stroke management

1. Diagnosis and Management
of Stroke
Dr. Anoop K R
Asst professor
Dept of general medicine
MMCH,Calicut

2. Objectives
• Review etiology of strokes
• Identify likely location/type of stroke based on
physical examination
• Acute management of ischemic stroke
• Acute management of hemorrhagic stroke

3. 1. WHO - A NEUROLOGICAL DEFICIT OF
• Sudden onset
• With focal rather than global dysfunction
• In which, after adequate investigations, symptoms are presumed to be of
non-traumatic vascular origin
• and last for >24 hours
2. NINDS 2005 - When the blood supply to part of the brain is suddenly
interrupted or when a blood vessel in the brain bursts
3. TIA - neurological deficit of vascular origin lasting from few minutes to hours
and resolves within 24 hours
Definitions

4. Stroke
Atherosclerotic
(20%)
Cryptogenic
(30%)
Unusual causes
Prothrombotic
Dissections
Arteritis
Migraine
Drug abuse
(5%)
Haemorrhage
Intraparenchymal
Subarachnoid
(15%)
Cardioembolic
(20%)
Penetating artery
Disease
(lacunar)
(25%)
ISCHEMIC 85%
HEMORRHAGIC 15%

5. How to asses stroke?

7. NIHSS
• NIHSS (National Institute of Health Stroke Scale)
– Standardized method used by health care professionals to
measure the level of impairment caused by a stroke
– Purpose
• Main use is as a clinical assessment tool to determine
whether the degree of disability is severe enough to warrant
the use of tPA
• Another important use of the NIHSS is in research, where it
allows for the objective comparison of efficacy across
different stroke treatments and rehabilitation interventions
– Scores are totaled to determine level of severity
– Can also serve as a tool to determine if a change in exam has
occurred

8. Possible Points: Summary
LOC 7
Cranial Nerves (Portions of CN II,III,V,VI,VII) 8
Motor 8x2 = 16
Ataxia 2
Sensory 2
Language 5
Inattention 2
=42

9. NIHSS and Patient Outcomes
• Total scores range from 0-42 with higher values representing
more severe infarcts
– >25 Very severe neurological impairment
– 15-24 Severe impairment
– 5-14 Moderately severe impairment
– <5 Mild impairment
Adams, HP, et al. (1999). Neurology: 53: 126-131.
• A 2-point (or greater) increase on the NIHSS administered
serially indicates stroke progression. It is advisable to report
this increase.

10. TIA - ABCD2 Score
Symptom Score
Age > 60 years 1 point
Blood pressure > 140/80 1 point
Clinical (neurological
deficit)
2 points for hemiparesis
1 point for speech problem without
weakness
Duration 2 points for >60 minutes
1 point for 10-60 min
Diabetes 1 point
Maximal score is 7

11. • The Alberta Stroke Programe Early CT Score (ASPECTS) is a 10-point
quantitative topographic CT scan score used in patients with middle
cerebral artery (MCA) stroke.
• Segmental assessment of MCA territory is made and 1 point is
removed from the initial score of 10 if there is evidence of infarction in
that region.
• caudate
• putamen
• internal capsule*
• insular cortex
• M1: "anterior MCA cortex," corresponding to frontal operculum
• M2: "MCA cortex lateral to insular ribbon" corresponding to anterior
temporal lobe
• M3: "posterior MCA cortex" corresponding to posterior temporal lobe

12. •M4: "anterior MCA territory immediately superior to M1"
•M5: "lateral MCA territory immediately superior to M2"
•M6: "posterior MCA territory immediately superior to M3"
(M1 to M3 are at the level of the basal ganglia and M4 to
M6 are at the level of the ventricles immediately above
the basal ganglia)
An ASPECTS score less than or equal to 7 predicts
worse functional outcome at 3 months as well as
symptomatic haemorrhage.

13. TIA – Management
People who have had a suspected TIA who are at lower risk of stroke
ABCD2 score of 3 or below: should have
•aspirin (300 mg daily) started immediately
•specialist assessment and investigation as soon as possible, but definitely within
1 week of onset of symptoms
•measures for secondary prevention introduced as soon as the diagnosis is
confirmed, including discussion of individual risk
NB: People who have had a TIA but who present late (more than 1 week
after their last symptom has resolved) should be treated as though they are
at lower risk of stroke.

14. -cont
People who have had a suspected TIA who are at high risk of stroke
TIAs with ABCD2 score ≥ 4 or above should have:
•aspirin (300 mg daily) started immediately
•specialist assessment and investigation within 24 hours of onset of
symptoms
•measures for secondary prevention introduced as soon as the diagnosis is
confirmed, including discussion of individual risk
TIAS with a score of 5 or greater to be admitted for immediate Dx and Tx (within
24 Hrs)

15. • Most likely related to decreased level of consciousness (LOC),
dysarthria, dysphagia
• GCS < 8 - INTUBATE
• Avoid Hyperventilation or Hypoventilation
• NPO until swallow assessment completed- high aspiration risk
• Begin mobilization as soon as clinically safe
• Keep HOB greater than 30 degrees
Airway Mx

16. Imaging
CT scan
• Non- contrast CTH remains
the gold standard as it is
superior for showing IVH
and ICH
• CT with contrast may help
identify aneurysms, AVMs,
or tumors but is not
required to determine
whether or not the patient
is a tPa candidate
MRI
• Superior for showing
underlying structural lesions
• Contraindications

19. Watershed zones

21. Acute (4 hours)
Infarction
Subtle blurring of gray-white
junction & sulcal effacement
Subacute (4 days)
Infarction
Obvious dark changes &
“mass effect” (e.g.,
ventricle compression)
RR L L

22. Multimodal Imaging
Multimodal CT
• Typically includes non-
contrast CT, perfusion CT,
and CTA
• Two types of perfusion CT
– Whole brain perfusion CT
– Dynamic perfusion CT
Multimodal MRI
• Standard MRI sequences
(T1 weighted, T2 weighted,
and proton density) are
relatively insensitive to
changes in cerebral
ischemia
• Multimodal adds diffuse-
weighted imaging (DWI)
and PWI (perfusion-
weighted imaging)

23. Treatment

25. tPa
Fast Facts
• Tissue plasminogen
activator
• “clot buster”
• IV tpa window 3 hours
• IA tpa window 4.5 hours
• Disability risk ↓ 30% despite
~5% symptomatic ICH risk
Contraindications
• Hemorrhage
• SBP > 185 or DBP > 110
• Recent surgery, trauma or
stroke
• Coagulopathy
• Seizure at onset of symptoms
• NIHSS >21
• Age?
• Glucose < 50

26. Patients should receive endovascular therapy with
a stent retriever if they meet all the following
criteria (Class I). (New recommendation):
– pre-stroke Modified Rankin Scale score 0 to 1
– acute ischemic stroke receiving IV r-tPA within 4.5
hours of onset according to guidelines from
professional medical societies
– causative occlusion of the ICA or proximal MCA
– age ≥18 years
– NIHSS score of ≥6
– Alberta Stroke Program Early CT score (ASPECTS) ≥6
– treatment can be initiated (groin puncture) within 6
hours of symptom onset

27. Administration of rTPA
Main eligibility criteria
FOR IV INFUSION
 Treatment given within 3hrs)
 Intracranial bleeding excluded
 Age <80
 Early major infarction excluded (parenchyma hypo-attenuation or brain swelling
>1/3rd
MCA territory)
 NIHSS SCORE <22
 BP < 185/110
 Not on warfarin or heparin, platelets and coagulation normal
 Treatment given by a specially trained physician
 Facilities for close monitoring

28. Mechanical Thrombolysis
• Often used in adjunct with tPa
• MERCI (Mechanical Embolus Removal in
Cerebral Ischemia) Retrieval System is a
corkscrew-like apparatus designed to remove
clots from vessels
• PENUMBRA system aspirates the clot

29. Blood Pressure Management
– The goal is to maintain cerebral perfusion!!
– CPP = MAP – ICP (needs to be at least 70)
– Higher BP goals with Ischemic stroke
– Lower BP goals with Hemorrhagic stroke (avoid
hemorrhagic expansion, especially in AVMs and
aneurysms)

30. BP Relationship
• BP increase is due to
arterial occlusion (i.e., an
effort to perfuse
penumbra)
• Failure to recanalize (w/
or w/o thrombolytic
therapy) results in high
BP and poor neuro
outcomes
• Lowering BP starves
penumbra, worsens
outcomes
Penumbra
Core
Clot in
Artery

31. Save the Penumbra!!
CEREBRAL
BLOOD
FLOW
(ml/100g/min)
CBF
< 8
CBF
8-18
TIME (hours)
1 2 3
20
15
10
5
PENUMBRA
CORE
Neuronal
dysfunction
Neuronal
death
Normal
function

32. STROKE SURGERY
HEMORRHAGIC
A. Lobar hemorrhage
STICH Trial - Mendelow AD et al. Lancet 2005
-No difference in outcome in stable patients
-Surgery Outcome better than conservative RX in
progressive Neurological deterioration.
B. Basal ganglia Hemorrhage
Endoscopy Evacuation better than conservative treatment,
Vol.> 50cc, age < 50 years
C. Cerebellar Hemorrhage with obstructive hydrocephalus
Surgical Emergency

33. UROKINASE OR TPA INSTILATION AND MINIMALLY INVASIVE ASPIRATION

34. ISCHEMIC
People with middle cerebral artery (MCA) infarction who meet all of the
criteria below should be considered for decompressive hemicraniectomy
(decimal trial).
• They should be referred within 24 hours of onset of symptoms and
treated within a maximum of 48 hours
• aged 60 years or under
• clinical deficits suggestive of infarction in the territory of the MCA with a
score on the NIHSS of above 15
• decrease in the level of consciousness to give a score of 1 or more on item
1a of the NIHSS
• signs on MRI of an infarct of at least 50% of the MCA territory, with or
without additional infarction in the territory of the anterior or posterior
cerebral artery on the same side, or
• infarct volume greater than 145 cm3 as shown on diffusion-weighted MRI

35. Supportive Therapy
Glucose Management
– Infarction size and edema increase with acute and chronic
hyperglycemia
– Hyperglycemia is an independent risk factor for hemorrhage
when stroke is treated with t-PA
Antiepileptic Drugs
– Seizures are common after hemorrhagic CVAs
– ICH related seizures are generally non-convulsive and are
associated to with higher NIHSS scores, a midline shift, and tend
to predict poorer outcomes

36. Hyperthermia
• Treat fevers!
– Evidence shows that fevers > 37.5 C that persists
for > 24 hrs correlates with ventricular extension
and is found in 83% of patients with poor
outcomes

37. • Every hospital should have a stroke unit
• A stroke should be managed by a multidisciplinary stroke
team
• An efficient referral and rehabilitation system to be
established for the success of a stroke unit
• Stroke units significantly reduce death, dependency,
institutionalization and length of hospital stay.
STROKE UNIT

38. Thank you for your attention!

39. Etiology of Ischemic Strokes
LARGE VESSEL THROMBOTIC:
Virchow’s Triad….
• Blood vessel injury
- HTN, Atherosclerosis, Vasculitis
• Stasis/turbulent blood flow
- Atherosclerosis, A. fib., Valve disorders
• Hyper coagulable state
- Increased number of platelets
- Deficiency of anti-coagulation factors
- Presence of pro-coagulation factors
- Cancer

40. LARGE VESSEL EMBOLIC:
• The Heart
– Valve diseases, A. Fib, Dilated cardiomyopathy, Myxoma
• Arterial Circulation (artery to artery emboli)
– Atherosclerosis of carotid, Arterial dissection, Vasculitis
• The Venous Circulation
– PFO w/R to L shunt, Emboli

41. Determining the Location
• Large Vessel:
– Look for cortical signs
• Small Vessel:
– No cortical signs on exam
• Posterior Circulation:
– Crossed signs
– Cranial nerve findings
• Watershed:
– Look at watershed and border zone areas
– Hypo-perfusion

42. Cortical Signs
RIGHT BRAIN: LEFT BRAIN:
- Right gaze preference - Left gaze preference
- Neglect - Aphasia
• If present, think LARGE VESSEL stroke

43. Large Vessel Stroke Syndromes
• MCA:
– Arm>leg weakness
– LMCA cognitive: Aphasia
– RMCA cognitive: Neglect, topographical difficulty, apraxia,
constructional impairment
• ACA:
– Leg>arm weakness, grasp
– Cognitive: muteness, perseveration, abulia, disinhibition
• PCA:
– Hemianopia
– Cognitive: memory loss/confusion, alexia
• Cerebellum:
– Ipsilateral ataxia

44. Aphasia
• Broca’s
– Expressive aphasia
– Left posterior inferior
frontal gyrus
• Wernicke’s
– Receptive aphasia
– Posterior part of the superior temporal gyrus
– Located on the dominant side (left) of the brain

45. Etiology of ICH
• Traumatic
• Spontaneous (non traumatic)
– Hypertensive
– Amyloid angiopathy
– Aneurysmal rupture
– Arteriovenous malformation rupture
– Bleeding into tumor
– Cocaine and amphetamine use

47. Hypertensive ICH
• Spontaneous rupture of a small artery deep in the brain
• Typical sites
– Basal Ganglia
– Cerebellum
– Pons
• Typical clinical presentation
– Patient typically awake and often stressed, then abrupt
onset of symptoms with acute decompensation

48. Ganglionic Bleed
• Contralateral hemiparesis
• Hemisensory loss
• Homonymous hemianopia
• Conjugate deviation of eyes toward the side of the bleed or
downward
• AMS (stupor, coma)

49. Cerebral Hemorrhage
JPG

50. Cerebellar Hemorrhage
• Vomiting (more common in ICH than SAH or Ischemic CVA)
• Ataxia
• Eye deviation toward the opposite side of the bleed
• Small sluggish pupils
• AMS

51. Pontine Hemorrhage
• Pin-point but reactive pupils
• Abrupt onset of coma
• Decerebrate posturing or flaccidity
• Ataxic breathing pattern

52. Subarachnoid Hemorrhage
• “Worst headache of my life”
• AMS
• Photophobia
• Nuchal rigidity
• Seizures
• Nausea and vomiting

53. Case 1
• 74 year old African American female with sudden
onset of left-sided weakness
• She was at church when she noted left facial droop
• History of HTN and atrial fibrillation
• Meds: Losartan

54. • BP- 172/89, P– 104, T- 98.0, RR– 22, O2- 94%
• General exam: Unremarkable except irregular rate and rhythm
• NEURO EXAM:
- Speech dysarthric but language intact
- Right gaze preference
- Left facial droop
- Left- sided hemiplegia
- Neglect

56. Answer
• Right MCA infarct, most likely cardioembolic from atrial fibrillation
• Patient underwent mechanical thrombectomy with intra-arterial
verapamil, clot removal successful
• Excellent recovery – patient was discharged 48 hours later on
Coumadin
• Small vessel disease – since there are no cortical signs on exam
• Risk factors – HTN, DM, tobacco use, sleep apnoea

57. Case 2
• 85 year old male who woke up with left face, arm, and leg
numbness
• History of HTN, DM, and tobacco use
• Meds: Insulin, aspirin

58. • BP- 168/96, P– 92
• General exam: Unremarkable, RRR
• NEURO EXAM:
- Decreased sensation on left face, arm, and leg

59. Case 2

60. Answer
• Right thalamic lacunar infarct
• Not a candidate for intervention
• Discharged to rehab 72 hours after admission
• location – posterior circulation – due to crossed signs, cranial
nerve findings.

61. Brainstem Stroke Syndromes
• Rarely presents with an isolated symptom
• Usually a combination of cranial nerve abnormalities, and crossed motor/sensory
findings such as:
– Double vision
– Facial numbness and/or weakness
– Slurred speech
– Difficulty swallowing
– Ataxia
– Vertigo
– Nausea and vomiting
– Hoarseness

62. Case 3
• 55 year old male with acute onset of right sided numbness
and tingling, left sided face pain and numbness, gait
imbalance, nausea/vomiting, vertigo, swallowing difficulties,
and hoarse speech
• History of CAD s/p CABG, DM2, HTN, HLD, OSA
• Meds: Aspirin, plavix, insulin, lipitor, metoprolol, lisinopril

63. • NEURO EXAM: BP- 194/102, P– 105
• General exam: Unremarkable, RRR
• NEURO EXAM:
- Decreased sensation on left face
- Decreased sensation on right body
- Left ataxia on FNF, and unsteady gait
- Voice hoarse
- Nystagmus

65. Answer
• Brainstem Stroke
• Received IV tPa
• Post-tPa symptoms greatly improved
regained sensation, ataxia resolved
• Discharged home with out patient PT/OT
• Location – watershed pattern

66. Case 4
• 56 year old female who upon waking post-op after elective
surgery was found to have L sided weakness and neglect
• History of HTN
• Meds - Lisinopril

67. • BP- 132/74, P– 84
• General exam: Unremarkable, RRR
• NEURO EXAM:
- Left face, arm, and leg weakness
- Neglect
- DTR’s brisk on the left, toe up on left

71. • Right hemisphere watershed infarct secondary to
hypoperfusion in the setting of Right ICA stenosis
• On review of anesthesia records, blood pressure dropped to
82/54 during the procedure
• Patient was discharged to in-patient rehab
Answer