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Approach to a patient with stroke,[object Object],AshwinHaridas,[object Object],Asem Ali Ashraf,[object Object],Adam EAH Adam,[object Object]
Definitions,[object Object],Stroke,[object Object],Clinical syndrome of rapid onset of focal deficits of brain function lasting more than 24 hours or leading to death,[object Object],Transient Ischemic attack (TIA),[object Object],Clinical syndrome of rapid onset of focal deficits of brain function which resolves within 24 hours,[object Object]
Definitions,[object Object],Progressive Stroke ,[object Object],A stroke in which the focal neurological deficits worsen with time,[object Object],Also called stroke in evolution,[object Object],Completed Stroke,[object Object],A stroke in which the focal neurological deficits persist and do not worsen with time,[object Object]
Epidemiology,[object Object],Third most common cause of death after cancer and ischeamic heart disease,[object Object],Most common cause of severe physical disability,[object Object],Prevalence of stroke in India is about 1.54 per 1000,[object Object],Death rate is about 0.6 per 1000,[object Object],Incidence  and prevalence of stroke is on the rise due to increasing adoption of unhealthy lifestyle & an increasing life expectancy,[object Object]
Stroke Risk Factors,[object Object],Fixed,[object Object],Age,[object Object],Gender (Male>Female),[object Object],Race (Afro-Caribbean>Asian>European),[object Object],Heredity,[object Object],Previous vascular event eg. MI, peripheral embolism,[object Object],High fibinogen,[object Object],Modifiable,[object Object],Hypertension,[object Object],Heart disease (Atrial fibrillation, endocarditis),[object Object],Diabetes mellitus,[object Object],Hyperlipidaemia,[object Object],Smoking,[object Object],Excess alcohol consumption,[object Object],Oral contraceptives ,[object Object]
Types of Stroke,[object Object],Ischemic,[object Object],Hemorrhagic,[object Object]
Anterior Circulation,[object Object],Posterior Circulation,[object Object]
Middle Cerebral Artery,[object Object]
Anterior Cerebral Artery,[object Object]
Posterior Cerebral Artery,[object Object]
Ischemic Stroke,[object Object],80% of strokes,[object Object],Arterial occlusion of an intracranial vessel leads to hypoperfusion of the brain region it supplies,[object Object]
Etiology of ischemic stroke,[object Object],Thrombotic,[object Object],Lacunar stroke,[object Object],Large vessel thrombosis,[object Object],Hypercoagulable disorders,[object Object],Embolic,[object Object],Artery to artery,[object Object],Carotid bifurcation,[object Object],Aortic arch,[object Object],Cardioembolic,[object Object],Atrial fibrillation,[object Object],Myocardial infarction,[object Object],Mural thrombus,[object Object],Bacterial endocarditis,[object Object],Mitral stenosis,[object Object],Paradoxical embolus,[object Object]
Thrombotic Stroke,[object Object],Atherosclerosis is the most common pathology leading to thrombotic occlusion of blood vessels,[object Object],Hypercoagulable disorders – uncommon cause,[object Object],Antiphospholipid syndrome,[object Object],Sickle cell anemia,[object Object],Polycythemiavera,[object Object],Homocysteinemia,[object Object],Vasculitis: PAN, Wegener’s granulomatosis, giant cell arteritis,[object Object]
Thrombotic Stroke,[object Object],Lacunar stroke,[object Object],Accounts for 20% of all strokes,[object Object],Results from occlusion of small deep penetrating arteries of the brain,[object Object],Pathology: lipohyalinosis & microatheroma,[object Object],Thrombosis leads to small infarcts known as lacunes,[object Object],Clinically manifested as lacunar syndromes,[object Object]
Embolic Stroke,[object Object],Cardioembolic stroke,[object Object],Embolus from the heart gets lodged in intracranial vessels,[object Object],MCA most commonly affected,[object Object],Atrial fibrillation is the most common cause,[object Object],Others: MI, prosthetic valves, rheumatic heart disease,[object Object],Artery to artery embolism,[object Object],Thrombus formed on atherosclerotic plaques gets embolized to intracranial vessels,[object Object],Carotid bifurcation atherosclerosis is the most comon source,[object Object],Others: aortic arch, vertebral arteries etc.,[object Object]
Etiology of ischemic stroke,[object Object]
Blood supply to the brain is autoregulated,[object Object],Blood flow,[object Object],If zero leads to death of brain tissue within 4-10min ,[object Object],<16-18ml/100g tissue/min         infarction within an hour,[object Object],Ischemia leads to development of an ischemic core and an ischemic penumbra,[object Object],Pathophysiology of Ischemic Stroke,[object Object]
Approach to a patient with stroke - Pathophysiology of stroke
Ischemic Penumbra,[object Object],Tissue surrounding the core region of infarction which is ischemic but reversibly dysfunctional,[object Object],Maintained by collaterals,[object Object],Can be salvaged if reperfused in time,[object Object],Primary goal of revascuralization therapies,[object Object]
Thrombus/embolus,[object Object],Hypoperfusion,[object Object],ATP depletion,[object Object],Failure of Na+/K+ATPase membrane ionic pump,[object Object],Activation of pro-coagulant pathways,[object Object],Membrane depolarization & cytotoxic cellular edema,[object Object],Free fatty acid release,[object Object],Calcium entry,[object Object],Glutamate release,[object Object],Activation of lipid peroxidases, proteases & NO synthase,[object Object],Destruction of intracellular organelles, cell membrane & release of free radicals,[object Object],Liquefactive necrosis,[object Object]
Hemorrhagic Stroke,[object Object],Two types,[object Object],Intracerebral hemorrhage(ICH),[object Object],Subarachnoid hemorrhage(SAH),[object Object],Higher mortality rates when compared to ischemic stroke,[object Object]
Intracerebral Hemorrhage,[object Object],[object Object]
Small arteries are damaged due to hypertension
In advanced stages vessel wall is disrupted and leads to leakage

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Approach to a patient with stroke - Pathophysiology of stroke

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