management, complication, surgery

1. Neurosurgery-Stroke
Haybusak university
5th year medicine
dr. Avet Petrosyan

2. D E F I N I T I O N
• Stroke is defined by the World Health
Organization as a clinical syndrome consisting of
‘rapidly developing clinical signs of focal
disturbance of cerebral function, lasting more
than 24 h or leading to death with no apparent
cause other than that of vascular origin’.

3. C L A S S I F I C A T I O N O F
S T R O K E
Hemorrhagic
(20% of Strokes)
Thrombotic
50%
Embolic
30%
Intracerebral
Hemorrhage
15%
Subarachnoid
Hemorrhage
5%
Ischemic (80%
of Strokes)

4. Each year nearly 800,000 people have a new or recurrent stroke
A stroke happens every 40 seconds
Stroke is the fifth leading cause of death in the U.S
Every 4 minutes someone dies from stroke
Up to 80 percent of strokes can be prevented
Stroke is the leading cause of adult disability in the U.S
S T R O K E B Y N U M B E R S

5. T Y P E S O F S T R O K E
80%
Ischemic
20 %
hemorrhagic

6. E V A L U A T I O N O F S T R O K E
• 1. symptoms
• 2. Localize of lesion
• 3. type of stroke
• 4. cause
• 5. The clinical assessment

7. T H E M A I N S Y M P T O M S

8. I N V E S T I G A T I O N S
• full blood count, serum electrolytes, renal function tests,
cardiac enzymes, and coagulation studies
• Blood sugar
• An electrocardiogram (ECG) : arrhythmias and
myocardial infarction
• Echocardiography : valve disease and intra-cardiac clot

9. N E U R O I M A G I N G
• Brain CT scan: sensitive to the intracranial blood
• MRI: better at detecting posterior fossa lesions
Pons or cerebellum
• carotid ultrasound
• doppler ultrasound: speed and direction of the
blood stream

10. P O O R P R O G N O S T I C F A C T O R S
• Accompanying fever
• Hypotension and severe hypertension
• Low oxygen saturation
• Hyperglycaemia and hypoglycemia
• heart failure
• severity of hemiparesis

11. M A N A G E M E N T : A I R W A Y A N D
V E N T I L A T I O N
• Foreign Bodies, dentures, tongue
• Indications for intubation:
- hypoxia (pO2 <60 mm Hg or PCO2 >50 mm Hg) -
risk of aspiration with or without impairment of
arterial oxygenation
• elective tracheostomy: after 2 weeks of prolonged
coma or pulmonary complications

12. M A N A G E M E N T : V O L U M E S T A T U S
• Hypovolemia has been associated with worse
outcome and increased mortality in acute ischemic
stroke
• Isotonic saline, typically 3 litres per day is given
• Do not give hypotonic solution, eg 5% Dextrose in
water, as it may worsen cerebral oedema

13. M A N A G E M E N T : T E M P E R A T U R E
• Fever worsens outcome:
• 1. increased metabolic demands
• 2.enhanced release of neurotransmitters
• for every 1°C rise in temp, risk of poor outcome
doubles
• Greatest effect in the first 24 hours
• Treat aggressively with acetaminophen

14. M A N A G E M E N T : B L O O D P R E S S U R E
• lowering of blood pressure by approximately 15 percent
during the first 24 hours after stroke onset is suggested
1. Labetalol IV
2. Nicardipine infusion
3. oral agents (captopril, calcium channel blockers)
• Systolic blood pressure > 185 and diastolic > 110 is a
contraindication for thrombolysis

15. M A N A G E M E N T : B L O O D P R E S S U R E
Reducing formation of brain edema
lessening hemorrhagic transformation
preventing early recurrent stroke

16. M A N A G E M E N T : G L Y C A E M I C
C O N T R O L
Hyperglycemia may augment brain injury by several
mechanisms including:
• increased tissue acidosis
• free radical generation
• increased blood brain barrier permeability

17. M A N A G E M E N T : G L Y C A E M I C
C O N T R O L
• Hypoglycemia- Hypoglycemia can cause focal
neurologic deficits mimicking stroke
• Hypoglycemia (blood glucose <60 mg/dL)
should be treated in patients with acute ischemic
stroke

18. A N T I C O A G U L A N T S
• Heparin 5,000 units 12 hourly(or 8hrly)
• unfractionated heparin may be considered for
prevention of DVT in patients with intracerebral
hemorrhage

19. A N T I P L A T E L E T A G E N T S
• Aspirin prevent risk of recurrent by 13%
• Aspirin –within 48hrs – reduce risk of mortality/
disability in ischemic stroke
• Anti-platelets contraindicated in hemorrhagic stroke

20. Tissue Plasminogen Activator TPA
< first three hours following the onset of symptoms
Contraindicated in hemorrhagic stroke
T H R O M B O L Y T I C S

21. M E D I C A L C O M P L I C A T I O N S O F S T R O K E
• 85% of patients with stroke
• 50% of mortality after the first week of stroke
• the most important causes of mortality in the early
period following a stroke are cardiac (arrhythmias,
myocardial infarction), infections (pneumonia,
urosepsis), and venous thrombo-embolism
(pulmonary embolus)

22. M ED IC AL C O M PL IC AT ION S IN H O SPIT AL IZ ED
PAT IEN T S W IT H ST R O KE
Complications of Immobility
• Deep vein thrombosis/pulmonary embolism
• Falls
• Pressure sores or ulceration
Infections
• Chest infection- aspiration pneumonia
• Urinary tract infection

23. MEDICAL COMPLICATIONS IN
HOSPITALIZED
PATIENTS WITH STROKE
Pain
• Shoulder pain in the weak limb
• Central post-stroke pain
Neuropsychiatric Disturbances
• Depression, anxiety ,Emotional incontinence
• Acute confusional states (delirium)
Miscellaneous
• Cardiac complications (arrhythmia, myocardial ischemia)
• Gastrointestinal complications( bleed, Constipation)
• Sleep apnea

24. S U R G I C A L M A N A G E M E N T
• Ischemic stroke:
A) endovascular interventions: angioplasty and stenting
B) carotid endarterectomy
C) bypass surgery

25. • Hemorrhagic stroke: Surgical evacuation of hematoma
S U R G I C A L M A N A G E M E N T

26. S U R G I C A L M A N A G E M E N T
• Subarachnoid hemorrhage: Clipping and coiling of aneurysm

29. • Cerebral edema Decompressive craniectomy
S U R G I C A L M A N A G E M E N T

30. • Intra ventricular hemorrhage /acute
hydrocephalus: Ventricular drainage
S U R G I C A L M A N A G E M E N T
VENTRICLES
ventricles catheter

31. what type of stroke?

32. what type of stroke?

33. thank you…