2. • Stroke is a clinical syndrome characterized by
rapidly developing clinical symptoms and/or
signs of focal, and at times global, loss of
cerebral function, with symptoms lasting more
than 24 hours or leading to death, with no
apparent cause other than that of vascular
origin – WHO
• TIA (Transient Ischaemic Attack) recovery is
complete within 24 hours.

3. • 3rd most common cause of death in
Malaysia NASAM 2013
• Incidence of Stroke in Malaysia increasing
trend but inhospital mortality rate is in
declining trend. Information and Documentation Unit, Ministry Of health 1998
• The incidence of stroke has been reported
to be more in men compared to women (Hu
et al, 1992; al-Rajeh et al, 1993; Lopez et al, 1995; Korv et al, 1996; Rozenthul-
Sorokin et al, 1996)

4. • Every two seconds, someone in the
world suffers a stroke.
• Every six seconds, someone dies of a
stroke.
• Every six seconds, someone’s quality
of life will forever be changed – he will
be physically disabled permanently due
to a stroke.
REF :
http://thestar.com.my/health/story.asp?file=/2011/10/30/health/9788575&sec=health

5. • 3 Simple Questions
☺Ask the person to
smile
☺Ask the person to
raise both arms
☺Ask the person to
say a simple
sentence “The sky is
blue in Johor”
The sky is
blue in Johor

6. Sudden numbness or
weakness of face, arm or leg,
especially on one side of the
body
Sudden confusion,
trouble speaking or
understanding
Sudden trouble
seeing in one or
both eyes
Sudden trouble
walking, dizziness, los
s of balance or
coordination
Sudden severe
headache with no
known cause

7. Non-modifiable Modifiable
Age (uncommon below 40) High blood pressure (systolic &
diastolic)
Sex M>F Cigarettes smoking
Ethnic/race Diabetes melitus
Family history of stroke Atrial fibrillation
Coronary heart disease
Hyperlipidemia
Obesity & physical inactivity
High dietary salt intake
Heavy alcohol consumption
Previous stroke
High homocystein level

8. Atherosclerosis,thrombosis,embolism,
arterial spasm,hypotension,
Vasculitis cerebral venous infarction
infarction
Destruction of brain substance
Mark oedema of
surrounding brain
Oedema of surrouding brain tissue
HPT, aneurysm, bleeding diathesis,
arteriovenous malformation
neoplasm
Space occupying lessions
Expending mass from
arterial haemorrhage
Destruction of brain substance

9. Increase intracranial pressure
Localizing sign
(due to destruction of brain tissue/
Substance and oedema)
Loss of sensation
Slurred speech
Numbness and weakness of
Left upper limb
Upper motor lession
Left upper limb
-hypertonia
-hyperreflexia

11. Occlusion in brain blood flow
♣ Thrombotic stroke: clot forms in an area of
atherosclerosis. Plaques that completely clog or
markedly narrow an artery also can cause
ischemic stroke.
♣ Embolic stroke: clot, or piece of plaque formed in
one of the arteries leading to the brain or in the
heart, is brought by bloodstream to lodge in
narrower brain arteries.

12. Three main causes of ischemic stroke are:
1. Atherothromboembolism (50%)
i. Large vessel occlusion or stenosis (e.g.: carotid
artery)
ii. Branch vessel occlusion or stenosis (e.g.: MCA)
iii. Perforating vessel occlusion (lacunar infarction)
2. Intracranial small vessel disease (penetrating artery
disease) (25%)
i. Collagen disease e.g.: RA, SLE
ii. Vasculitis e.g.: PAN, temporal arteritis
iii. Granulomatous vasculitis e.g.: Wegener’s
granulomatosis
iv. Miscellaneous: syphilitic vasculitis, fibromuscular
dysplasia, sarcoidosis, trauma
3. Cardiogenic embolism (20%) – Valvular heart disease,

13. Disease of Blood
• E.g.: Coagulopathies, Haemoglobinopathies
Venous Thrombosis
• Venous Thrombosis may occur with infection and
dehydration or in a/w arterial occlusion when related
to estrogen excess (pregnancy, oral contraceptives)
Decrease cerebral perfusion
• Infarction between arterial territories may result from
impaired perfusion e.g.: cardiac dysrhythmia, GI
blood loss

14. Artery occluded Areas Infarcted Clinical Effect
Anterior Cerebral
Artery
Frontal lobe Confusion, disorientated
Motor and sensory cortex
(leg area)
C/lateral weakness, max in leg,
cortical type sensory loss, max in
leg
Middle cerebral
artery
Lateral surface C/lateral hemiparesis, face>leg;
c/lateral cortical type sensory loss
Speech area (dominant) Expressive aphasia
Optic Radiation Hemianopia
Posterior cerebral
artery
Occipital lobe Cortical type-visual loss
Vertebrobasilar
arteries
Cerebellum Intention tremor, incoordination,
hypotonia
Brain stem C/lateral hemiparesis and sensory
loss; ipsilateral CN palsies

15. • Hemorrhagic stroke occurs when a vessel
in the brain suddenly ruptures and blood
begins to leak directly into brain tissue
and/or into the clear cerebrospinal fluid
that surrounds the brain and fills its
ventricles.

16. • Hemorrhagic strokes are less common
than ischemic strokes but cause a
significant number of deaths worldwide.
• Approx. 70-80% of all strokes are
ischemic,
20-30% are hemorrhagic
(10-20%-intracerebral hemorrhage
5-10% -subarachnoid hemorrhage)
Kase et al., 2004

17. • The fatality rate for hemorrhagic strokes is
higher than for ischemic strokes and the
overall prognosis is poorer
• It is the location of the hemorrhage, rather than
the amount of bleeding, that tends to be the
bigger factor in influencing the severity of the
stroke.
• For example, bleeds in the brainstem, though
relatively tiny, can be quite lethal, whereas the
same-sized bleed in the frontal lobe may not
even be noticeable

18. A = Penetrating
cortical branches
ACA, MCA or PCA
B = Basal ganglia
C = Thalamus
D = Pons
E = Cerebellum

20. 1. Consciousness point
i. Alert 0
ii. Drowsy and stupor 1
iii. Semicoma and coma 2
2. Vomiting/ headache within 2 hrs
i. No 0
ii. Yes 1
3. Atheroma(diabetic history, angina,
claudication)
i. None 0
ii. ≥1 1
Formula:
(2.5 x consciousness) + ( 2 x vomiting) + ( 2 x headache) + ( 0.1 x DBP) – ( 3 x atheroma) – 12
Diagnosis
>1 cerebral
haemorrage
90. 0%