Date post: | 12-Apr-2017 |
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Neurosurgery-Stroke
Haybusak university 5th year medicine dr. Avet Petrosyan
By:Hanoon Alsana
Sergio Mogalyan10.03.2017
DEF IN IT ION
• Stroke is defined by the World Health Organization as a clinical syndrome consisting of ‘rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin’.
CL ASS IF ICAT ION OF STROKE
Hemorrhagic (20% of Strokes)
Thrombotic 50%
Embolic 30%
Intracerebral Hemorrhage
15%
Subarachnoid Hemorrhage
5%
Ischemic (80% of Strokes)
Each year nearly 800,000 people have a new or recurrent strokeA stroke happens every 40 secondsStroke is the fifth leading cause of death in the U.SEvery 4 minutes someone dies from strokeUp to 80 percent of strokes can be preventedStroke is the leading cause of adult disability in the U.S
ST R O K E BY N U M B E R S
T Y P E S O F S T R O K E
80% Ischemic
20 % hemorrhagic
EVALUAT ION OF STROKE
• 1. symptoms • 2. Localize of lesion• 3. type of stroke• 4. cause• 5. The clinical assessment
THE MAIN SYMPTOMS
INVEST IGAT IONS
• full blood count, serum electrolytes, renal function tests, cardiac enzymes, and coagulation studies
• Blood sugar• An electrocardiogram (ECG) : arrhythmias and
myocardial infarction• Echocardiography : valve disease and intra-
cardiac clot
NEUROIMAG ING
• Brain CT scan: sensitive to the intracranial blood
• MRI: better at detecting posterior fossa lesions Pons or cerebellum
• carotid ultrasound• doppler ultrasound: speed and direction of
the blood stream
PO O R P RO G N O ST IC FAC TO RS
• Accompanying fever
• Hypotension and severe hypertension• Low oxygen saturation• Hyperglycaemia and hypoglycemia• heart failure• severity of hemiparesis
M A N AG EM ENT: A I RWAY A N D V EN T I L AT ION
• Foreign Bodies, dentures, tongue• Indications for intubation:- hypoxia (pO2 <60 mm Hg or PCO2 >50 mm
Hg) - risk of aspiration with or without impairment of arterial oxygenation
• elective tracheostomy: after 2 weeks of prolonged coma or pulmonary complications
MANAGEMENT:VOLUME STATUS
• Hypovolemia has been associated with worse outcome and increased mortality in acute ischemic stroke
• Isotonic saline, typically 3 litres per day is given• Do not give hypotonic solution, eg 5% Dextrose
in water, as it may worsen cerebral oedema
MANAGEMENT:TEMPERATURE
• Fever worsens outcome:• 1. increased metabolic demands• 2.enhanced release of neurotransmitters
• for every 1°C rise in temp, risk of poor outcome doubles
• Greatest effect in the first 24 hours
• Treat aggressively with acetaminophen
M AN AG EM EN T:BLO O D P RESSU RE
• lowering of blood pressure by approximately 15 percent during the first 24 hours after stroke onset is suggested
1. Labetalol IV2. Nicardipine infusion 3. oral agents (captopril, calcium channel blockers)
• Systolic blood pressure > 185 and diastolic > 110 is a contraindication for thrombolysis
M AN AG EM EN T: BLO O D PRES SU RE
Reducing formation of brain edema
lessening hemorrhagic transformation
preventing early recurrent stroke
MANAGEMENT:GLYCAEMIC CONTROL
Hyperglycemia may augment brain injury by several mechanisms including:
• increased tissue acidosis• free radical generation• increased blood brain barrier permeability
MANAGEMENT:GLYCAEMIC CONTROL
• Hypoglycemia- Hypoglycemia can cause focal neurologic deficits mimicking stroke
• Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients withacute ischemic
stroke
ANT I COAGUL ANTS
• Heparin 5,000 units 12 hourly(or 8hrly)• unfractionated heparin may be considered
for prevention of DVT in patients with intracerebral hemorrhage
ANT IPL ATELET AGENTS
• Aspirin prevent risk of recurrent by 13%
• Aspirin –within 48hrs – reduce risk of mortality/ disability in ischemic stroke
• Anti-platelets contraindicated in hemorrhagic stroke
Tissue Plasminogen Activator TPA< first three hours following the onset of symptomsContraindicated in hemorrhagic stroke
T H R O M BO LY T I C S
M ED IC AL CO M PL ICAT IO N S O F ST RO K E
• 85% of patients with stroke • 50% of mortality after the first week of stroke• the most important causes of mortality in the
early period following a stroke are cardiac (arrhythmias, myocardial infarction), infections (pneumonia, urosepsis), and venous thrombo-embolism (pulmonary embolus)
MEDICAL COMPL ICAT IONS IN HOSP ITAL IZEDPAT IENTS WITH STROKE
Complications of Immobility• Deep vein thrombosis/pulmonary embolism• Falls• Pressure sores or ulceration Infections• Chest infection- aspiration pneumonia• Urinary tract infection
MEDICAL COMPL ICAT IONS IN HOSP ITAL IZEDPAT IENTS WITH STROKE
Pain• Shoulder pain in the weak limb• Central post-stroke pain Neuropsychiatric Disturbances• Depression, anxiety ,Emotional incontinence• Acute confusional states (delirium) Miscellaneous• Cardiac complications (arrhythmia, myocardial
ischemia)• Gastrointestinal complications( bleed,
Constipation)• Sleep apnea
SURG ICAL MANAGEMENT
• Ischemic stroke: A) endovascular interventions: angioplasty and
stenting B) carotid endarterectomy C) bypass surgery
• Hemorrhagic stroke: Surgical evacuation of hematoma
SURG ICAL MANAGEMENT
SURG ICAL MANAGEMENT
• Subarachnoid hemorrhage: Clipping and coiling of aneurysm
• Cerebral edema Decompressive craniectomy
SURG ICAL MANAGEMENT
• Intra ventricular hemorrhage /acute hydrocephalus: Ventricular drainage
SURG ICAL MANAGEMENT
VENTRICLES
ventricles catheter
what type of stroke?
what type of stroke?
thank you…