1. Acute Stroke Coordinator
Time is Brain
Janet Liefso
Acute Stroke Coordinator

2. Acknowledgement to:
Richard Wilson
Linda Kelloway
Andrea Fisher
Work revised by:
Janet Liefso, 2010

3. Objectives For Session
Increase Stroke Recognition
- signs and symptoms
Review Basic Neuroanatomy
the implications of stroke location
Review complications
Need to understand basic neuroanatomy to understand and predict signs and symptoms.

5. Jim
67 year old semi- retired accountant married to Laura. From Niagara region - visiting friends in Teeswater
Suddenly at 2100 hours wife witnessed right arm weakness and leg weakness, unable to get up on own, speech slurred
Wife called 911- paramedics responded and redirected Jim to Goderich Hospital on stroke protocol- arrived at 2130.
Diagnosed as an ischemic stroke- given tPA at new telestroke site at 2220

6. What Happened?

7. Stroke is a Brain Attack
Abrupt development of a focal neurological deficit as a consequence of a local disturbance in the cerebral circulation
The brain can’t store glucose and is dependent on circulation to provide oxygen and glucose for energy production. When circulation is interrupted, brain cells die within minutes.
Acute stroke may cause death…it actually leaves 20% of its victims dead within 30 days of their stroke. And for those who survive their stroke, many are left with significant disability necessitating institutionalization. It places a considerable cost burden on the society. But most importantly, it plays an important burden on patient and family.
With the emergence of new therapies, like tPA, and new diagnostics and treatments, there is now a window of opportunity to intervene.
A stroke is a brain attack. It should be treated with the same urgency as a heart attack.

8. Know the Warning Signs of Stroke
Sudden Weakness
Sudden Trouble Speaking
Sudden Vision Problems
Sudden Headache
Sudden Dizziness (especially with any of the above signs)

9. Stroke Stroke is undoubtedly one of the most
devastating events experienced by
humans
“Many stroke victims would rather die
than live without their dignity and quality
of life”
Bahle, J. (1998).
No choice
Stroke means to be struck down

10. Stroke is an Emergency Act Fast
Key Message
Stroke is an Emergency
Act Fast
* 6 Million Neurons a Minute are lost
Time is Brain
Dr. Lownie

11. Basic Neuro-anatomy

12. Left Brain and Right Brain

13. THE BRAIN IS DIVIDED INTO 3 MAJOR AREAS
Cerebrum
Brain stem
Cerebellum 1
3 lb organ – 2% of our body weight but % of our cardiac OP
Cerebrum- this is the largest protion and contains 2 hemispheres.
Left side controls the right and the right controls the left
The two hemispheres are joined by the corpus collosum-
Brain Stem
Cerebellum 3 2

14. THE CEREBRUM IS COMPOSED OF FOUR LOBES Each lobe has many functions
Frontal lobe is involved in planning, organizing, problem solving and personality. Frontal injuries often identified by behaviour- lack inhibitions- prefrontal cortex- higher cognitive function and personality
Speech centre in left frontal lobe in 95% of Right handed and 70% of Left handed- Broca’s aphasia- speech is slow, know what they want to say, utter sounds, simple words- expressive aphasia
Parietal lobe controls the sensory sensations such as temperature, pain and light touch, awareness of the body on the other side
Temporal lobe organs of hearing- lesion here can cause deafness
Wernicks speech are ( receptive speech area in the temporal lobe) Speech is fluent and rapid but not comprehensible- receptive aphasia.
Occipital lobe is responsible for visual preception
Cerebellum is responsible for movement and balance-
Brainstem
Pons – BP and respiratory function- hemodynamic function
Each lobe has many functions

15. Key functions are to receive information and control muscle of the head- cranial nerves
Composed of 3 specific areas

16. THE BRAIN STEM HAS 3 MAJOR DIVISIONS
Midbrain
Pons
Medulla 1 2
Midbrain- connections to cerebellum
Pons- respiratory, BP, vomiting
Medulla- respiratory , BP , swallowing, and connections to cerebellum- movement control 3

17. THE CEREBELLUM Cerebellum is a compact area.
Maintains posture and coordinated movement
Do they look drunk???
Cerebellar strokes can cause swelling which puts pressure on brain stem- Dr. Brisbins experience of the cerebellar infarct that they sent to London and Neurosurgery removed the cerebellar lobe
The swelling puts pressure on the brain stem- and pushes up into the cerebellum- like a reverse coning

18. Follow the circulation to
the brain in
the following slides….
If you understand the blood flow and anatomy you are better able to care for your patient.

19. The Carotid Arteries R Internal carotid L Internal carotid
Anterior & middle cerebral arteries
Anterior & middle cerebral arteries
R Internal carotid
L Internal carotid
Common carotid a
Common carotid a
Blood supply from the aorta supplies the carotids and the vertebral arteries. Carotids supply the anterior 2/3 and the vertebrals supply the posterior 1/3
First lets follow the carotid-
Carotids supply 2 divisions- internal and external – internal supplies anterior 60% of cerebrum ( some of the temporal and occipital areas not supplied from the interior carotids
External carotids supply the face and scalp
L subclavian a
R subclavian a
ANTERIOR
VIEW
Aorta

20. Vertebral-basilar Arteries Posterior cerebral a’s
L. Vertebral a
R Vertebral a
Vertebral arteries supply the posterior 2/5 of the cerebrum and the cerebellum and brainstem.
Basilar is at the level of the pons
Bring the neck from the clinic
L subclavian a
R subclavian a
POSTERIOR
VIEW
Aorta

21. Anterior and middle cerebral a’s
Post communicating a
Post cerebral a
Basilar a
Internal Carotid
Vertebral a
The vertebral artery changes its name. It is called the basilar artery at the level of the pons and the and then dvides off into 2 posterior cerebral arteries at the level of the cerebrum.
Common carotid
Subclavian a
Aorta

22. CIRCLE OF WILLIS Anterior C. artery Internal carotids Posterior C.
Communicating
artery
Anterior C.
artery
Internal
carotids
Post. Communicating
artery
Posterior C.
artery
Basilar C. artery
Circle of Willis is an important structure in circulation
This circle provides multiple paths of oxygenated blood to the brain. . At the base of the brain the carotid and vertral arteries form a circle of communication . If any become occluded the attempt is to ensure circulation. Aproximately the size of a loonie. Most aneurysms occurr at the circle of Willis
The anterior and posterior communicating arteries connect the right and left side of blood vessels.

23. Anterior cerebral arteries Middle cerebral arteries
Circle of Willis
Inferior view
Ant. communicating a
Anterior cerebral arteries
Middle cerebral arteries
Internal carotid arteries
Post Communicating a’s
Posterior cerebral arteries
Basilar artery
Vertebral arteries 22

24. CIRCULATION WITHIN THE LOBES OF THE BRAIN IS OFTEN SUPPLIED BY
MORE THAN ONE CEREBRAL ARTERY
E.g.. ACA and MCA to the frontal lobe

25. Generally, the Anterior Cerebral Artery (ACA) runs between the left and right hemispheres of the brain within the great longitudinal fissure.
Stems from internal carotid
Supplies blood to the frontal and anterior parietal areas
ACA supplies the primary motor area HAL leg and foot
2nd most common area of stroke
Longitudinal
fissure

26. Generally, the Middle Cerebral Artery (MCA) runs on the lateral side of the 2 hemispheres and portions of the ventral (bottom) side of the lobes.
The MCA is the largest of the blood vessels and supplies blood to over 2/3 of the cerebrum.
It stems from the internal carotid.
Most common stroke area.
Gina’s tip
ACA and MCA supplies eyes, most of hypothalamus, frontal. Parietal, and most of the temporal lobes.

27. Generally, the Posterior Cerebral Artery (PCA)
is located on the bottom of the brain.
Stems from the vertebral artery to basilar to posterior cerebrals.
Supplies the blood to the brain stem, hypothalamus, thalamus, posterior parietal lobe, parts of temporal and occipital lobe and spinal cord.

28. POSTERIOR CEREBRAL ARTERY Note the ventral location of this artery

29. DEFICITS IN A PATIENT WITH A STROKE CAN BE EXPLANED BY:
AREAS OF THE BRAIN
CIRCULATION OF THE BRAIN
AND/OR A COMBINATION OF BOTH
Very important to have this information on you patient
Lack of 02 for 2 min can result in ischemia. Lack of o2 for 5 min can result in irreversible damage.
6 million cells per minute- from Dr. Lownie.

30. THIS PATIENT MAY EXPERIENCE:
A STROKE IN
FRONTAL LOBE
BLOOD SUPPLIED
BY ACA AND MCA
THIS PATIENT MAY EXPERIENCE:
Contralateral paralysis or paresis of face, arm, leg
Difficulty expressing language “ stuttering, using wrong word, articulation, repeating word(s)” (BROCA’S APHASIA)
Urinary incontinence
Personality changes and emotional lability ,

31. FRONTAL LOBE CONTINUED Controls ability to express language
IMPORTANT STRUCTURES
Broca is speech
Controls ability to express language

32. FRONTAL LOBE CONTINUED Control of muscle movement
IMPORTANT STRUCTURES
Primary motor strip
What is the motor strip called?
Homunculus- HAL hand – arm - leg
Control of muscle movement

33. primary motor cortex ( strip )
“ Homunculus”
THE HOMUNCULUS SHOWS THE LOCATION OF
BODY FUNCTION WITHIN THE MOTOR STRIP
Hals lower body bends over the top of the cerebrum- therefore an occlusion of the ACA can result in loss of strenght and sensation in the lower part of the body and an occlusion in the MCA predominately affects the upper body strength.
DEFINITION : A figurative representation of the body map encoded in the
primary motor cortex ( strip )

34. THIS PATIENT MAY EXPERIENCE
A STROKE IN
PARIETAL LOBE
BLOOD SUPPLIED BY
ACA, MCA, PCA
THIS PATIENT MAY EXPERIENCE
Sensory deficit – loss of sensation i.e. pain, pressure, touch
Talk about neglect- pt.not only cannot use the affected side but unaware that it is there. We will talk later about how to best care for a patient
Parietal lobe- remember we said that it was responsible for sensation and awareness-
Neglect – patient does not recognize a body part
Denial of deficits (often with neglect)

35. PARIETAL LOBE CONTINUED
The primary sensory cortex (strip) of the parietal lobe
is arranged in the same topographic scheme
as the motor strip in the frontal lobe.

36. A STROKE IN TEMPORAL LOBE
BLOOD SUPPLIED
BY MCA AND PCA
THIS PATIENT MAY EXPERIENCE
Severe communication problem : loss of comprehension of spoken language
( Receptive Aphasia also called Wernicke’s Aphasia)
Memory loss or disturbances in memory
Aggressiveness

37. Note location of Wernicke’s Area

38. BLOOD SUPPLIED BY MCA AND PCA THIS PATIENT MAY EXPERIENCE
A STROKE IN
OCCIPITAL LOBE
BLOOD SUPPLIED BY MCA AND PCA
THIS PATIENT MAY EXPERIENCE
VISUAL DISTURBANCES
Types of blindness- total or hemianopsia’s
Loss of recognition of objects when shown them
Hallucinations

39. BLOOD SUPPLIED BY VERTEBROBASILAR ARTERIES PATIENT MAY EXPERIENCE
IF A STROKE IN
CEREBELLUM
BLOOD SUPPLIED BY VERTEBROBASILAR ARTERIES
PATIENT MAY EXPERIENCE
A gait that looks similar to an inebriated person
Tell Dr. Brisbins story of the infarcted Cerebellum- increased swelling pushes up into the brain. Surgical removal of the cerebellum
Cerebellum- smooth coordinated body movements
Poor balance
Complaints of dizziness, light headedness, “floating”

40. BLOOD SUPPLIED BY VERTEBROBASILAR AND PCA A STROKE IN THE BRAIN STEM
The signs and symptoms depend on the location of the stroke in the 3 areas of the brain stem
Mid brain
Pons
Medulla

41. KEEP IN MIND THAT THE AREAS INTERACT AND SHARE FUNCTION TO
SOME DEGREE

42. A STROKE IN THE MEDULLA dysphagia
cardiac, respiratory, blood pressure difficulties
limb weakness
Can cause bilateral weakness but very rare.

43. A STROKE IN THE PONS often this stroke is so severe that
Respiratory function can be effected and
often this stroke is so severe that
the patient may die.

44. Types of Stroke Ischemic (80 %) Caused by blockage of an artery
Usually the result of a blood clot
Thrombotic or embolic
Hemorrhagic (20%)
- Caused by an arterial rupture
Subarachnoid hemorrhage (SAH)
Intracerebral Hemorrhage (ICH)
80% of strokes are ischemic- obstruction of flow.
Of the 80% % of those are caused by blood clots forming within the cerebral arteries caused by atherosclerosis- show picture of atherosclerosis- Thrombus
30% of these are caused by an embolus originating somewhere else in the circulation ie. Heart or carotid artery and this travels to the area of the brain affected
20% are hemorrhagic- rupture of an artery
These may be intracerebral hemorrhage in which a diseased artery within the brain ruptures or it may be a SAH in which a blood vessel on the surface of the brain ruptures and bleed into the meninges.
Main causes of hemorrhagic bleeds are AVM or ruptured aneuryms. Elevated blood pressure is often a predisposing factor
Hemorhagic strokes can be treated with surgical evacuation, control of edema and control of ICP, control of BP

45. Stroke Types CIHI/NACRS, 2005-06
Less bleeds probably due to better control of hypertension
10 % of TIA patients will go on to stroke within 3 months and 5.5 % within 48 hours.
CIHI/NACRS,

46. Definition of TIA
TIA = transient ischemic attack – resolution must be complete
Sudden onset of focal neurological dysfunction, presumably of vascular origin, lasting less than 24 hours.
1/3 last less than 15 min
70% < 1 hour
10 % more than 12 hours
No permanent damage

47. Mechanism of Stroke Feature Hemorrhage Ischemic Preceding TIA No 30%
Onset
With Activity
Sedentary
Hypertension
Usually Present
Often Present
Clinical Course
Rapidly Progressive
Stepwise or static
Signs of ICP
Present
Absent - later
CT Scan
Presence of blood
Normal or
subtle changes
Motor weakness is the most common manifestation of stroke %
Dizziness is rarely the only neurological symptom
Headache, vomiting and decreased LOC often more indicative of hemorrhagic rather than ischemic stroke

48. Ischemic (80%) Hemorrhagic (20%)
Let’s now shift to stroke mechanism. Strokes may be classified into two general types: ischemic and hemorrhagic.
The ischemic strokes account for 88% of all strokes whereas hemorrhagic strokes for 12%

49. What is tPA?
Clot buster
Works by dissolving the clot that is blocking the vessel in the ischemic stroke patients
Not all patients are eligible
Must be initiated within 4.5 hrs. from onset of symptoms
Given by IV bolus and infusion- takes about 1 hour
Management of Ischemic stroke
See attached handout for tPA inclusion and exclusion criteria
The active drug is an enzyme that binds to fibrin in a thrombus and breaks it down.
Cochrane review – good evidence for tPA- increased likelhood of a neurological recovery. 42% reduction in odds of being dead or dependent ( see save the brain powerpoint-Dr. Sahlis)

50. Penumbra Penumbra is the salvageable brain
Remember 6 million cells per minute.

51. Occlusion and Re-canalization

52. Conclusion Time is Brain
Deficits of a stroke can be explained by area of the brain affected, circulation of the brain or a combination of both.
Rapid Assessment and treatment is critical
Time is Brain

53. Coffee Break!