Prof. Kanu BalaMBBS, PhD [USTC], PhD [DU], FRCP [Dublin], FRCP [Edinburgh]
Professor of Medicine
Gonoshasthaya Samajvittik Medical College
Savar, Dhaka, Bangladesh
Management of Stroke
Savar GK Hospital
About 20% of the patients admitted in the medicine wardAcute stroke patients or receiving physiotherapy
What is a Stroke?
• Stroke is classically characterized as a focal neurological deficit for more than 24 hours attributed to an acute focal injury of central nervous system by a vascular cause
What is TIA & Silent Stroke?
• Transient Ischaemic Attack [TIA] is stroke symptoms and signs that resolve within 24 hours
• Silent Stroke is any brain changes identified on neuroimaging or neuropathological examination without any history of stroke or TIA
Who Defined Stroke First?
• Hippocrates (460 to 370 BC) used the term ‘Apoplexy’ to describe very acute non-traumatic brain injuries
• The word ‘Stroke’ was first introduced in 1689 by ‘William Cole’
What is Stroke’s Impact?
• Stroke is the third most frequent cause of death after cancer & coronary artery disease, accounting for 6.4 million deaths (12% in 2013)
• About 3.3 million deaths resulted from ischemic stroke while 3.2 million deaths resulted from hemorrhagic stroke
• In 2010 approximately 17 million people had a stroke (180-300 per 100,000 population annually) and 33 million people had previously had a stroke and were still alive
What is Stroke’s Impact? – contd.
• Between 1990 and 2010 the strokes decreased by 10% in the developed world and increased by 10% in the developing world
• One-fifth of the patients with an acute stroke die within a month, half of those survived have physical disability
• About half of people who have had a stroke live less than one year
• South Asians are at high risk for stroke, accounting for 40% of global stroke deaths
What are the Types of Stroke?
• Ischaemic Stroke [85%]: – Caused by a blockage in the blood vessel of the brain
• Haemorrhagic Stroke [15%]: – Caused by rupture of a weakened blood vessel due to
aneurysm or arteriovenous malformation
What Causes Ischaemic Stroke?
• Thrombus: Formed within the vessel– Thrombosis in situ 20%
• Embolus: A travelling particle – From carotid artery & aortic arch 20%– From heart 20%
What Causes Haemorrhagic Stroke?
• Haemorrhage due to rupture of weakened blood vessel due to aneurysm or arteriovenous malformation :– Brain Parenchyma 10%– Subarachnoid Space 5%
What are the Risk Factors?
What are the Risk Factors? Not Modifiable:
• Age • Sex [Male > Female]• Race [Afro-Caribbean >
Asian > European]• Previous vascular events
– Myocardial infarction– Stroke– Peripheral vascular
• Heredity
Modifiable:
• Blood pressure• Cigerette smoking• Hyperlipidaemia• Heart disease
– Atrial fibrillation– CCF– Infective endocarditis
• Diabetes mellitus• Excessive alcohol intake• Oestrogen drugs• Polycythaemia
What are the Effects of Stroke?
What are the Effects of Stroke?
What are the Effects of Stroke?
How Stroke Can Be Suspected?
What Are The Stroke Warning Signs?
What Are The Clinical Examinations?
What is the Differential Diagnosis?
Structural Stroke Mimic
• Primary cerebral tumours• Metastatic tumours• Subdural haematoma• Cerebral abscess• Peripheral nerve lesions• Demyelination
Functional Stroke Mimic
• Todd’s paresis• Hypoglycaemia• Migrainous aura• Focal seizures• Meniere’s disease• Conversion disorder• Encephalitis
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Neuroimaging
Investigations: Vascular Imaging
Investigations: Risk Factors
Diagnostic question Investigation
Is there any cardiac source of embolism ?
ECG24 hour ECGElectrocardiogram
What are the risk factors? Chest X-rayFull blood count, Hb%, ESRLipid profileBlood glucoseBUN, CreatinineElectrolytes Prothrombin time, PTT
Is it subarachnoid haemorrhage? Lumber puncture
Is there an unusual cause? Serum protein electrophoresisClotting/ thrombophilia Syphilis screening
What Is the First Thing To Do?
• Early admission to a specialized stroke unit facilitates coordinated care from a multidisciplinary team
• Reduces both mortality and residual disability amongst the survivors
Pharmacological & Surgical Treatments
Thrombolysis Intravenous thrombolysis with recombinant tissue plasminogen activator [rt-PA]Given within 4.5 hours of symptom onset
Aspirin 300 mg daily started immediately, then 75 mg/dayWhen rt-PA given, withheld for at least 24 hours
Heparin Heparin should not be used routinelyIntracranial haemorrhage must be excluded
Coagulation abnormalities
Coagulation abnormalities should be reversedUse of clotting factors is not useful
Surgery Carotid endarterectomy is most effective with patients with severe stenosis [70-99%]Within first 2 weeks of the TIACarotid angioplasty and stenting not so useful
What is the Role of Treatment?
Treatment Target group Eligible for treatment
Number treat to prevent 1 death
Aspirin Acute ischaemic stroke 90% 80
Thrombolysis with tissue plasminogen activator [rt-PA]
Acute ischaemic strokeWithin 3 hoursWithin 3-4.5 hours
10%10%
920
Hemicraniectomy Large cerebral infarction <1% 2
Stroke unit care Acute care 80% 20
What Are The Supportive Cares?
• Airway: Examine airway and perform bedside swallow screening and keep patient nothing by mouth if swallowing unsafe and aspiration occurs
What Are The Supportive Cares?
• Breathing: Check respiration and oxygen saturation and give oxygen if saturation <95%
What Are The Supportive Cares?
• Circulation: Check peripheral perfusion, pulse and blood pressure and treat abnormalities with fluid replacement, anti-arrhythmics and inotropic drugs as appropriate
What Are The Supportive Cares?
• Hydration: If signs of dehydration, give fluids parenterally or by nasogastric tube
What Are The Supportive Cares?
• Nutrition: Assess nutritional status and provide nutritional supplements if necessary. If dysphagia persists for >48 hours, start feeding via nasogastric tube
What Are The Supportive Cares?
• Medication: If patient is dysphagic, consider alternative routes for essential medications
What Are The Supportive Cares?
• Blood Pressure: unless there is heart or renal failure, evidence of hypertensive encephalopathy or aortic dissection, do not lower blood pressure in first week
What Are The Supportive Cares?
• Blood Glucose: Check blood glucose and treat when levels are >11.1 mmol/L [by insulin infusion or glucose/potassium/insulin]. monitor closely to avoid hypoglycaemia
What Are The Supportive Cares?
• Temperature: If pyretic, investigate and treat underlying cause. Control with antipyretics, as raised brain temperature may increase infarct volume
What Are The Supportive Cares?
• Pressure Areas: Reduce risk of skin breakdown by treating infection, maintaining nutrition, providing pressure relieving mattress, and turning immobile patients regularly
What Are The Supportive Cares?
• Retention, Constipation, & Incontinence: Check for constipation and urinary retention; treat appropriately. Avoid urinary catheterization unless patient is in acute urinary retention or incontinence is threatening pressure areas
What Are The Supportive Cares?
• Mobilization: Avoid bed rest & early mobilization is helpful for early recovery
What are the Complications of Stroke?
Complications Prevention Treatment
Chest infection Nurse semi-erect, avoid aspiration, nasogastric tube
Antibiotics, physiotherapy
Epileptic seizures Maintain cerebral oxygenation avoid metabolic disturbances
Anticonvulsants
DVT/ Pulmonary embolism
Hydration, early mobilization, anti-embolism stockings, heparin
Anticoagulats
Painful shoulder Avoid traction injury, support, physiotherapy
Physiotherapy, local corticosteroid inj.
Pressure sores Frequent turning, monitor pressure, avoid urine injury
Nursing care, mattress
Urinary infection Avoid catheterization antibiotics
Constipation Appropriate aperients, diet Appropriate aperients
Depression/ anxiety Maintain positive attitude, provide information
antidepressants
What is the Risk of Further Stroke?
ISCHAEMIC STROKE/ TIA
• 5-10% within 1st week• 15% in the first year• 5% per year thereafter
HAEMORRHAGIC STR.
• 5-10% within 1st week• 15% in the first year• 5% per year thereafter
Secondary Prevention of StrokeINTERVENTIONS
Antiplatelet drugs • Aspirin 300 mg at once, then 75 mg daily• Clopidogrel 75 mg daily if aspirin intolerant
Lower cholesterol • If total cholesterol > 135 mg/dL• Simvastatin 40 mg nocte, after checking LFT
Lower BP • If BP > 130/70 mmHg 1-2 weeks after onset• Thiazide diuretics • ACE inhibitors or other agents
Cartotid endarterectomy • If > 70 % stenosis on symptomatic side
Warfarin • Atrial fibrillation
Lifestyle • Smoking cessation• Lower salt intake• Lower fat intake• Lower excess alcohol intake• Increase exercise• Lose excess weight
Stroke Rehabilitation Team
• Consultant physicians• Nurses• Physiotherapists• Occupational therapists• Speech therapists• Clinical psychologists• Rehabilitation assistants• Social workers
Stroke Rehabilitation
Conclusion
• Supportive care is the cornerstone of stroke management
Thank YouThank You
Poppy Bala25 November 2013
Dr. Poppy Bala