Mangament of Ischemic Cerebral

vasculaire accident in a resource

limited setting
Dr. Mulenga E .M. L., MD,MBA
 Demographics
• Name: j M
• Age: 60
• Gender: Male
• DoA: 5th may, 2017
 AT NCH – ON ADMISSION
• Presenting complaint:
– severe headache 1/7
– left sided paralysis 1/7

• HOPC:
- sudden onset of the above symptoms while
patient was at night duty as a security guard.
Patient reports having suddenly lost balance.
no hx of HTN,DM or EpilepsyFamily hx:
nil of note
 Review of Systems

• CNS: headache,neckache,no photophobia

• CVS: No palpitations,no PND nor Orthopnoea.
• RS: Nil of note
• GIT: nil of note
• GUT: nil of note
 Past Medical History
• RVD NR (documented)
• No DM, HTN, Epilepsy, TB

Drug/Allergic/Surgical Hx
• Nil of note
 Family Hx
• No similar illness in an close or distant
relations

Social Hx
• Alcohol: used to drink heavily 17yrs ago,no
longer drinks
• Smoking: Nil
 EXAMINATION
• P0, J0, C0
• General condition: ill looking elderly man
• Vitals:
– BP 143/78mmHg Pulse: 178/min regular with
good vol.
– SPO2: 97%
– T: 36.5
• CNS: GCS 15
effacement of left nasolabial fold
efaacement of wrinkle fold (lower motor neurone affection)
slight deviation of mouth to the right
muscle power. Right upper and lower limbs=5
Left upper and lower limbs= 0

Chest: clear,equal air entry

• CVS: S1S2 heard and normal
pulse good volume

• Abdomen: soft, no organomegaly noted

 IMPRESSION
• Ischemic CVA
– DDX
• hemmoragic CVA
• meningitis
• Brain tumeur
• HIV disease( CNS OI)
 Investigations
• Tests Ordered
• LABs
– FBC/DC
– lipogram
– RBS
– X-Match
– U and Es + Creatinine
– LFT
– HIv test
– RDT/MPS

• Imaging
– CT Brain
– ECG,CXR
 Initial Treatment
Investigate as above
• Add
– Atovarstatin 20mg OD
– vit Bcomplex 1tab PO OD
• Consult Physiotherapy
Patient was Discahrged on
-ASa 300mg PO od
Atovastatin 80mg PO OD
Antihypertensives
PHysiotherapy sessions
 Other results obtained

• CXR: clear
• ECG: RBBB
DIAGNOSIS

Ischemic Cerebral Vascular

Accident
 DEFINITIONS
• WHO definition of stroke:
Rapidly developing clinical signs of focal (or global)
disturbances of cerebral functions with symptoms
lasting 24hours or longer leading to death with no
apparent cause other than vascular origin.

By this definition is excluded, TIA<24hrsand

patient with stroke symptoms caused by subdural
hematoma,tumors, poisoining or trauma
 EPIDEMIOLOGY
• Global epedimiology:
– Annually 15 million world wide suffer a stroke-5 million die, 5 million
are permanently disabled.
– WHO estimates that a stroke occurs every 5 seconds
– Stroke accounts for 10% of deaths world wide.
– Second leading cause of Death
 Stroke in Zambia
The annual mortality rate per 100,000 people from ischemic
stroke in Zambia has increased by 51.1% since 1990, an
average of 2.2% a year.

he deadliness of ischemic stroke in Zambia peaks at age 80+. It kills

men at the lowest rate at age .
Women are killed at the highest rate from ischemic stroke in Zambia
at age 80+.

Hypertension was said to be the first cause of stroke followed

by Dietary risks.
 Back ground
cureent guidelines, Time and resource
dependant
established guidelines require emergent CT
brain,acute transfer to specialized unit
guidelines emanate from high resource limited
areas
 Classification
Thrombosis -in situ obstruction of an artery

Embolism- Particles of debris originating elsewhere that block

arterial access to a particular brain region.

Systemic Hypoperfusion- More general circulatory problems

manifesting itself in the brain and perhaps other organs
 CLINICAL FEATURES
• unilateral motor deficit
• higher cerebral function deficit(aphasia or neglect)
• ataxia, diplopia , vertigo (may indicate brain stem or
cerebellum affection)
 DIFFERENTIAL DX
• Space occupying lesions( Abces, tumors,subdural
hematoma)
• subarchnoid hemorrage
• hypoglycemia
• syncope
• Seizures
 NIH score
• Designed for acute stroke trials.
• Quick (5-10 min) & reproducible.
• Requires speech/language cards & safety pin.
• Quantifies clinical stroke deficit:
• < 4 = mild stroke
• > 15 = poor prognosis if no treatment
• > 22 =  risk for ICH
 cont’d
• 1a. LOC
• 1b. LOC questions
• 1c. LOC commands
• 2. Best gaze
• 3. Visual fields
• 4. Facial palsy
• 5a. Right arm motor
• 5b.Left arm motor
6a. Right leg motor
• 6b. Left leg motor
• 7. Limb ataxia
• 8. Sensory
• 9. Best language
• 10. Dysarthria
• 11. Extinction/
• inattention
 rosier scale
• has there been any loss of consciousness
• seizure activity y or n -
• is there new acute onset or no?
-asymetrical facial weakness
-asymetrical leg weakness
-speech disturbance
-visual field defect
Total score -2 to 5, score of one or more suggest
stroke is present,zero or less suggest stroke unlikely
but not completely excluded
 Evaluation and Treatment
• Initial work up

• Stat CT brain or MRI

• ECG

• LABs:
• CBC, Platelet, PT, PTT
• Accucheck & blood glucose, serum electrolytes
• Cardiac markers, ABG’s,Lipid profile
• Blood alcohol level, Toxicology screen, Pregnancy test
 Admission checklist in a low income
setting
• Airway- Can patient protect airway i.e can
he/she swallow without evidence of aspiration
• breathing- check Oxygen saturation, O2
if<95%
• Circulation are peripheral perfusion,pulse and
BP adequate.treat as appropriate
Cont’d
 cont’d
• Temp- pyrexia,treat as early as possible and
rule out any infection
• Pressure areas-formally address and reduce
risk,treat infection
• Incontinence- avoid catheterisation unless
acute retention or incontinence threatening
pressure areas.
 summary
• while further research is needed to establish
evidence based outcomes when resources are
limited, tthe check list provides foundational
essentials for acute stroke care and evaluation
based on current optimal practices
• establish ‘stroke protocol’ using current best
practices and resources available.
 TIME IS BRAIN
• THANK YOU!
 BIBILIOGRAPHY
• Aaron L Berkowitz a
• Managing acute stroke in low-resource settings
• a. Department of Neurology, Brigham and Women’s Hospital, Harvard
Medical School, 75 Francis Street, Boston, MA 02445, United States of
America.
• Bulletin of the World Health Organization 2016;94:554-556.

• Thomas K et al., Epidemiology of Ischaemic and hemorrhagic cerebral

vascular accident., Lancet 2008

• Global disease health burden. Heath groove.com

• The Socio-economic Impact of Stroke on Households in Livingstone District,
Zambia: A Cross-sectional Study
• M Mapulanga, S Nzala,1 and C Mweemba1