Strokes
185,000 recurrent strokes every year Stroke Facts 610,000 new strokes every year 185,000 recurrent strokes every year Leading cause of disability, cognitive impairment, and death In 2012 = cost $71.5 billion (US)
Where We’re Headed By 2030 ~ 4% of the US population over the age of 18 is projected to have had a stroke Total annual costs of stroke are projected to increase to $240.67 billion by 2030, an increase of 129%
Intracerebral Hemorrhage Subarachnoid Hemorrhage Three Stroke Types Ischemic Stroke Clot occluding artery 85% Intracerebral Hemorrhage Bleeding into brain 10% Subarachnoid Hemorrhage Bleeding around brain 5%
ISCHEMIC STROKES
Etiology of Ischemic Strokes LARGE VESSEL THROMBOTIC (aka Clots) Blood vessel injury Stasis/turbulent blood flow Hypercoagulable state Blood vessel injury HTN, Atherosclerosis, Vasculitis Stasis/turbulent blood flow Atherosclerosis, A. fib., Valve disorders Hypercoagulable state Increased number of platelets Cancer etc
Etiology Of Ischemic Stroke: LARGE VESSEL EMBOLIC (aka clots from somewhere else): The Heart Arterial Circulation (artery to artery emboli) Venous Circulation (vein to artery emboli) The Heart Arterial Circulation (artery to artery emboli) Venous Circulation (vein to artery emboli)
Aphasia (speech /language) Broca’s Expressive aphasia I understand you but I can’t talk Wernicke’s Receptive aphasia I can talk but I don’t understand you
SMALL VESSEL (<1.5cm) Risk Factors HTN HLD DM Tobacco Use Etiology of Stroke SMALL VESSEL (<1.5cm) Risk Factors HTN HLD DM Tobacco Use Sleep apnea
Intracranial Hemorrhages (Brain bleed)
Cocaine and amphetamine use Etc Etiology of ICH Traumatic Spontaneous Hypertensive Rupture of aneurysm Bleeding into tumor Cocaine and amphetamine use Etc
Spontaneous rupture of a small artery deep in the brain Hypertensive ICH Spontaneous rupture of a small artery deep in the brain Typical clinical presentation Patient typically awake and often stressed, then abrupt onset of symptoms Basal Ganglia Cerebellum Pons
Cerebral Hemorrhage JPG
Cerebellar Hemorrhage
Subarachnoid Hemorrhage “Worst headache of my life” Altered Mental Status Photophobia Nuchal rigidity Seizures Nausea and vomiting
Subarachnoid Hemorrhage
Subacute (4 days) Infarction Acute (4 hours) Infarction Subacute (4 days) Infarction R L
Have to use within 3 hours tPa Facts Contraindications “clot buster” Have to use within 3 hours Recent Major bleeding Seizures High high BP (>185) Recent Surgery
Blood Pressure Management The goal is to maintain cerebral perfusion!! Higher than normal BPs can be okay! Blood Pressure Management For the most part, ICH stroke guidelines recommend using IV medications to lower SBP < 160 while still maintaining adequate MAP and CPP Ischemic strokes are a bit trickier to manage. One must keep in mind that the patient’s blood pressure will lower on its own by approximately 25 – 30 % within the first 24 hours. Furthermore aggressive treatment of hypertension in ischemic strokes has been shown to worsen neurological function by reducing perfusion pressure Castillo and collegues performed a study in 2004 that showed that a drop in either SBP or DBP > 20 points were associated with higher rates of mortality and larger volumes of infarctions. They also noted that early administration of antihypertensinve medications to patients with SBP > 180 was associated with an increased risk of death. **** CHHIPS trial *** According to the guidelines, sbp should be reduced by 15 – 25% within the first day as excessively high blood pressures are associated with an increased risk of hemorrhagic conversion.
BP and acute ischemic stroke Relationship Penumbra Core Clot in Artery Penumbra is the area “at risk” BP increase is an effort to provide more blood to the penumbra Lowering BP starves penumbra, worsens outcomes www.acponline.org/about_acp/chapters/ok/gordon.ppt
Preventing Strokes Healthy Diet Healthy Weight Exercise No Smoking Limit Alcohol
Preventing Strokes Check Cholesterol Control Blood Pressure Manage Diabetes Manage Heart Disease Take Your Medicines!