Lecture Slides Presented at SIMS by Medical Unit SIMS Hospital

1. Dr. Tahir Bashir
Assistant Professor
Medical unit-4

2.  Stroke is an acute CNS injury that results in
neurologic signs and symptoms caused by a
reduction or absence of perfusion to a territory
of the brain. The disruption in flow is from
either an occlusion (ischemic) or rupture
(hemorrhagic) of the blood vessel.

3.  Cerebrovascular Accident
 Ischemic Stroke
 Thrombotic
 Embolic
 Lacunar infarct
 TIA
 Hemorrhagic Stroke
 ICH
 SAH

5.  Occlusion of large
cerebral vessel
 Older population
 Sleeping/resting
 Rapid event, but slow
progression (usually
reach max deficit in 3
days)

6.  Embolus becomes lodged in
vessel and causes occlusion
 Bifurcations are most common
site
 Sudden onset with immediate
deficits

7.  Minor deficits
 Paralysis and sensory loss
 Lacune
 Small, deep penetrating
arteries
 High incidence:
 Chronic hypertension
 Elderly
 DIC

8.  Warning sign for stroke
 Brief localized ischemia
 Common
manifestations:
 Contralateral
numbness/
weakness of hand,
forearm, corner of
mouth
 Aphasia
 Visual disturbances-
blurring
 Deficits last less than
24 hours (usually less
than 1 or 2 hrs)
 Can occur due to:
 Inflammatory artery
disorders
 Sickle cell anemia
 Atherosclerotic
changes

9.  Intracerebral hemorrhage
 Intracranial hemorrhage
 Parenchymal hemorrhage
 Intraparenchymal hematoma
 Contusion
 Subarachnoid hemorrhage

10.  Rupture of vessel
 Sudden
 Active
 Fatal
 HTN
 Trauma
 Varied
manifestations

11.  Intracerebral
Hemorrhage
 Subarachnoid
Hemorrhage

12.  Changes in vasculature
 Tear or rupture
 Hemorrhage
 Decreased perfusion
 Clotting
 Edema
 Increased intracranial pressure
 Cortical irritation

14. Hearing/association
& Smell & taste
Short term Memory
Voluntary
Motor
Sensations
Pain & Touch
Taste
Balance,
Coordination of each
muscle group
Arms
Head
Legs
Mom: Bowel/bladder
Reasoning/judgment
Long term memory
Vision &
visual
memory
CN 5,6,7,8
P,R, B/P CN 9,10,11,12
Tracks cross over
Coordinate
movement,
HR,B/P

16. Right Side

18. NON-MODIFIABLE MODIFIABLE
 Age
 2/3 over 65
 Gender
 M=F
 Female>fatality
 Race
 AA > hispanics, NA
 Asians > hem
 Heredity
 Family history
 Previous TIA/CVA
 Hypertension
 Diabetes mellitus
 Heart disease
 A-fib
 Asymptomatic carotid stenosis
 Hyperlipidemia
 Obesity
 Oral contraceptive use
 Heavy alcohol use
 Physical inactivity
 Sickle cell disease
 Smoking
 Procedure precautions

19. EMBOLISM PROTHROMBOTIC STATES
 Atrial fib
 Sinoatrial D/O
 Recent MI
 Endocarditis
 Cardiac tumors
 Valvular D/O
 Patent foramen ovale
 Carotid/basilar artery
stenosis
 Atherosclerotic lesions
 Vasculitis
 Hemostatic regulatory
protein abnormalities
 Antiphospholipid
antibodies

20.  Chronic HTN**
 Cerebral Amyloid Angiopathy*
 Anticoagulation*
 AVM
 Ruptured aneurysm (usually subarachnoid)
 Tumor
 Sympathomimetics
 Infection
 Trauma
 Transformation of ischemic stroke
 Physical exertion, Pregnancy
 Post-operative

21.  Localized dilation of arterial lumen
 Degenerative vascular disease
 Bifurcations of circle of Willis
 85% anterior
 15% posterior

22.  SAH
 Mortality 70%
 Nuchal rigidity
 Fever
 Photophobia
 Lethargy
 Nausea
 Vomiting

23.  Complications
 HCP
 Vasospasm
 Triple H Therapy
 HTN
 Hemodilution
 Hypervolemia
 Surgical treatment
 Clip
 Coil
 INR

24.  AVM
 Tangled mass of arteries and veins
 Seizure or ICH

25.  Sudden onset
 Focal neurological deficit
 Progresses over minutes to hours
 Depends on location

26.  SUDDEN numbness or weakness of face, arm
or leg
 SUDDEN confusion, trouble speaking or
understanding.
 SUDDEN trouble with vison.
 SUDDEN trouble walking, dizziness, loss of
balance or coordination.
 SUDDEN severe headache.

27.  Vertebral Artery
 Pain in face, nose, or eye
 Numbness and weakness of face (involved side)
 Gait disturbances
 Dysphagia
 Dysarthria (motor speech)

28.  Internal carotid artery
 Contralateral paralysis (arm, leg, face)
 Contralateral sensory deficits
 Aphasia (dominant hemisphere involvement)
 Apraxia (motor task),
 Agnosia (obj. recognition),
 Unilateral neglect (non-dominant hemisphere
involvement)
 Homonymous hemianopia

29.  Neurological
 Hyperthermia
 Neglect syndrome
 Seizures
 Agnosias (familiar
obj)
 Communication
deficits
 Aphasia (expressive,
receptive, global)
 Agraphia
 Visual deficits
 Homonymous
hemianopia
 Diplopia
 Decreased acuity
 Decreased blink reflex

30.  Neurological (cont.)
 Cognitive changes
 Memory loss
 Short attention
span
 Poor judgment
 Disorientation
 Poor problem-
solving ability
 Behavioral
changes
 Emotional
lability
 Loss of
inhibitions
 Fear
 Hostility

31.  Musculoskeletal
 Hemiplegia or
hemiparesis
 Contractures
 Bony ankylosis
 Disuse atrophy
 Dysarthria - word
formation
 Dysphagia – swallow
 Apraxia – complex
movements
 Flaccidity/spasticity
 GU
 Incontinence
 Frequency
 Urgency
 Urinary retention
 Renal calculi

32.  Integument
 Pressure ulcers
 Respiratory
 Respiratory center damage
 Airway obstruction
 Decreased cough ability
 GI
 Dysphagia
 Constipation
 Stool impaction

33.  Neurological assessment
 Call “Stroke Alert” Code
 Ensure patient airway
 Vital signs
 IV access
 Maintain BP within parameters
 Position head midline
 CT Brain
 Anticipate thrombolytic therapy for ischemic
stroke

36. Tests for the Emergent Evaluation of the Patient with
Acute Ischemic Stroke
 CT head (-)
 Electrocardiogram
 Chest x-ray
 Hematologic studies (complete blood count, platelet
count, prothrombin time, partial thromboplastin time)
 Serum electrolytes
 Blood glucose
 Renal and hepatic chemical analyses

37. ISCHEMIC STROKE HEMORRHAGIC STOKE

38.  BP
 Factor VII, Vit K, FFP
 ICP
 Sedation
 Hyperventilation
 Paralytics
 Fluid management
 Seizure prophylaxis
 Sedation
 Body temperature
 DVT prophylaxis

39. ISCHEMIC HEMORRHAGIC
 Medical management
 TpA
 Endovascular
 Carotid endarectomy
 Merci clot removal
 Medical management
 Decompression
 Craniotomy
 Craniectomy
REHABILITATION

40.  Anti-coagulants – A fib & TIA
 Antithrombotics
 Calcium channel blockers – Nimotop (nimodipine)
 Diuretics – Mannitol, Lasix (Furosemide)
 Anticonvulsants – Dilantin (phenytoin) or Cerebyx
(Fosphenytoin Sodium Injection)
 Thrombolytics - tPA (recombinant tissue plasminogen
activator)