Stroke Objectives: At the end of this session, the trainees should; be able to outline the epidemiology and pathophysiology of ischemic stroke be able to discuss protocols for the identification, evaluation, and treatment of ischemic stroke be able to address the challenges of family physicians for managing stroke be able to mention recent guidelines for the prevention and rehabilitation of stroke

Outline: - Why stroke -Definition -Anatomic and physiologic overview - Types of CVA - Effects Of A Stroke - Risk Factors - Signs and Symptoms - Complications - Diagnosis - Management

Epidemiology of stroke Morbidity: – Every year: 500,000 have a first stroke – Every year: 200,000 have a subsequent stroke – Frequency of stroke doubles every 10 years after 55 y.o. Mortality: – 3 rd leading cause of mortality in the US (i.e., more than chronic lung disease, accidents, diabetes…) – Causes about 7% of all US deaths

Stroke morbidity

Definition - A stroke (cerebrovascular accident) “ CVA ” is a "brain attack" that happens when a part of the brain experiences a problem with blood flow. - This disruption in blood flow cuts off the supply of oxygen to the cells in that part of the brain, and these cells begin to die.

Brain Blood Supply

Types of CVA There are two main types of stroke: I. Ischemic stroke Stroke caused by a blockage in the artery supplying blood to a particular region of the brain (called cerebral infarction). This is the most common type of stroke. Ischemic stroke can further be divided into two main types: thrombotic and embolic

1- Thrombotic strokes: are strokes caused by a thrombus (blood clot) that develops in the arteries supplying blood to the brain. 2- Embolic strokes: often Result from heart disease or heart surgery and occur rapidly and without any warning signs.

A second major cause of stroke is bleeding in the brain hemorrhagic stroke. This can occur when small blood vessels in the brain become weak and burst. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood after the blood vessel ruptures damages brain cells.. II. Hemorrhagic stroke

There are two main types of hemorrhagic strokes: 1- A subarachnoid hemorrhage: occurs when a blood vessel on the brain bursts and bleeds into the fluid- filled space between the brain and the skull. This type of stroke can happen at any age. 2- An intracerebral hemorrhage: occurs when an artery bursts inside the brain, flooding the surrounding brain tissue with blood. This type of stroke is often associated with high blood pressure

Autopsy of Intracerebral Hemorrhage

TIA. – Focal neurologic deficit (e.g., hemiparesis, slurred speech, diplopia, ataxia) resolving in 24 hours (60-70% within 1 hour) – Usual cause: temporary ischemia from emboli, vasospasm, hypotension

What Parts of the Brain Are Affected by Stroke?

Effects Of A Stroke - Speech changes - Vision changes - Memory and concentration difficulties - Paralysis - Weakness and stiffness - Difficulty eating and swallowing - Mood changes - Difficulties with personal relationships - Other challenges (e.g.: numbness, Control of bowels and bladder may be lost temporarily)

What Are the Effects of Stroke? Left Brain

What Are the Effects of Stroke? Right Brain

Primary prevention: risks

Lifestyle Risk Factors Smoking – Risk of stroke doubles with each pack – Risk of stroke returns to baseline 2 yrs after quitting Drinking – Regular intake of > 4 drinks/wk=small increase in risk of stroke,moderate increase on risk of death after stroke

Lifestyle Risk Factors Diet

Primary prevention: medical risks HTN: RR of stroke in untreated hypertensive (>140/90) is 1.2 – 4.0 MI: Risk of stroke increases 30% in the first month post-MI, then 1-2% each year after that. AF: strong independent risk for ischemic stroke (RR = 5). 70% are cardioembolic, 30% are ‘other-embolic’.

Primary prevention: medical risks DM – The bad news: increased RR of – The bad news: glycemic control may not help Hypercholesterolemia: RCTs on those with TC>240, when treated, had decreased RR of 0.7 Carotid artery stenosis: isolated as risk factor in 1914 – The bad news: only 33% of significant stenosis=bruit – The bad news: only 60% of bruits=significant stenosis – Risk of same-side stroke is 2%

Coumadin and stroke prevention

In patients >75 y.o., more strokes (hemorrhagic and ischemic) in those on warfarin vs those just on aspirin The best balance of INR seems to be 2.0 – 3.0 for most patients

Coumadin and stroke prevention: the final word?

Secondary prevention for special populations TIA

Secondary prevention for special populations TIA

Symptoms and signs * Weakness or paralysis of an arm, leg, side of the face, or any part of the body Numbness, tingling, decreased sensation Vision changes Slurred speech, inability to speak or understand speech, difficulty reading or writing Swallowing difficulties or drooling Loss of memory Vertigo (spinning sensation)

*fits * Loss of balance or coordination * Personality changes * Mood changes (depression, apathy) * Drowsiness, lethargy, or loss of consciousness Uncontrollable eye movements or eyelid drooping

Conditions That Mimic AIS Bell’s Palsy Bell’s Palsy is a viral infection of the facial nerve which causes stroke-like symptoms: unilateral facial droop, sensory deficit, dysarthria, etc.

Conditions That Mimic cva Hypoglycemia Metabolic conditions – fever, hyponatremia, drugs, etc. Psychogenic Complex migraines Hypertensive crisis

Stroke - Management Door: ER Triage – Stroke evaluation targets for stroke patients who are thrombolytic candidates Door-to–doctor first sees patient…….…………10min Door-to–CT completed…….…………………..25min Door-to–CT read...…………..…………………45min Door-to–fibrinolytic therapy starts…………….. 60min Neurologic expertise available*…..……………15min Neurosurgical expertise available* …………… 2hours Admitted to monitored bed..……...…………… 3hours *By phone or in person

Exclusion Criteria

mangment Acute stage Supportive – ER –ICU Complication prevention

pitfall A cautious approach should be taken toward the treatment of arterial hypertension in the acute stage ASA C Antihypertensive agents should be avoided unless the systolic blood pressure is > 220 mm Hg or the diastolic blood pressure is > 120 mm Hg

mangment After discharge Team approach Physical therapy Home modification Care giver stress Social services Home care

Air mattress

splint

zimmer frame.

cane

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