anti thrombotic drugs

3. Anticoagulation

4. Surgery: carotid

endarterectomy

Gold Standard

1. ASA 50-325 mg is first choice

2. Where available ASA 25 mg +

Dipyridamole 200 mg bid

3. Clopidogrel, when ASA is not

tolerated or efficacious

8

Anticoagulantion: 5 Rheumatic

5 MI

5 CHF

5 Cardiomyopathy

5 Arrhythmia, AF

5 PFO

Gold Standard

1. Stroke with AF, INR 2-3

2. Prosthetic heart valve, INR 3-4

3. Cardioembolic stroke, INR 2-3

Risk FactorsRisk FactorsRisk FactorsRisk Factors

9

� Smoking cessation � ARR 2.3%� NNT -"+'S 43 �#!� *"#D&IR"#!

� <��+< 0 T#� � '�(1!���<��*"#T,1� Xw�I 12,700 T#�

Secondary prevention