Stroke

AveryselfishorganThebrainrequires20%ofthetotalbloodpumpedbytheheart.NostorageinthebrainforeitherfueloroxygenRequiresconstantsupplyofoxygenandglucose.BloodSupplytotheBrainCarotidarteries–anteriorneckLargeFrequentlycongestedwithplaqueCanbecleanedoutsurgicallyVertebralarteriesPassthroughcervicalvertebraeWellprotectedNotaccessibleforsurgicalcleaningCircleofWillisBothbloodsupplies(carotidandvertebral)joinontheundersurfaceofthebrain.Fail-safemechanismincaseofablockagesomewhereincirculationBUTsomehardcornersincirclewheredebriscangetcaughtandsiteofmostcerebralaneurysmsStroke:BrainAttackSuddenlossoffunctionofapartofthebrainDuetoaproblemwithbloodsupplyTypesofStrokeLossofbloodsupplytoapartofthebrain:Ischaemic(85%)Bleedingwithinbrainmatter:Haemorrhagic(15%)TypesofStrokeNotaSingleDisease:StrokeSubtypesandIncidenceAlbersGetal.Chest.2001;119(suppl):300S.Ischaemicstroke85%Hemorrhagicstroke15%Other5%Unknowncause30%Cardiacdisease20%Smallvesseldisease“lacunes”25%Atheroscleroticcerebrovasculardisease20%ThrombosisEmbolismHaemorrhageIschemicStrokea.Atherosclerosisandstrokeb.CardiacEmbolismArterialEmbolismTransientIschemicAttack“OneFreeSpin”Lookslikeastrokebutsymptomsimprovein1-24hoursTemporarydisruptionofbloodflowtothebrain–LikeUnstableAnginaofthebrainWarningsign(15%ofstrokeshaveTIAfirst)Mimickedbylowbloodsugar(bloodsugarsignsandsymptomsgoaway)1in20patientswillhaveatruestrokein3months2.HemorrhagicSTROKEAneurysm–weakenedareainarteryCongenitalYoungerpopulationyoungerthan40yearsComplainof“worstheadacheinmylife”SpontaneousHypertensiveBleedDuetoBP200/100MalformedArtery50%youngerthan30yearsAneurysmsandcerebralhaemorrhageWhyisStrokeImportant?ThirdleadingcauseofdeathHeartdiseaseCancerStroke700,000strokesperyearinUSA;450,000inEuropeAlmost8%ofischaemicand40%ofhaemorrhagicstrokesdiein30daysADeadlyDisease,BecomingMoreFrequentIncreasedincidenceofstrokeAsthepopulationgrowsolderduetolongerlifeexpectancy,LifestylechangesinIndiaHighincidenceofdiabetesMyocardialInfarction(HeartAttack)PercentofstrokepatientswithsubsequenteventsStrokeBegetsStrokeAlbersG.Neurology.2000;14(5):1022-8.CATS0246810121416TASSCAPRIE*ESPS2Stroke14%3%13%7%10%2%13%3%StrokepatientsaremostatriskofanotherstrokeTrialsPreviousstrokeisthesinglemostimportantriskfactorforstrokeSignsandSymptomsofSTROKEHemorrhagicSuddenanddramaticViolentexplosiveheadache“worstheadacheofmylife”VisualdisturbanceFlashinglights,auraNauseaandvomitingNeckandbackpainDuetobloodinsub-arachnoidspaceSensitivitytolightWeaknessononesideCanpresentlikeamigraineheadacheSignsandSymptomsofSTROKEIschemicStrokeHardertodetectWeaknessinonesideFacialdroopingNumbnessandtinglingLanguagedisturbanceVisualdisturbanceLeftBrainStrokeRightsideparalysisSpeechandlanguagedisturbanceBehavioralchangesSwallowingproblemsRightBrainDamageLeftsideparalysisSpatialperceptionWhereyourlimbsareinrelationtotheroomCoordinationproblemsPerceptionRecognitionoffamiliarobjectsFacialWeaknessBrainstemStrokesMotor&sensorydeficitsChangeinvoiceSwallowingproblemsEyedeviation,eyeparalysisLossofconsciousnessGaitchange(“drunken”gait)Vertigo/dizzinessUsea“FAST”STROKEAssessmentModificationofCincinnatiPre-HospitalStrokeScreenFaceArmSpeechTimeofonsetFACELookforFacialDroopHavethepatientsmileorshowhis/herteethNORMALBothsidesofthefacemoveequallyABNORMALOnesideofthepatient’sfacedroopsordoesnotmoveARMSMotorWeakness:LookforarmdriftbyaskingthepatienttocloseeyesandliftarmsNORMAL-armsremainextendedequallyordriftdownwardequallyABNORMAL–OnearmdriftsdowncomparedtotheotherProblemwithgrippinghandsManyelderlyhavearthritisinhandsHurtstogriphandsMaymimicweaknessSPEECHAskthepatienttosay“Youcan’tteachanolddognewtricks”Lotsoft’s,k’sandc’sNORMAL–PhraserepeatedclearlyandplainlyABNORMAL–Wordsslurred,abnormalorunabletospeakAbnormalSpeechSlurringofspeechUnabletothinkofwordsInappropriatewordsExpressiveaphasia–unabletospeakwordsAreaofbrainwherewordsarecreatedisdamagedReceptiveaphasia–unabletounderstandwordsAreawherewordsareinterpretedisdamagedTIMEOFONSETThewindowofopportunitytoeffectivelytreatSTROKEis3hours(180minutes)Maybeextendedto4½hoursinsomecasesNeedtoknow“lastknownwell”.DifficultwhenPatientlivesaloneWokeupwithsymptoms180minutesDon’tthinkofas3hours,but180minutesTimegetseatenupfastShortscenetimeTaketransporttimeintoconsiderationInvestigations/LabTestsCTscanheadECG,EchocardiogramHemogramBloodGlucose,LipidprofileCarotiddoppler.MRIDiffusionWeightedMRI(DWI),Perfusion-CTandMRI(PWI)UsesofCTUsualfirstinvestigationPlain&ContrastExcludeintracranialhaemorrhageExclusionofextensiveischemicinfarctions.CTscaninstrokeCTscaninintracerebralhaemorrhageMRIinstrokeT2weighted/DiffusionCTvsMRI/MRADopplerStudiesSpecialultrasoundexaminationforarteriesintheneckDetectsclotornarrowingHelpsplantreatmenttopreventrecurrentstroke.TreatmentPrimaryPreventionPersonswhohaveneverhadastrokeSecondaryPreventionPersonswithstroke,topreventanotherTreatmentofacutestrokeTreatmentofchronicstroke