Professional Documents
Culture Documents
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stroke
• Ischemic 80-85%
Atherosclerotic CVD in 20%
Lacunar in 25%
Cardiogenic embolism in 20%
Cryptogenic 30%
Unusual causes 5%
• Hemorrhagic
10 ICH 10-15%
SAH 5%
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EPIDOMOLOGY
• The 3rd leading cause of death
• 100-300/100,000 pop/yr
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RISK FACTORS
• MODIFIABLE • NON MODIFIABLE
AF increased age
Smoking male gender
HTN Family historyy of
Hyperlipidemia stroke
DM
Asxm Carotid Stenosis
TIA
Heavy Alcohol use
Oral CP
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Risk factors
• HTN
Single most important risk factor
It increases risk for stroke of all types
Also plays a role in SAH
Continuous association b/n both systolic and
diastolic BP and the risk of stroke
• Cardiac disease
Cardio embolism is responsible for ~20% of all
ischemic stroke
Most significant causes are AF, MI, RHD and
ICMP
Non rheumatic AF is the most common cause of
cerebral embolism : average annual risk ~ 5%
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• Risk factor for stroke with AF
older age, HTN , poor LV function, prior cardio
embolism, DM, thyrotoxicosis, LA enlargement,
CHF
• RHD usually causes ischemic stroke when there is
prominent MS or AF
• MI uniformly ischemic and generally embolic
90% in 1st 2 weeks
increased in older age , prior stroke, AF, ant.
Apical MI, thrombosis in LV
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• Carotid artery stenosis • Cigarette smoking
common cause of Major independent risk
factor for ischemic
stroke stroke
Depends on degree The risk associated with
of stenosis smoking is present at
all ages in both sex and
Natural hx of among different racial
Asymptomatic and ethnic groups
stenosis is ~ • DM
2%/yr/stroke rate • Hyperlipidemia
Symptomatic pt • Alcohol
~13% /yr risk of
stroke • Hypercoagulable states
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Risk factors for stroke
Risk factor Cerebral infarction Intracerebral Subarachnoid
haemorrhage haemorrhage
Greater age ++ ++ +
Hypertension ++ ++ +
Ischaemic heart disease ++ 0 0
Atrial fibrillation ++ 0 0
Diabetes mellitus ++ 0 0
Peripheral vascular disease ++ 0 0
Raised haematocrit + 0 0
High cholesterol + 0 0
Low cholesterol 0 + 0
High plasma fibrinogen + 0 0
Smoking ++ + ++
Alcohol _ ++ +
Obesity + + ?
Transient ischaemic attack ++ 0 0
• Hypoglycemia
• Hyperglycemia
• Seizure
• Subdural
Hematoma
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Stroke Mimics
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Stroke Mimics
• Hypoglycemia
• Hyperglycemia
• Seizure Altered consciousness
Hemiparesis
• Subdural (Todd’s paralysis)
History of seizures
Seizure medications
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Stroke Mimics
• Hypoglycemia
• Hyperglycemia
• Seizure
• Subdural Altered consciousness
Hemiparesis
Signs of trauma
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CONDITIONS IN THE TROPICS
• HIV positive
consider CNS infection, e.g. toxoplasma, CMV. Also
lymphoma.
• Syphilis
• Cerebral abscess
• Neurocysticercosis
• Tuberculoma
• Echinococcus cysts
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Transient ischemic attacks (TIA)
• Symptoms and signs resolve within 24
hours (most within 30 minutes).
• As many as 20% may sustain a small
infarct visible on CT.
• 5-10 times risk of subsequent stroke.
• Only 15% of strokes are preceded by a
TIA.
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TIA - differential
• Focal epilepsy and migraine may cause
transient focal neurological symptoms.
• Transient global amnesia causes loss of
recent memory without other cognitive
impairment.
• Hypoglycaemia may cause transient
hemiparesis.
• Vertigo and dizziness rarely due to TIA.
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Pathophysiology of Ischemic stroke
• Occlusion of intracranial vessel
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CON..
• Ischemic Penumbra ► tissue
surrounding the core region of infarction is
ischemic but reversibly dysfunctional
• Ischemic penumbra eventually will infarct
if no change in flow occurs
Saving the ischemic penumbra is the
goal of thrombolytic Rx and newer Rx
under Ix
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Clinical Features of stroke
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CON….
• Stem:
contralateral hemiplegia
Hemianaesthesia
homonymous hemianopia
with dominant hemisphere : global aphasia
• Upper division
Hemiparesis usually affects face and arm more
than the leg
Broca aphasia more common
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CON….
• Lower division
Wernicke type aphasia with dominant hemisphere
Behavioral change with non-dominant infarction
• Lenticulostriate branches
Lacunar infarction with involvement of theInternal
capsule producing a syndrome of pure motor
hemiparesis
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ACA Posterior circulation
uncommon <3 P1 3rd CN palsy with
contralateral
Contralateral weakness ataxia(Claud’s syndrome)
involving primarily the or with contralateral
lower extremity and to hemiplegia of face, arm
lesser extent the arm and leg(Weber’s
Impaired memory and syndrome)
abulia P2 Contralat.
Ant. Coroidal artery Homonymous
syndrome hemianopia with macular
sparing
Hemi paresis
Hemi sensory loss
Hemianopia
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CON….
Vertebral artery
Lat. Medullary syndrome/Wallenberg synd.:
• Vertigo, numbness of ipsilateral face and
contralat. Limbs, diplopia, hoarsness,
dysarthria, dysphagia and ipsilateral Horner’s
syndrome
Basilar artery
Locked in syndrome:
quadriplegia and aphonia
Complete Basilar occlusion is easy to recognize: bilateral long tract
signs motor and sensory with signs of CN palsy and cerebellar
dysfunction
Superior Cerebellar artery occlusion
Severe ipsilateral cerebellar ataxia, nausea and vomiting, dysarthria,
contralateral loss of pain and To sensation over the extremities, body
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CON….
Lacunar syndrome
Syndrome of small vessel disease
Results in infarcts < 2cm in size
This same vessels are responsible for typical
location of HTNive ICH
>20 described lacunar syndromes
Pure motor hemiparesis
Pure sensory stroke
Ataxic hemiparesis
Dysarthria – Clumsy hand syndrome
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Diagnosis
• Hx: a number of features in the Hx may be
useful in determining the type of stroke
Clinical course, etiology, previous TIA,
activity at onset or just before the stroke,
associated sxs
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Embolic Thrombosis ICH
Clinical course Most often occur Fluctuates Progresses
suddenly, maximal Progressive in gradually during
at onset step wise minutes or few hrs
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INV
LAB MRI
CBC, PT, PTT, U/A, ESR, Documents the extent and
VDRL, ANA, FBS, Lipids, RFT, location of infarction in all
CXR, ECG, ECHO areas of the brain
Imaging: Is less sensitive than CT in
CT performed to deff ischemic detecting acute blood.
from hemorrhagic infarct may DW imaging is more sensitive
not be seen reliably for 24-48h. for early brain infarction
Limited sensitivity to acute MRIP brain regions showing
ischemic changes 40-60% in poor perfusion but no
the first 6hrs abnormality in diffusion are
Remains the best method for considered equivalent to
detection of ICH ischemic penumbra.
Contrast enhanced CT add Spf MRAngiography highly
by showing contrast sensitive for a stenosis of extra
enhancement of sub acute cranial ICA
infarcts.
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CT SCAN; Ischemia
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Lab con
Cerebral angiography:
Gold standard for identifying and
quantifying athesc stenosis of the cerebral
arteries
Carotid duplex u/s to identify and quantify
a stenosis at the origin of ICA
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INTRAPARENCHYMAL HAEMORRAGE
• Most common type of ICH
• Account for about 10% of all stokes
• Associated with 50% of case fatality
• Incidence higher in Asian & AM
CAUSES:
HTN
TRAUMA
CEREBRAL AMYLOID ANG
RISK:
advanced age
heavy alcohol consumption
cocaine use
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INTRAPARENCHYMAL HAEMORRAGE
• Results from spontaneous rupture of a small penetrating
artery deep in the brain
• Most common sites:
basal ganglia
deep cerebellum
pons
• Most hypertensive IPH develop within 30-90\min
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CLINICAL
• Almost always in awake & some times
stressed pt
• Abrupt onset of focal neurologic deficit
typically worsen over 30-90\min
• Diminished level of consciousness
• Headache & vomiting
• Seizure uncommon
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SIGNS
• Putamen: contralateral hemiparesis
• Thalamic: contralateral hemiplegia ,prominent
sensory deficit ,typical ocular disturbances
• Pontine: deep coma with quadriplegia ,pin point
pupils
• Cerebellar: develop over several hours occipital
headache ,repeated vomiting, ataxia of gait &
dizziness or vertigo
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IMAGING
• CT
– the most reliable
– after 2 wks value decreases → mimic infarct
• MRI ,CT angiog:
– when the cause of ICH is uncertain
– if pts presented >1-2wks after onset
– younger non hypertensive
– hematoma is unusual site for HTN
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hemorrhage
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Subarachnoid Hemorrhage
• Characterized by extravasations of blood into the spaces
covering the CNS that are filled with CSF
• common cause of SAH:
– head trauma
– rupture of saccular aneurysm ~ 80% of cases
– vascular anomaly and extension from 10 ICH
• Incidence accounts for 2-5% of all new strokes
• Affects 21000-33000 popn each yr in US
• Aggregate world wide incidence is ~ 10.5 cases/100,000
persons/yr
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.
• .
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• Incidence increases with age:
– mean age at presentation is 55yrs
• Risk for women is 1.6x that of men
• Risk for blacks is 2.1 x that of whites
• Average case fatality rate is 51% and
accounts for 5% of deaths from stroke
• Most deaths occur within 2wks after the
ictus, 10% before pt receives medical
attention, 24% within 24 hrs after the event
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SAH
Forms of Aneurysm
1. Saccular aneurysm :
3 most common locations are the terminal ICA, MCA bifurcation
and top of basilar artery
Annual risk of rupture for aneurysm
< 10mm in size ~ 0.1%
> 10mm 0.5-1%
Risk of rupture ~ 6% in the 1st yr after identification
2. Mycotic aneurysm :
Located distal to the 1st bifurcation of major arteries of the circle
of Willis
Most result from infected emboli due to bacterial endocarditis
3. Atherosclerotic aneurysm: rarely rupture
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CON…..
• Aneurysm size and sites are important in
predicting risk of rupture:
– those > 7mm in diameter
– those at top of Basilar artery and
– at origin of Post. Communicating artery are at high
risk of rupture.
• Major modifiable risk factors
– Cigarette smoking
– HTN
– Cocaine use
– Heavy alcohol use
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Clinical Manifestation
• Sudden transient loss of consciousness: ~½ pts
• Severe headache: ~ 45% pts
• Nausea, vomiting, neck pain and photophobia
• P/E
– Retinal hage
– Meningismus
– Focal neurologic deficit
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Diagnosis
CT:
– a good quality CT will reveal SAH in 100% of cases within 12 hr
after onset of Sxs and in > 93% within 24 hr
– Can also demonstrate intraparenchymal hematoma,
hydrocephalus and cerebral edema
– Can locate the underlying aneurysm
– Most reliable test for predicting cerebral vasospasm and poor
outcome
– Sensitivity drops to 50% at 7days
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DIAGNOSIS
LP:
– should be performed in any pt with suspected SAH and
negative or equivocal results on CT
– the CSF should be collected in 4 consecutive tubes
The findings:
─ increased OP, increased RBC count that doesn’t diminish from
tube 1 to tube 4
Xanthochromia:
> 12 hr to develop
Cerebral angiography or CT angiography:
– localize and define the anatomic details of the aneurysm
• ECG
• Electrolytes
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Complications
1. Rebleeding :
• Incidence ~ 30% in un Rxed SAH
• Peak in 1st 7days
• Associated with 60% of mortality
• Can be prevented with early Rx
2. Hydrocephalus
• Complicates 20% of pts
• Develops insidiously
• Caused by decreased absorption of CSF
3. Vasospasm
• Sxic vasospasm in ~ 30- 46%
• an inflammatory rxn in the blood vessel wall
• Develops b/n 4 and 12 days after SAH
• The best predictor for vasospasm is the amount of blood seen in the
initial CT
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4. Hyponatremia
• Seen in 1/3rd of pts
• Develops in the 1st 2wks ff SAH
• Results from inappropriate secretion of vasopressin and
secretion of atrial and brain natriuretic factors which produce
natriureses
5. Seizure
• Seen in up to 1/3rd of pts
• May lead to rebleeding
• Prophylactic anticonvulsant mandatory
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