STROKE

Definition
CVA / CVD / Stroke: Clinical syndrome characterized by signs / symptoms of focal or global loss of cerebral function which last for more than 24 hours or leading to death with no apparent cause other than that of vascular origin

Classification
Type:
Ischemic / Infark stroke Bleeding Stroke

Clinical Course:
TIA (Transient Ischemic Attack) Neurological deficits lasts for fewer than 24 hours RIND (Reversible Ischemic Neurologial Deficit Neurological deficits lasts from 24 hours since 3 weeks PRIND (Progressive RIND) : more than 3 weeks

 Progressive Stroke / Stroke in Evolution Symptoms are gettin worse Complete Stroke Neurological deficits remain the same since the onset of the disease

Clinical Manifestation
Based on the lesion site (of the artery)
Based on artery that supplies the brain region

 Based on its type ICH&SAH

ICH
Headache Nuchal Rigidity ++ +

SAH
+++ +++

Meningeal Sign
Paresis of N III & IV Weakness

+
+ Plegi

+++
+++ Paresis

Hypertension
Cerebrospinal fluid

++
>1000

+
>25000

Difference between Ischemic and Bleeding Stroke

Infark Onset Activity Warning sign (TIA) Cephalgia Papil Edema Bradikardia Vomiting Seizures Altered Mental Status Paresis of N III IV VI Sub Acute While rest + -/+ -/+ Bleeding Acute While doing activity + + +

Retinal Bleeding
Meningeal Sign Location CT SCAN Prognosis

Depends on lesion site Hypodense Disability

+
+ Cortical / subcortical Hyperdense mortality

 Why at sleep? While sleeping, the heart pumps the blood within the blood vessels slower than at activity. This cause the mean arterial pressure is also decreasing and when the thrombotic or emboli occured and ischemia process is developing, it is gettin worse because the cardovascular system is not adequate to mantain the normal cerebral blood flow

Pathophysiology of CVA
Cerebral Blood Flow determined by: 1. Extrinsic Factors
Systemic Blood Pressure Cardiac Output (the ability of the Heart to pump the blood to the systemic circullation) The quality of caroticovertebral Arteries Blood Viscosity

2. Intrinsic Factors
Cerebral Arteries Autoregulation Regional Biochemistry Factors

Pathophysiology - Infark
N CBF = 50 60 ml/min ; aerob metablism (36 ATP) 18 20 ml / 100g / min: Neuronal electrical activity

Normal cell structure Isch. Penumbra: Reversible inactive neuron area

10ml / 100g / min: Anaerobic metabolism (2ATP) +Lactate: Deprived Na K ATPase channel function (Na Intracell & K Extracell) caused (1) edema of the brain (2) NMDA depolarisation that lead to: 1. Cell necrosis (<5ml) 2. Activation of Glutamate cascade (Ca extracell influx cause catastrophic membrane cell injury and acceleration of cell apoptosis) which all leads to (1) Cognitive deficit and neurological impairment, cell death, and (2) activation of PFE (proteinase, Fosfolipase, Endonuklease)

Pathophysiology Bleeding
AVM / Aneurysm / Hypertension cause the blood vessel to RUPTURE, lead to an increased intracranial pressure ICP symptoms perivascular bleeding edema

 Unmodifiable

Risk Factors

Male > Female Age >50 y o more susceptible to CVA Race white skin > black skin, hereditary

Modifiable Major Risk factor

HT DM CHD AF

Minor Risk factors

Obesity / Hyperlipidemia; Hyperuricemia; Infection; Smoking; Alcoholism; Oral Contraception; CNS Stimulant; Stress; TIA

Clinical Diagnoses of Stroke

Lab examination
CBC; Lipid Profile; Blood Sugar; LFT; RFT; Uric Acid Clinical Chemistry: Albumin/Globulin; Electrolyte; BGA; Toxicology

Radiology
Thorax Photo: Cardiomegaly; Tumour; TB; etc ECG MRI / CT: GOLD STANDARD
Head CT: Initial Assess ( Bleeding > Infarct) MRI : to assess infarct stroke, brain stem origin

LP

Topical Diagnoses
Carotis vascular origin
ICA: Blindness; dysphagia; contralat hemiparesis ACA: Mental disorder; seizures; urine incontinence; hemiparesis contralateral (leg> arm) MCA: Hemi / hyperesthesia; Aphasia; Spatial disorder; Hemiparesis contralateral (leg=arm / leg<<arm&face) Double hemisphere: Hemiplegic duplex; disphagia; dysartria; emotional disorder; pseudobulbar paralysis

 Vertebrobasilar vascular origin

PCA: hemianopsia homonimus kontralateral lesi (occipital); hemihipestesia/anastesi kontralat (thalamus); extrapyramidal symptoms (cerebellum) Vertebralis artery: Synd Wallenberg (vertigo; nystagmus; neausea/vomiting; dysartria; dysfonia; singultus/hiccup Basilaris Artery: Cranial Nerve Paralysis (with midline nucleus predilection: N III IV XII); Contralateral Hemiparesis PICA: Wallenberg synd ; Horner synd (narrowing of palpebra fissure; myosis; enophtalmus + anhydrosis and vasodilatation ipsilateral)

Dx Etiology DD
1. Tumor 2. Trauma 3. Infeksi 4. Stroke 5. Metabolic (Hypoglicemia) 6. Todds Paralysis 7. Multiple Scerosis 8. CP 9. Toxin 10.HT encephalopathy

Therapy
B1-B6 1. B1 Breathing
Free the airway: tilt/oblique position; O2; ETT;etc

2. 3. 4. 5. 6.

B2 Blood B3 Brain B4 Bladder B5 Bowel B6 Bone

Infact Stroke Therapy

TIA

Anti Platelet Aggregtion RIND (progressive) IVFD Anti Platelet Aggregation Phentoxyphilline Metabolit Ativator Neuroprotectant + Neurotropic Rehab + avoid risk fx Complete Stroke +CCB

Bleeding Stroke Therapy

1. 2. 3. 4. 5. IVFD Anti Fibrinolytic / Traexamat acid 100mg/cc CCB Mannitol OP