Stroke

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Introduction to Common CNS Disorders:

Introduction to Common CNS Disorders UNIT 3 PART 1: STROKE PR 6 th edition: Chapter 15, p645 - 664 (Stroke)

I. Stroke = CVA:

I. Stroke = CVA

Epidemiology American Stroke Association, 2013 :

Epidemiology American Stroke Association, 2013 Stroke is the #4 killer (after MI , CA, chronic lower respiratory disease) 20% fatality rate #1 cause of disability 5.5 million living with stroke Effects 795 000 Americans / yr 200 000 are recurrent Aging population = increased incidence Women account for 40% of new strokes but 62% of deaths I - Stroke

Etiology:

Etiology 1. Ischemic ~80% (occlusive/clot) Embolus Thrombus 2. Hemorrhagic ~20% (abnormal bleeding) Subarachnoid Intracerebral I - Stroke

Type 1: Ischemic Stroke – 80%:

Type 1: Ischemic Stroke – 80% Thrombus: cerebral clot that blocks blood flow causing neuronal cell death Embolus: traveling clot (usually cardiac in origin, possibly trauma) Thrombus I - Stroke

Atherosclerosis – caused from HTN, Smoking, Diabetes, High cholesterol, aging:

Atherosclerosis – caused from HTN, Smoking, Diabetes, High cholesterol, aging Athero = plaques: fat, calcium, cholesterol - LDL ) Sclerosis = hardening Increased pressure causes plaques to rupture causing platelet adhesion ( thrombus formation ) Also leads to aneurysm and hemorrhagic stroke I - Stroke

Type 2. Hemorrhagic Stroke – 20%:

Type 2. Hemorrhagic Stroke – 20% Ruptured blood vessel (aneurysm) that causes blood to leak into or around the brain causing damage Also causes a restriction of distal blood flow (ischemia) If severe may increase ICP Causes an intense, sudden HA I - Stroke

Types of hemorrhages:

Types of hemorrhages Intracerebral Usually small arteries that penetrate brain Related to chronic HTN & atherosclerosis Most deadly Subarachnoid Usually large arteries (congenital berry aneurysm 70-90% mortality rate)

Pathophysiology:

Pathophysiology Core area Prenumbra area Cascade: Prenumbra neurons ++ glutamate released from infarcted neurons Ca+ influx Ca+ sensitive destructive enzymes Core Neuron

Cerebral Edema:

Cerebral Edema Edema: Begins almost immediately peaks at 3-4days resolves by 3weeks With large infarcts increases in ICP lead to further damage, coma, or death (secondary brain damage)

Stroke Warning Signs and Symptoms:

Stroke Warning Signs and Symptoms F A S T Face Drooping Arm Weakness Speech Difficulty Time to call 911, note the time of onset

Risk Factors:

Risk Factors HTN* Diabetes* Smoking* High cholesterol* and blood lipids (LDL) Obesity (3/10 US Adults) Inactivity Stroke belt TIA or prior stroke* MI* Atrial Fibrillation* Age Male (women post-menopause) African-American Women in third trimester and 6 weeks post-natal Congenital AVM    I - Stroke

TIA- transient ischemic attack:

TIA- transient ischemic attack temporary interruption of blood supply (ischemia) to the brain not lasting more than 24 hours Symptoms usually last less than 5mins Newer definition: ischemia occurs but not infarction (diagnosed via MRI) I - Stroke

Vascular syndromes (ant circulation) :

Vascular syndromes (ant circulation) Anterior cerebral artery (less common) Supplies medial aspect of frontal and parietal lobes, Anterior limb of internal capsule LE>UE Middle cerebral artery (*most common) Supplies lateral aspect of frontal, parietal, temporal lobes and occipital, basal ganglia, parts of internal capsule UE, face >LE Homonymous Hemianopsia Neglect (right sided brain damage) Apraxia and aphasia (left sided brain damage) Coma if proximal MCA occluded

PowerPoint Presentation:

http://youtu.be/YMzVywpbNes http://youtu.be/YMzVywpbNes

Vascular syndromes (posterior circulation):

Vascular syndromes (posterior circulation) Posterior cerebral artery Supplies occipital lobe, medial-inferior temporal lobe, midbrain, thalamus Visual deficits (homonymous hemianopsia or cortical blindness) Vertebrobasilar Supplies brainstem and cerebellum Bulbar paralysis (cranial nerve symptoms) Ipsilesional Ataxia and coordination impairments Death if complete occlusion, “Locked – in” (basilar a) I - Stroke

The Diving Bell and the Butterfly:

The Diving Bell and the Butterfly 1995-1997

Medical Management:

Medical Management CT and MRI tPA (ischemic only) 3 hr window < 50% arrive to hospital on time Neuroprotectives (glutamate and CA antagonists) Clot evacuation Anticoagulants/ antiplatelets Heparin, coumadin / aspirin Carotid endarterectomy Surgical removal of clot Balloon angioplasty with stent Clipping/coils Preventative management Acute management I - Stroke

PowerPoint Presentation:

Invasive – craniotomy performed Less Invasive

PowerPoint Presentation:

Carotid endarterectomy Stent

Right CVA (left hemiparesis), table 15.5 p 659:

Right CVA (left hemiparesis ), table 15.5 p 659 Neglect Agnosia Quick/impulsive Poor judgment Overestimate abilities Emotional lability SAFETY IS A CONCERN! I - Stroke

Left CVA (right hemiparesis), table 15.5 p 659:

Left CVA (right hemiparesis), table 15.5 p 659 Aphasia Apraxia Slow & cautious Realistic Depressed & -ve NOT MOTIVATED, NEED SUPPORT! I - Stroke

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