ISCHEMIC STROKE Mangubat, Mansukhani, Manzana, Manzano, Maranion, Marayag, Marcelo, Marcial

History of Present Illness  A 57-yr. old hypertensive and diabetic woman, who had very poor compliance with her antihypertensive and hypoglycemic maintenance medications, awoke one morning noting that she was unable to move her entire left side of the body. She called for help and her daughter noticed that her mother had a slurred speech with saliva drooling on the left corner of her mouth.

 Mental status examination showed an awake, conscious and coherent individual who followed commands, with poverty of verbal response.  Mood was dysthymic, teary eyed even on neutral queries, withdrawn with disturbances in sleep and appetite.  Neurologic examination disclosed the following: can raise both her eyebrows, can close both eyes tightly, pupils 3mm reactive to light and isocoric, extraocular muscle movements were full and conjugate.

 On confrontation test, she was unable to see the left side of her visual field. She can clench both teeth tightly, had a shallow nasolabial fold on the left, and her tongue deviates to the left on protrusion.  Manual Muscle testing revealed 2/5 weakness on the left upper extremity and 3/5 on the left lower extremity. The right limbs were unaffected.  Deep tendon reflexes were generally hyperactive on the left with babinski reflex on the left foot.  No sensory deficit noted.

 On precordial auscultation, the patient had irregular heartbeat with an ECG finding of atrial fibrillation.  Blood chemistries showed an elevated cholesterol level.

Pertinent PositivesPertinent Negatives 57-year old woman Sudden onset Hypertensive, diabetic Poor compliance to medications Hemiparesis (left) Slurred speech with saliva drooling on left corner of mouth Poverty of verbal response Dysthymic, teary-eyed even on neutral queries, withdrawn Disturbance in sleep and appetite Awake, conscious, coherent Followed commands Neuro exam: raise both eyebrows, close both eyes tightly, pupil 3mm reactive to light and isocoric, full and conjugate extraocular muscle movements

Pertinent PositivesPertinent Negatives Unable to see L side of visual field Shallow nasolabial fold on left Tongue deviation to the left on protrusion 2/5 weakness on LU extremity; 3/5 on LL DTR hyperactive on left (+) babinski on left Irregular heartbeat (ECG: atrial fibrillation) Elevated cholesterol levels Clench both teeth tightly MMT: unaffected right limbs No sensory deficit

Clinical impression: Ischemic stroke

Gamitin ang UTAK Utal Slurred Speech Utal Slurred Speech U U Tabingi ang mukha Saliva drooling on L corner of mouth Tabingi ang mukha Saliva drooling on L corner of mouth T T Angal (sakit ng ulo/pamamanhid) Unable to move entire L side of body Angal (sakit ng ulo/pamamanhid) Unable to move entire L side of body A A Kumilos kaagad K K

Stroke or TIA? Stroke Sudden onset of focal brain lesion Vascular origin Sx lasting for >24hours or leading to death Sudden onset of focal brain lesion Vascular origin Sx lasting for >24hours or leading to death TIA Transient Ischemic Attack TIA Transient Ischemic Attack Not included in definition of stroke, although with common cause Sx last <24hours Complete resolution within 24 hours Not included in definition of stroke, although with common cause Sx last <24hours Complete resolution within 24 hours

Diagnosis of Stroke Stroke Ischemic Thrombotic Embolic Hypoperfusion Hemorrhagic Intracerebral Subarachnoid 80%

Hemorrhagic Stroke

Intracerebral hemorrhage ( bleeding within the brain) – Accounts for 20% of stroke – Usually results from chronic high blood pressure that weakens the arteries causing it to break – Sudden onset of severe headache, vomiting, focal neurologic deficits that progress over minutes – May present with agitation and lethargy  stupor and coma – Other causes: trauma, ruptured aneurysm, AV malformation, anticoagulant, thrombolytic agents, CV amyloidosis, bleeding disorders

Hemorrhagic Stroke Subarachnoid hemorrhage (bleeding between the inner and outer layers of the tissue covering the brain) – 10% of stroke – Most common cause is ruptured aneurysm – Other cause: AV malformation – Symptoms: sudden, severe headache that peaks within seconds followed by a brief loss of consciousness but others remain coma or unconscious – stiff neck as well as continuing headaches, often with vomiting, dizziness, and low back pain – Weakness/paralysis and loss of sensation on one side of the body, aphasia

Ischemic stroke  Death of brain tissue resulting from an inadequate supply of blood and oxygen to the brain due to blockage of an artery.  by blood clots or fat deposits

Ischemic Stroke  death of an area of brain tissue (cerebral infarction) resulting from an inadequate supply of blood and oxygen to the brain due to blockage of an artery most commonly a branch of one of the internal carotid arteries

Etiology Ischemic stroke Atherosclerosis Hypoperfusion Arteriogenic emboli Small vessel “lacunes” 25% Cardiogenic Embolism 20% Others 35% (cryptogenic, dissection, arteritis,Prothrombotic state etc) Illustration of different clinical courses of MS.(Adapted from Lublin FD, Reingold SC. Defining the clinical course of multiple sclerosis: results of an international survey. Neurology 1996;46: )

Pathophysiology In situ thrombosis of intracranial vessels affecting small penetrating arteries that arise from major intracranial arteries Occlusion by an embolus (cardiogenic sources such as atrial fibrillation or artery-to artery emboli from carotid atherosclerotic plaque; often affecting large intracranial vessels Hypoperfusion- flow limit stenosis of major extracranial (internal carotid) or intracranial vessel

Ischemic Stroke

Cardioembolism 20 % of all ischemic strokes Embolism of thrombotic material forming on the atrial or ventricular wall or the left heart valves  may fragment or lyse producing TIA or occlude arteries producing stroke Sudden in onset with maximum neurologic deficit at once Emboli most often lodge in the MCA,PCA or their other branches Most common cause: atrial fibrillation Others:MI, prosthetic heart valve, rheumatic heart dse, ischemic cardiomyopathy

Artery-Artery Embolism  Thrombus formation on atherosclerotic plaques may embolize to intracranial arteries  Carotid Atherosclerosis  Carotid bifurcation is the most common source  RF for carotid disease: Male gender, old age, HPN, Diabetes, hypercholesterolemia, smoking  Produces 10% of ischemic stroke

Other Causes Lacunar infarction one of the small arteries deep in the brain becomes blocked by a mixture of fat and connective tissue—a blood clot is not the cause This disorder is called lipohyalinosis and tends to occur in older people with diabetes or poorly controlled high blood pressure Only a small part of the brain is damaged in lacunar infarction.

Clinical manifestations depends on which artery is blocked and thus which part of the brain is deprived of blood and oxygen branch from the internal carotid artery are affected, the ff are most common: – Blindness in one eye – Inability to see out of the same side in both eyes – Abnormal sensations, weakness, or paralysis in one arm or leg or on one side of the body branch from the vertebral arteries: – Dizziness and vertigo – Double vision – Generalized weakness on both sides of the body

Risk Factors Age (>65 y/o) Gender (M>F) Family History Prior strokes or MI HPN Diabetes atrial fibrillation (AF) and other specific cardiac conditions High blood cholesterol Arterial disease obesity lifestyle (exposure to cigarette smoke, excessive alcohol use, physical inactivity and unhealthy diet)

Clinical manifestations  Others:  difficulty speaking (for example, slurred speech)  impaired consciousness (such as confusion)  loss of coordination  urinary incontinence  Severe strokes may lead to stupor or coma.  behavioral problems (depression or an inability to control emotions)

Diagnosis based on the history of events and PE. Can usually identify which artery in the brain is blocked based on symptoms. – weakness or paralysis of the left leg suggests blockage of the artery supplying the area on the right side of the brain that controls the left leg's muscle movements. CT – usually done first – helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities.

CT Scan Ischemic Stroke Hemorrhagic Stroke

Motor Homunculus

Diagnosis  Measure the blood sugar level to rule out a hypoglycemia.  Diffusion MRI  which can detect ischemic strokes within minutes of their start, may be done next.

Identifying the precise cause of the stroke is important. – ECG - look for abnormal heart rhythms – Echocardiography - check the heart for blood clots, pumping or structural abnormalities, and valve disorders – Imaging tests (angiography) - to determine whether arteries, especially the internal carotid arteries, are blocked or narrowed. Blood tests – check for anemia, polycythemia, blood clotting disorders, vasculitis, and some infections and for risk factors such as high cholesterol levels or diabetes

Treatment

Atherothrombotic Disease  Management in Acute Phase  Measures to Restore the circulation and Arrest Pathologic Process  Physical Therapy and Rehabilitation  Measures to Prevent Further Strokes and Progression of Vascular Disease

Acute Phase  Prevention of Aspiration and Pneumonia  Prevention of Venous Thrombosis, Pulmonary Embolism, and Coronary Syndromes  Special Care of Skin, Eyes, Mouth, Bladder and Bowel  Monitor BP, Pulmonary Function, Blood Gases

Restore Circulation and Arrest In Pathologic Process  Complete stroke= none effective  Diagnosis of thrombosis earliest as possible  Maintaining nearly horizontal in bed on first day  Maintenance of Normal Blood Pressure

Thrombolytic Agents  IV Recombinant t-Pa and Streptokinase  Convert plasminogen to plasmin  Now have been shown to have a role in treatment of stroke  Treatment within 3h of onset of symptoms led to 30 percent increase in number of patients who remained with little or no deficits after 3 months.

Acute Surgical Revascularization  Immediate surgical removal of the clot or performance of bypass  Usually several hours will have elapsed before the diagnosis is established  Interval longer than 12h, opening the occluded vessel is usually of little value

Infarctive Cerebral Edema  Mass effect on CT scan in the first 24h  Clinical deterioration within several days of the stroke but may evolve quickly  Drowsiness  Fixed dilated pupil  Babinski sign  Due to secondary tissue shifts  IV mannitol 1g/kg then 50g q2-3 hours

Anti-Coagulant Drugs  Warfarin and Heparin  used extensively to prevent TIA’s and reduce the chances of an impending stroke.  Halt the advance of a progressive thrombotic stroke  Administration is not of great value once a stroke is fully developed.

Anti-Coagulant Drugs  Accurate diagnosis  Intracranial hemorrhage must be excluded by CT scan  Estimation of PT and PTT before start of therapy

Heparin  Given IV beginning with a bolus of 100 U/kg followed by continuous drip (1000U)v adjusted according to PTT.  PTT exceeds 100s- discontinue, check blood clotting values, and reinstitute at a lower rate.  LMWH- given SC within the first 48h of the onset of symptoms may improve outcome from stroke.

Warfarin  Greatest usefulness is in the first 2 to 4 months following onset of ischemic attacks  After that time, the risk of intracranial hemorrhage may exceed the benefits ( Sandok et al)

Anti-Platelet drugs  Aspirin (325mg daily) has proved to be perhaps most consistently useful drug in the prevention of thrombotic and embolic strokes.  In patient who cannot tolerate aspirin, the platelet aggregate inhibitor clopidogrel ( or ticlopidine, dipyridamole) can be substituted.

Other forms of Medical Treatment  Hemodilution – lowering blood viscosity improved regional blood flow to heart and brain  Enhancing CO- ( aminophylline, pressor agents)  Improving Microcirculation- ( mannitol dextran)  Vasodilating Drugs

Physical Therapy and Rehabilitation  Paralyzed limbs should ideally be carried through full range of passive motion several times a day  Should be moved to chair as soon as the stroke is completed and BP is stable  Prophylaxis for DVT  Assessment of swallowing difficulty and dietary adjustments  Nearly all hemiplegics regain the ability to walk after 3-6 months

Preventive Measures  Reducing the future occurrences of strokes  Aspirin  Any required anti-hpn should be administered with caution  Cholesterol lowering drugs should be administered unless cholesterol level is already low or with contraindications  Smoking cessation  Maintenance of systolic BP, oxygenation, and intracranial BF during general surgical procedures

PROGNOSIS

 According to the World Health Organization, 15 million people worldwide will suffer from stroke this year. Five million will die and another five million will be permanently disabled. In the Philippines, stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos, according to Dr. Navarro in his study published in The Philippine Journal of Neurology. Stroke prevention campaigns By Rafael Castillo, MD Inquirer First Posted 00:52:00 12/01/2007

PROGNOSIS  Depends on  the type of stroke  Ischemic vs hemorrhagic  the location, degree and duration of obstruction or hemorrhage  the extent of brain tissue death

Stroke Scales  Glasgow Coma Scale  National Institute of Health (NIH) Stroke Scale  Modified Rankin Scale

Glasgow Coma Scale

Modified Rankin Scale

NIH Stroke Scale Helps predict the severity and outcome of stroke. It includes 11 different factors measured during a neurological exam: 1.Level of consciousness 2.Gaze 3.Visual field 4.Facial movement 5.Motor function in arms 6.Motor function in legs 7. Coordination (Limb Ataxia) 8.Sensory loss 9.Language problems 10.Ability to articulate (Dysarthria) 11.Attention (Extinction and Inattention or Neglect)

NIH Stroke Scale Each impairment noted during the exam is assigned a certain number of points, so the higher the score, the worse the stroke: 0 1 – 4 5 – – – 42 No stroke Mild stroke Moderate stroke Moderate to severe stroke Severe stroke

0 1 – 4 5 – – – 42 No stroke Mild stroke Moderate stroke Moderate to severe stroke Severe stroke

Baseline NIH Stroke Scale score strongly predicts outcome after stroke H. P. Adams, Jr., MD, P. H. Davis, MD, E. C. Leira, MD, K.-C. Chang, MD, B. H. Bendixen, PhD, MD, W. R. Clarke, PhD, R. F. Woolson, PhD and M. D. Hansen, MS  At 3 months, excellent outcomes were noted in 46% of patients with NIHSS scores of 7 to 10 and in 23% of patients with scores of 11 to 15.  The NIHSS score strongly predicts the likelihood of a patient’s recovery after stroke. A score of >16 forecasts a high probability of death or severe disability whereas a score of <6 forecasts a good recovery. Neurology 1999;53:126 © 1999 American Academy of NeurologyAmerican Academy of Neurology

 Factors that Affect Quality of Life in Survivors  Those patients with ischemic strokes who score less than 10 in NIH Stroke Scale have a favorable outlook after a year, while only % of patients do well if their score is more than 20. Review Date: 5/21/2009 Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

 Factors Affecting Recurrence  The risk for recurring stroke is highest within the first few weeks and months of the previous stroke. But about 25% of people who have a first stroke will go on to have another stroke within 5 years. Risk factors for recurrence include:  Older age  Evidence of blocked arteries (a history of coronary artery disease, carotid artery disease, peripheral artery disease, ischemic stroke, or TIA)  Hemorrhagic or embolic stroke  Diabetes  Alcoholism  Valvular heart disease  Atrial fibrillation

Neurologic Deficits and Recovery  If clinical recovery does not begin in 1 or 2 weeks from stroke attack, outlook is bad for both motor and language functions  Whatever motor and language deficits remaining after 5-6 months from attack will be permanent Page 690

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