Stroke

Introduction Cerebrovascular disease is the most common acute neurologic illness. It is also the most important cause of disability for adults and the third leading cause of death for both men and women. Stroke is defined as rapidly developing clinical signs of disturbances of cerebral function lasting more than 24 hours with no apparent cause other than that of vascular origin.

The use of the term "brain attack" has been championed by the educational campaigns of national health organizations to help inform the public about the urgency of stroke.
Transient ischaemic attack ( TIA) is an acute loss of focal brain function with symptoms lasting less than 24 hours.

Epidemiology Stroke is the third commonest cause of death for both men and women. Stroke occurs in all age groups across the world, although the risk increases markedly with age - 90% of all stroke cases are in people who are 55 or older. Stroke incidence is higher among men than women, and mortality increases with age reaching major proportions after age 55. Incidence: 1-2 per 1000 population per year. Prevalence: 5 per 1000 population.

Pathological types: It has been estimated that 80 % of stoke are due to brain infarction, 10 % to intracerebral haemorrhage and 10 % to subarachnoid haemorrhage.

Causes: Ischaemic stroke Atherothrombosis Embolism from heart or from a plaque complicated by thrombosis in
an extracranial artery

Inflammatory vascular disease: Giant-cell arteritis,Takayasu's

disease , Systemic lupus erythematosus, meningitis, syphilis) Hematologic abnormalities lead to thrombosis include deficiencies of proteins C and S and antithrombin III; sickle cell anemia; hyperhomocystinemia; and antiphospholipid antibody (aPL) syndrome.

Haemorrhagic stroke: HTN, aneurysm, AVM , Trauma, amyloidosis Haematological disorders: Haemophilia, leukemia Subarachnoid haemorrhage: aneurysm, AVM

Risk Factors
HTN DM Cardiac Disease Smoking Previous TIA hyperlipidaemia Alcohol Raised haematocrit

All patients evaluated for stroke should have an emergent computed tomography (CT) scan of the brain to rule out other potential mimics of an ischemic event such as an intracranial tumor, abscess, or hemorrhage.

The following investigations should be done for all patients to evaluate and determine the most likely cause of a stroke : Chest x rays, and laboratory studies ( CBC, platelets, ESR, RFT, blood glucose , electrolytes and urine analysis). Additional diagnostic testing in selected cases, such as electrocardiography (ECG), carotid ultrasound and transcranial Doppler ultrasonography, magnetic resonance imaging (MRI), echocardiography, abdominal US, fasting lipids, clotting screen, autoantibodies, blood culture, treponemal serology may be used in the subsequent evaluation to determine the cause of a stroke.

Angiography: indications for cerebral angiography in stroke patients : To identify a suspected intracerebral arteriovenous malformation or aneurysm in patients with intracerebral haemorrhage (in atypical location of hypertensive angiopathy) for whom active surgical management is contemplated. Investigation of primary subarachnoid haemorrhage.

Features of Stroke
MCA: Hemiparesis ( arm > leg) hemianaesthesia Dysphasia ACA Hemiparesis ( leg > arm), urine incontinence.

PCA: Hemianopia, cortical blindness, amnesia, thalamic pain.

Basilar: ataxia, diplopia, nystagmus, dysphagia, facial weakness, loss of consciousness.

The differential diagnosis

Trauma (eg, subdural hematomas); Tumour Seizures Acute metabolic disorders

Medical complications
Many medical complications of stroke are preventable or controllable. These include fever, dysphagia/aspiration pneumonia, deep vein thrombosis (DVT), decubitus ulcers, fluid/electrolyte problems, hyperglycemia, pulmonary embolism, and urinary tract infection.

Neurologic complications
Several neurologic sequelae occur in the acute period of stroke. Cerebral edema/herniation. Seizures. About 5% to 10% of patients with stroke have seizures, one-third of which occur within the first 2 weeks.

Management of acute stoke

General measures Careful nursing: Regular turning of patient to avoid pressure sores, skin kept dry and clean. Care of airway: Oropharyngeal tube with regular suction of secretions if patient unconscious. Fluids balance: Nasogastric feeding if patient cannot swallow, bladder catheterisation if patient incontinent. Physiotherapy: Start immediately to prevent joint contractures, to clear chest secretions, to promote recovery of strength and coordination. Speech and occupational therapy to assess functional problems and to encourage recovery of skills.

Medical treatment
Rapid lowering of blood pressure should be avoided unless it is critically high ( persistent diastolic pressure higher than 120 mm Hg ) and of course hypotension should be reversed. Intravenous solutions that contain excessive amounts of free water such as 5% dextrose may increase cerebral edema and are contraindicated. A solution of 5% dextrose and 0.45% normal saline is preferable.

General precautions:

Acute Stroke Therapy Tissue plasminogen activator (tPA): Intravenous (IV) tissue plasminogen activator (tPA) has been proven to be beneficial for carefully selected patients who can be treated within 3 hours of onset of ischaemic stroke.

Anticoagulants
The possible indications for heparin in acute cerebral ischemia include: -Deep vein thrombosis prophylaxis.

-Progressing stroke -Vertebrobasilar ischemia. -Permanent source of embolism e.g Cardioembolic stroke ( Prosthetic valves, Atrial fibrillation ).

Oedema-reducing agents Osmotic agents such as mannitol or glycerol are

probably more effective in reducing ICP. It is important to keep in the mind that these agents may have only a transient benefit, and there is some evidence that a rebound increase in cerebral edema may occur when they are discontinued. The dosage of mannitol is usually 0.5 to 1.5 g/kg IV. The dosage of glycerol is 1 g/kg PO q 6h.

Corticosteroids have not been shown to be effective in

cerebral infarct or cerebral haemorrhage .

Stroke prevention Is directed to the underlying pathologic processes and risk factors such as atherosclerosis, arteritis, cardiac disease, HTN, and so on. The options for treatment or long-term prevention of ischemic or recurrent ischemic stroke include: Oral anticoagulants Antiplatelet agents: Aspirin, Ticlopidine, Dipyridamole, Clopidogrel Carotid endarterectomy (CEA) Angioplasty with placement of stents.

Treatment of intracerebral haemorrhage Medical treatment of intracerebral haemorrhage is supportive. For large cerebellar haemorrhage surgical decompression is required if vital structures of the medulla are at risk. Surgical evacuation of a hematoma is considered for lobar haemorrhage if there is signs of herniation.

Subarachnoid haemorrhage Clinical picture

SAH presents with severe headache of sudden onset that can be accompanied by loss of consciousness at onset. Neck stiffness, photophobia, Nausea and vomiting are due to increased intracranial pressure (ICP) and meningeal irritation. Focal neurological deficits may also occur.

An LP is indicated only if the CT scan is -ve or not available, but the risk of herniation by LP must be considered in patient with impaired conscious level or signs of increased intracranial pressure. The CSF of SAH is uniformly bloody in the early stages and xanthochromic (yellow) after few hours.

Diagnosis History taking and neurological examination are the essential core of the diagnosis of the SAH. Whenever a SAH is suspected, a CT scan is the diagnostic procedure of choice.

Angiography Cerebral angiography is the definitive diagnostic procedure for detecting intracerebral aneurysm(s) or AVM. TCD is recommended every 2-3 days to detect presence of vasospasm.

Management Management of patients with SAH is directed to prevent and manage relatively common complications of SAH, such as rebleeding, vasospasm, hydrocephalus, hyponatremia, and seizures. Bed rest, analgesics to relieve headache and stable maintenance of BP in hypertensive patients are generally recommended. Oral nomodipine in a dose of 60 mg every 4 h P.O is recommended to reduce the poor out come related to vasospasm.

Surgery
Early surgical clipping of the aneurysm is the method of the choice, but interventional endovascular occlusive procedures are occasionally used for surgically unclippable aneurysms such as balloon embolisation or coil embolisation. Complete excision of AVM is the most effective method of treatment of AVM. Embolisation and or stereotactic radiotherapy may provide an alternative method.