In this presentation I have tried to explain in brief about stroke, its etiology, types, diagnostic criteria, and its management.

1. STROKE
By: Dr. Ankit Gaur
Pharm.D, M.Sc, RPh

2. DEFINITION
Stroke (Cerebrovascular accident, CVA)
rapidly developing clinical signs of focal
or global disturbance of cerebral
function, with symptoms lasting 24
hours or longer, or leading to death,
with no apparent cause other than a
vascular origin
WHO

3. TYPES

4. STROKE SUBTYPES
Ischemic Stroke (83%)Hemorrhagic Stroke (17%)
Atherothrombotic
Cerebrovascular
Disease (20%)
Embolism (20%)Lacunar (30%)
Small vessel disease
Cryptogenic and
Other Known
Cause (30%)
Intracerebral
Hemorrhage (59%)
Subarachnoid Hemorrhage (41%)

5. ETIOLOGY
1) Non modifiable risk factors
• Age
• Gender
• Race
• Family history of stroke
• Low birth weight
2) Modifiable
• Hypertension
• Atrial fibrillation
• Diabetes
• Cigratte smoking, alcohol
• Sickle cell disease
• Post menopausal hormone therapy

6. 3) Potentially modifiable
• Oral contraceptives
• Migraine
• Drug and alcohol abuse
• Hemostatic and inflammatory factors
• Sleep disorder

7. SIGNS AND SYMPTOMS
• Hemorrhagic
– Sudden and dramatic sleeps
– Violent explosive headache
• “worst headache of my life”
– Visual disturbance
• Flashing lights, aura
– Nausea and vomiting
– Neck and back pain
• Due to blood in sub-arachnoid space
– Sensitivity to light
– Weakness on one side
– Can present like a migraine headache

8. Ischemic
Stroke
1. Harder to detect
2. Weakness in one side
3. Facial drooping
4. Numbness and tingling
5. Language disturbance
6. Visual disturbance

9. Basic Brain Facts
• The right side of your
brain controls the left
side of your body
• The left side of your
brain controls the right
side of your body
• Impairments following a
stroke depend on
where in the brain the
stroke occurred.

10. Strokes that occur on the left side of
the brain
He/she may experience the following:
• Difficulty moving the right side of the body
• Difficulty communicating daily wants and needs
• Visual impairments
• Behavioral changes
• Sensory changes
• Cognitive changes such as slowness in initiating
activity and responding

11. Strokes that occur on the right side of
the brain
He/she may experience the following:
• Difficulty moving the left side of the body
• Difficulty knowing where things are in space (for
example, over reaching for an object)
• Difficulty attending/seeing things on the left side
• Visual changes
• Cognitive changes such as poor short term memory,
attention and problem solving
• Difficulty determining what has changed since the
stroke and what the impact of those changes are (for
example, if a patient can’t walk without assistance, it
isn’t safe to try to go to the bathroom alone)

12. Seven D’s of STROKE Care
• Detection –of STROKE symptoms
• Dispatch– of EMS/ MET Team
• Delivery – to a facility prepared to manage
STROKE
• Door to treatment– rapid diagnosis and decision
making
• Data– CT Scan
• Decision– Ischemic or Hemorrhagic, does the
patient meet the criteria to receive thrombolytic
drugs
• Drug – thrombolytics when appropriate

13. Use a “FAST” STROKE Assessment
• Modification of Cincinnati Pre-Hospital Stroke
Screen
• Face
• Arm
• Speech
• Time of onset

14. FACE
• Look for Facial Droop
– Have the patient smile or show his/her teeth
– NORMAL Both sides of the
face move equally
– ABNORMAL One side of
the patient’s face droops
or does not move

15. ARMS
• Motor Weakness: Look for arm drift by asking
the patient to close eyes and lift arms
• NORMAL- arms remain
extended equally or drift
downward equally
• ABNORMAL – One arm
drifts down compared
to the other

16. Problem with gripping hands
Many elderly have arthritis
in hands
Hurts to grip hands
May mimic weakness

17. SPEECH
• Ask the patient to say “You can’t teach an old
dog new tricks”
– Lots of t’s, k’s and c’s
• NORMAL –Phrase repeated clearly and plainly
• ABNORMAL – Words slurred, abnormal or
unable to speak
SPEECH
• Ask the patient to say “You can’t teach an old
dog new tricks”
– Lots of t’s, k’s and c’s
• NORMAL –Phrase repeated clearly and plainly
• ABNORMAL – Words slurred, abnormal or
unable to speak

18. • Slurring of speech
• Unable to think of words
• Inappropriate words
• Expressive aphasia – unable to speak words
– Area of brain where words are created is damaged
• Receptive aphasia – unable to understand words
– Area where words are interpreted is damaged
Abnormal Speech

19. TIME OF ONSET
• The window of opportunity to effectively treat
STROKE is 3 hours (180 minutes)
– May be extended to 4 ½ hours in some cases
• Need to know “ last known well”.
• Difficult when
– Patient lives alone
– Woke up with symptoms

20. 180 minutes
• Don’t think of as 3 hours, but 180 minutes
• Time gets eaten up fast
• Short scene time
• Take transport time into consideration

21. • Door to doctor 10 minutes
• Door to CT completion 25 minutes
• Door to CT read 45 minutes
• Door to treatment 60 minutes
• Access to neurological expertise* 15 minutes
• Access to neuro-surgical expertise* 120 minutes
• Admit to monitored bed 180 minutes
• * by phone or in person
• ** National Institute of Neurological Diseases and Stroke

22. Assessing the Stroke Patient
• Initial Assessment
– General Impression
– Airway Airway Airway!!
– High-flow O2
– Circulation
– HIGH PRIORITY TRANSPORT

23. Focused history and physical exam
Perform thorough neurologic exam.
FAST Stroke Screen
History of Seizures
Headache
Nausea/vomiting
Neck pain
Obtain baseline set of vitals
Recheck Vital Signs frequently

24. Priorities of care
• Conduct general assessment
– Trauma – recent or within last month
• Recent seizure
• Could be a subdural hematoma
– Cardiovascular – on heart medications
• Does the patient have atrial fibrillation
• Does the patient take blood thinners
– Pulse oximetry > 94%
– Blood sugar treat if able
• Low blood sugars mimic a stroke
– Pupils

25. Body Position
• Protect potentially paralyzed parts

26. THE BRAIN
• The brain requires
20 % of
the total blood
pumped
by the heart.
• No storage
in the brain for
either fuel or oxygen
• Requires constant
supply of oxygen and glucose.

27. BLOOD SUPPLY TO THE BRAIN
• Carotid arteries – anterior neck
– Large
– Frequently congested
with plaque
– Can be cleaned out surgically
• Vertebral arteries
– Pass through cervical vertebrae
– Well protected
– Not accessible for
surgical cleaning

28. Circle of Willis
• Both blood supplies (carotid and vertebral) join
on the under surface of the brain.
• Fail-safe mechanism
in case of a blockage
somewhere in
circulation
• BUT some hard corners in
circle where debris can get
caught and site of most
cerebral aneurysms

29. What can go wrong???
• Disruption of blood flow to the brain
– Plaque – build up of cholesterol in interior of
blood vessel
– Foreign debris
– blood clot
bubble of fluid
air
– Broken vessel

30. ISCHEMIC STROKE
• Blockage of blood flow to brain
• Progressive Thrombus -- growing
– Plaque deposit – similar to process in heart with coronary
artery disease
• Cerebral Emboli --Clot from somewhere else --
floating debris
– Blood clot
– Air bubble
– Bubble of amniotic fluid
– Bone marrow from
a fracture

31. PATHOPHYSIOLOGY ISHEMIC STROKE
• Brain:
– 2% of human body’s mass
– 20% of cardiac output
• Inadequate perfusion: tissue death and functional
deficit
• Ischemic brain injury:
– A series of interlocking thresholds – the “ ischemic
thresholds ”
– Decrement in regional CBF  key pathologic events

32. Carotid atherosclerosis
Progressive accumulation of lipids and
inflammatory cells in the intima of the
affected arteries
Hypertrophy of arterial smooth muscle cells
Plaque formation
Stress
Plaque rupture ,collagen exposure ,platelet
aggregation & clot formation
Clot
remain in the vessel travel embolism

33. Local occlusion
thrombus formation
arterial occlusion
decreasing
cerebral blood flow
ishemia
ishemic cell
reduction in nutrients
Depletion of high energy phospahtes (ATP) –
maintains membrane integrity
Extracellular K+ Accumulates & Na and H2O
intracellularly
Electrolyte imbalance cell
swelling & lysis

34. leads to depolarization of the cell
influx of Ca ions
(+) lipases ,proteases, endonucleases ,release of
free fatty acids from membrane phospholipids
accumulation of free fatty acids (arachidonic
acids)
Formation of prostaglandins , leukotrienes, free
radicals
Intracellular acidosis
occurs in 2-3 hrs
Cell death

35. BRAIN STRUCTURE AND ITS
FUNCTIONS

36. What Is the Cause of Ischemic
Stroke?
• Atherothrombosis
• Embolus:
– Material: Red (fibrin rich) or White (platelet rich)
– Source: Cardiac? Aortic? Carotid Artery?
• Small artery disease
• Hypoperfusion: Hemodynamic
• Others: arterial dissection, arteritis, etc.

37. Ischemic Stroke: Atherothrombosis
• Thrombotic
– Acute occluding clot
– Superimposed on chronic narrowing

38. Ischemic Stroke: Cerebral Embolism
• Embolic
– Intravascular material, most often a clot,
separates proximally
– Flows through arterial system until
it occludes distally
– Atrial fibrillation

39. HEMORAGHIC STROKE
• Aneurysm – weakened area in artery
– Congenital
– Younger population younger than 40 years
– Complain of “worst headache in my life”
• Spontaneous Hypertensive Bleed
– Due to BP > 200/100
• Malformed Artery
– 50% younger than 30 years

40. PATHOPHYSIOLOGY OF STROKE
Presence of blood in the brain parenchyma ,
neurotoxicity of the blood
Damage to the surrounding tissue & hemorrhage
volumes >60ml mortality at 30 days
increase in intracranial pressure leads to
herniation and death

41. DIAGNOSIS
• EEG,ECG( Atrial fibrillation)
• MRI
• CT Scan-hyperintensity (white) –heamorrhage areas
normal or hypointense (dark)-infarction areas
• Carotid doppler –stenosis in carotid arteries
• Laboratory findings
1) Complete blood count
2) Coagulation test- protein c deficiency, anti -phospholipid
antibody
3) Blood lipid test
4) Measure of cardiac enzymes like troponin, creatinine kinase
LDH isoenzymes

42. • Hb, Hcr, thromb, leuc
• Glucose levels, CRP, SR, CK, CK-MB, creat
• APTT, TT-SPA/INR
• Electrolytes, osmolarity
• Urine analysis
• CSF (if needed for differential diagnosis and only
after CT scan, if available)
• Others, e.g., coagulation survey, homocysteine
for young stroke, rheumotology/immunology
screening
• Cardiac evaluation: ECG, echocardiography

43. Diagnosis: CT Scan
– Distinguishes reliably between haemorrhagic and
ischemic stroke
– Detects signs of ischemia as early as 2 h after
stroke onset
– Identifies haemorrhage immediately
– Detects acute SAH in 95% of cases
– Helps to identify other neurological diseases (e.g.
neoplasms)

44. PHARMACOTHERAPY
1) Non pharmacological treatment
•Speech therapy
•Psychological therapy
•Stroke rehabilitation
physical therapy
occupational therapy

45. PHARMACOTHERAPY
2) Pharmacological
•Acute ischemic stroke
plasminogen activator (alteplase) with in 3 hrs of onset
Dose -0.9 mg/kg I.V
aspirin within 48 hrs of onset . Dose -160-325 mg daily
started within 48 hrs
Secondary prevention of ischemic stroke
antiplatelet therapy
aspirin 50-325 mg daily
clopidogrel 75 mg daily
aspirin 25 mg +dipyridamole 200 mg twice
daily
Anti hypertensive agent
Statin therapy
AF , Cardiac source of embolism –warfarin (INR-2.5)

46. •Heamorrhage stroke
Nimodipine
( Ca channel blockers)
Carotid stenting

47. Antithrombotic Therapies to Prevent
Ischemic Stroke
Oral anticoagulants
Antiplatelet agents
Aspirin 50-325 mg/day
Ticlopidine 250 mg twice daily
Clopidogrel 75 mg/day
Aspirin (25 mg) plus extended-release
dipyridamole (200 mg) twice a day

48. 3) Surgical
•carotid endarterectomy
•EC/IC bypass surgery
•Dipping
•Detachable coil technique

49. Patient counselling
1. Educate about symptoms that might indicate
stroke and other brain disease
2. Avoid smoking and use of alcohol
3. Regular exercise is advised
4. Reduce overweight
5. Decrease intake of high cholesterol and fat
6. Regular check up of BP, sugar, lipid should be
done
7. Reduce salt intake

51. Thank You………….