Stroke and its management
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The document provides a comprehensive overview of strokes, including definitions, types, risk factors, symptoms, and management strategies. It details the differences between ischemic and hemorrhagic strokes, emphasizing the importance of rapid detection and treatment, as well as the roles of specific assessments and interventions. Additionally, it discusses pharmacotherapy and preventive measures for stroke patients.
Stroke and its management
- 1. STROKE By: Dr. Ankit Gaur Pharm.D, M.Sc, RPh
- 2. DEFINITION Stroke (Cerebrovascular accident, CVA) rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or longer, or leading to death, with no apparent cause other than a vascular origin WHO
- 3. TYPES
- 4. STROKE SUBTYPES Ischemic Stroke (83%)Hemorrhagic Stroke (17%) Atherothrombotic Cerebrovascular Disease (20%) Embolism (20%)Lacunar (30%) Small vessel disease Cryptogenic and Other Known Cause (30%) Intracerebral Hemorrhage (59%) Subarachnoid Hemorrhage (41%)
- 5. ETIOLOGY 1) Non modifiable risk factors • Age • Gender • Race • Family history of stroke • Low birth weight 2) Modifiable • Hypertension • Atrial fibrillation • Diabetes • Cigratte smoking, alcohol • Sickle cell disease • Post menopausal hormone therapy
- 6. 3) Potentially modifiable • Oral contraceptives • Migraine • Drug and alcohol abuse • Hemostatic and inflammatory factors • Sleep disorder
- 7. SIGNS AND SYMPTOMS • Hemorrhagic – Sudden and dramatic sleeps – Violent explosive headache • “worst headache of my life” – Visual disturbance • Flashing lights, aura – Nausea and vomiting – Neck and back pain • Due to blood in sub-arachnoid space – Sensitivity to light – Weakness on one side – Can present like a migraine headache
- 8. Ischemic Stroke 1. Harder to detect 2. Weakness in one side 3. Facial drooping 4. Numbness and tingling 5. Language disturbance 6. Visual disturbance
- 9. Basic Brain Facts • The right side of your brain controls the left side of your body • The left side of your brain controls the right side of your body • Impairments following a stroke depend on where in the brain the stroke occurred.
- 10. Strokes that occur on the left side of the brain He/she may experience the following: • Difficulty moving the right side of the body • Difficulty communicating daily wants and needs • Visual impairments • Behavioral changes • Sensory changes • Cognitive changes such as slowness in initiating activity and responding
- 11. Strokes that occur on the right side of the brain He/she may experience the following: • Difficulty moving the left side of the body • Difficulty knowing where things are in space (for example, over reaching for an object) • Difficulty attending/seeing things on the left side • Visual changes • Cognitive changes such as poor short term memory, attention and problem solving • Difficulty determining what has changed since the stroke and what the impact of those changes are (for example, if a patient can’t walk without assistance, it isn’t safe to try to go to the bathroom alone)
- 12. Seven D’s of STROKE Care • Detection –of STROKE symptoms • Dispatch– of EMS/ MET Team • Delivery – to a facility prepared to manage STROKE • Door to treatment– rapid diagnosis and decision making • Data– CT Scan • Decision– Ischemic or Hemorrhagic, does the patient meet the criteria to receive thrombolytic drugs • Drug – thrombolytics when appropriate
- 13. Use a “FAST” STROKE Assessment • Modification of Cincinnati Pre-Hospital Stroke Screen • Face • Arm • Speech • Time of onset
- 14. FACE • Look for Facial Droop – Have the patient smile or show his/her teeth – NORMAL Both sides of the face move equally – ABNORMAL One side of the patient’s face droops or does not move
- 15. ARMS • Motor Weakness: Look for arm drift by asking the patient to close eyes and lift arms • NORMAL- arms remain extended equally or drift downward equally • ABNORMAL – One arm drifts down compared to the other
- 16. Problem with gripping hands Many elderly have arthritis in hands Hurts to grip hands May mimic weakness
- 17. SPEECH • Ask the patient to say “You can’t teach an old dog new tricks” – Lots of t’s, k’s and c’s • NORMAL –Phrase repeated clearly and plainly • ABNORMAL – Words slurred, abnormal or unable to speak SPEECH • Ask the patient to say “You can’t teach an old dog new tricks” – Lots of t’s, k’s and c’s • NORMAL –Phrase repeated clearly and plainly • ABNORMAL – Words slurred, abnormal or unable to speak
- 18. • Slurring of speech • Unable to think of words • Inappropriate words • Expressive aphasia – unable to speak words – Area of brain where words are created is damaged • Receptive aphasia – unable to understand words – Area where words are interpreted is damaged Abnormal Speech
- 19. TIME OF ONSET • The window of opportunity to effectively treat STROKE is 3 hours (180 minutes) – May be extended to 4 ½ hours in some cases • Need to know “ last known well”. • Difficult when – Patient lives alone – Woke up with symptoms
- 20. 180 minutes • Don’t think of as 3 hours, but 180 minutes • Time gets eaten up fast • Short scene time • Take transport time into consideration
- 21. • Door to doctor 10 minutes • Door to CT completion 25 minutes • Door to CT read 45 minutes • Door to treatment 60 minutes • Access to neurological expertise* 15 minutes • Access to neuro-surgical expertise* 120 minutes • Admit to monitored bed 180 minutes • * by phone or in person • ** National Institute of Neurological Diseases and Stroke
- 22. Assessing the Stroke Patient • Initial Assessment – General Impression – Airway Airway Airway!! – High-flow O2 – Circulation – HIGH PRIORITY TRANSPORT
- 23. Focused history and physical exam Perform thorough neurologic exam. FAST Stroke Screen History of Seizures Headache Nausea/vomiting Neck pain Obtain baseline set of vitals Recheck Vital Signs frequently
- 24. Priorities of care • Conduct general assessment – Trauma – recent or within last month • Recent seizure • Could be a subdural hematoma – Cardiovascular – on heart medications • Does the patient have atrial fibrillation • Does the patient take blood thinners – Pulse oximetry > 94% – Blood sugar treat if able • Low blood sugars mimic a stroke – Pupils
- 25. Body Position • Protect potentially paralyzed parts
- 26. THE BRAIN • The brain requires 20 % of the total blood pumped by the heart. • No storage in the brain for either fuel or oxygen • Requires constant supply of oxygen and glucose.
- 27. BLOOD SUPPLY TO THE BRAIN • Carotid arteries – anterior neck – Large – Frequently congested with plaque – Can be cleaned out surgically • Vertebral arteries – Pass through cervical vertebrae – Well protected – Not accessible for surgical cleaning
- 28. Circle of Willis • Both blood supplies (carotid and vertebral) join on the under surface of the brain. • Fail-safe mechanism in case of a blockage somewhere in circulation • BUT some hard corners in circle where debris can get caught and site of most cerebral aneurysms
- 29. What can go wrong??? • Disruption of blood flow to the brain – Plaque – build up of cholesterol in interior of blood vessel – Foreign debris – blood clot bubble of fluid air – Broken vessel
- 30. ISCHEMIC STROKE • Blockage of blood flow to brain • Progressive Thrombus -- growing – Plaque deposit – similar to process in heart with coronary artery disease • Cerebral Emboli --Clot from somewhere else -- floating debris – Blood clot – Air bubble – Bubble of amniotic fluid – Bone marrow from a fracture
- 31. PATHOPHYSIOLOGY ISHEMIC STROKE • Brain: – 2% of human body’s mass – 20% of cardiac output • Inadequate perfusion: tissue death and functional deficit • Ischemic brain injury: – A series of interlocking thresholds – the “ ischemic thresholds ” – Decrement in regional CBF key pathologic events
- 32. Carotid atherosclerosis Progressive accumulation of lipids and inflammatory cells in the intima of the affected arteries Hypertrophy of arterial smooth muscle cells Plaque formation Stress Plaque rupture ,collagen exposure ,platelet aggregation & clot formation Clot remain in the vessel travel embolism
- 33. Local occlusion thrombus formation arterial occlusion decreasing cerebral blood flow ishemia ishemic cell reduction in nutrients Depletion of high energy phospahtes (ATP) – maintains membrane integrity Extracellular K+ Accumulates & Na and H2O intracellularly Electrolyte imbalance cell swelling & lysis
- 34. leads to depolarization of the cell influx of Ca ions (+) lipases ,proteases, endonucleases ,release of free fatty acids from membrane phospholipids accumulation of free fatty acids (arachidonic acids) Formation of prostaglandins , leukotrienes, free radicals Intracellular acidosis occurs in 2-3 hrs Cell death
- 35. BRAIN STRUCTURE AND ITS FUNCTIONS
- 36. What Is the Cause of Ischemic Stroke? • Atherothrombosis • Embolus: – Material: Red (fibrin rich) or White (platelet rich) – Source: Cardiac? Aortic? Carotid Artery? • Small artery disease • Hypoperfusion: Hemodynamic • Others: arterial dissection, arteritis, etc.
- 37. Ischemic Stroke: Atherothrombosis • Thrombotic – Acute occluding clot – Superimposed on chronic narrowing
- 38. Ischemic Stroke: Cerebral Embolism • Embolic – Intravascular material, most often a clot, separates proximally – Flows through arterial system until it occludes distally – Atrial fibrillation
- 39. HEMORAGHIC STROKE • Aneurysm – weakened area in artery – Congenital – Younger population younger than 40 years – Complain of “worst headache in my life” • Spontaneous Hypertensive Bleed – Due to BP > 200/100 • Malformed Artery – 50% younger than 30 years
- 40. PATHOPHYSIOLOGY OF STROKE Presence of blood in the brain parenchyma , neurotoxicity of the blood Damage to the surrounding tissue & hemorrhage volumes >60ml mortality at 30 days increase in intracranial pressure leads to herniation and death
- 41. DIAGNOSIS • EEG,ECG( Atrial fibrillation) • MRI • CT Scan-hyperintensity (white) –heamorrhage areas normal or hypointense (dark)-infarction areas • Carotid doppler –stenosis in carotid arteries • Laboratory findings 1) Complete blood count 2) Coagulation test- protein c deficiency, anti -phospholipid antibody 3) Blood lipid test 4) Measure of cardiac enzymes like troponin, creatinine kinase LDH isoenzymes
- 42. • Hb, Hcr, thromb, leuc • Glucose levels, CRP, SR, CK, CK-MB, creat • APTT, TT-SPA/INR • Electrolytes, osmolarity • Urine analysis • CSF (if needed for differential diagnosis and only after CT scan, if available) • Others, e.g., coagulation survey, homocysteine for young stroke, rheumotology/immunology screening • Cardiac evaluation: ECG, echocardiography
- 43. Diagnosis: CT Scan – Distinguishes reliably between haemorrhagic and ischemic stroke – Detects signs of ischemia as early as 2 h after stroke onset – Identifies haemorrhage immediately – Detects acute SAH in 95% of cases – Helps to identify other neurological diseases (e.g. neoplasms)
- 44. PHARMACOTHERAPY 1) Non pharmacological treatment •Speech therapy •Psychological therapy •Stroke rehabilitation physical therapy occupational therapy
- 45. PHARMACOTHERAPY 2) Pharmacological •Acute ischemic stroke plasminogen activator (alteplase) with in 3 hrs of onset Dose -0.9 mg/kg I.V aspirin within 48 hrs of onset . Dose -160-325 mg daily started within 48 hrs Secondary prevention of ischemic stroke antiplatelet therapy aspirin 50-325 mg daily clopidogrel 75 mg daily aspirin 25 mg +dipyridamole 200 mg twice daily Anti hypertensive agent Statin therapy AF , Cardiac source of embolism –warfarin (INR-2.5)
- 46. •Heamorrhage stroke Nimodipine ( Ca channel blockers) Carotid stenting
- 47. Antithrombotic Therapies to Prevent Ischemic Stroke Oral anticoagulants Antiplatelet agents Aspirin 50-325 mg/day Ticlopidine 250 mg twice daily Clopidogrel 75 mg/day Aspirin (25 mg) plus extended-release dipyridamole (200 mg) twice a day
- 48. 3) Surgical •carotid endarterectomy •EC/IC bypass surgery •Dipping •Detachable coil technique
- 49. Patient counselling 1. Educate about symptoms that might indicate stroke and other brain disease 2. Avoid smoking and use of alcohol 3. Regular exercise is advised 4. Reduce overweight 5. Decrease intake of high cholesterol and fat 6. Regular check up of BP, sugar, lipid should be done 7. Reduce salt intake
- 51. Thank You………….