Clinical Presentation and Complications of Stroke

8/8/2019 Clinical Presentation and Complications of Stroke

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Dr A SinhaST2 Clinical Pharmacology

St Georges [email protected]

Stroke: Clinical Features &Complications


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Learning Objectivesy Definition of stroke and classificationy Prevalence and Importancey Natural History and Clinical Presentation of Strokey Differential Diagnosisy Managementy Complications


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D efinitionsy Stroke or cerebrovascular accident (CVA): A clinical

syndrome, characterised by disruption of cerebral vascularity,typified by rapidly developing signs of focal or global cerebradysfunctionlasting more than 24 hours or leading to death.

y Transient Ischaemic Attack (TIA): A clinical syndrome, of presumed vascular origin, typified by rapidly developing

signs of focal or global cerebral dysfunctionresolving within24 hours


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Stroke Classification

y (1) Ischaemic- thrombotic or embolic event causing blockageof the blood supply to the cerebrum (80%)

y

(2) Haemorrhagic- rupture of a cerebral blood vessel leadingto extravasation of blood into the cerebrum and itssurrounding tissue compromising neural perfusion (20%)


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R elevancey Stroke is the neurological disease of modern timesy In one year 3 people in every 2000 will have a strokey For those over the age of 75 this rises to 20 people in every

2000 every yeary After heart disease and cancer it remains the third most

common cause of death after heart disease and cancer


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N atural History and R isk Factorsy Ischaemic Strokes: Underlying pathology is (usually)

atherothromboemolismy Haemorrhagic Strokes: Underlying pathology is vascular

rupture


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Ischaemic Stroke


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R isk Factors for Thrombosis andEmbolismy High blood pressurey Smokingy Diabetesy Elevated Cholesteroly Atrial Fibrillationy Structural heart lesions (e.g.. post-MI mural thrombus,

endocarditis, patent foramen ovale with DVT)y Thrombophillic States and Vasculitic States


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Haemorrhagic Stroke


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R isk Factors for Vascular R upturey Hypertensiony Arterio-Venous Malformationsy Trauma


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Clinical Presentationy Variable!y Presentation often depends on the area of the brain that has

been damaged


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Anatomy of the brainy B rain consists of two cerebral hemispheres (dominant and

non-dominant), the cerebellum and the brain stem.y The brain stem contains autonomic centres and houses the

nuclei of the cranial nervesy The cerebellum is involved with balance and planning of movements

y The cerebrum is involved with higher functions (speech,

spatial awareness etc)


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Anatomy of the Brain


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N euroanatomyFrontal Lobe

Parietal Lobe

Temporal Lobe

Occipital Lobe


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N euroanatomyFrontal Lobe

Parietal Lobe

Temporal Lobe

Occipital Lobe


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Vascular Anatomyy Three main cerebral arterial territories:y Anterior Cerebral Arteryy Middle Cerebral Arteryy Posterior Cerebral Arteryy Penetrating Arteries extend into the brain tissue itself y Verterobasilar Circulation supplies the brain stem


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Vascular Anatomy


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L inking Function to Structurey Frontal Lobe- Higher intellectual function (mood,

personality, frontal eye fields, language)y Parietal Lobe- Language (reading, writing) calculation, Visuo-

spatial function, Higher sensory function, visual pathwaysy Temporal Lobe- Memory, language, visual pathwaysy Occipital Lobe-Visual cortex and association areas


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Specialist Areas


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Specialist Areas


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Specialist Areas


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Clinical Presentationy Global Dysfunctiony Stupor or Comay Confusion or agitation/memory lossy Seizuresy Delirium


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Clinical Presentationy F ocal Dysfunctiony Aphasia (incoherent speech or difficulty understanding

speech)y

Facial weakness or asymmetryy Incoordination, weakness, paralysis, or sensory loss of one or

more limbsy Ataxia (poor balance, clumsiness, or difficulty walking)y Visual loss (Monocular or binocular; May be partial loss of

the field)


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D ifferential D iagnosisy Tr auma: Extradural haematoma, Subdural haematomay I nfection: Meningitis/encephalitisy I nt r ac r anial mass: Tumour, Abscessy I nflammation: SLEy M ig r aine with pe r sistent neu r ological signsy M etabolic causes : Hyperglycaemia, Hypoglycaemia,

Narcotic abuse, Alcohol abuse, Hypothyroidism


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Patterns of deficity Total Anterior Circulation Infarct (TACI). Significant Damage

of both Anterior and Middle Cerebral Arteries:HemiplegiaHemianopia

Cortical Deficit (dysphasia, visuo-spatial loss)y Partial Anterior Circulation Infarct (PACI). Partial Damage

of both Anterior and Middle Cerebral Arteries: Two of theabove


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Patterns of D eficity Posterior Circulation Infarct. Damage to the posterior

cerebral artery and Vertebrobasilar circulation:Limb or gait ataxiaDysarthria

Dysconjugate gazeNystagmusAmnesiaB ilateral visual field defects


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Patterns of D eficity Lacunar Infarct: Damage to small penetrating vessels:

Decreased sensation of face and limbs on one side of the bodywithout abno r malities of highe r b r ain function,moto r function, o r vision


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Investigations and D iagnosisy Aim is to establish the cause and prevent recurrencey Full blood count, ESR, U and Es, glucose, lipids, clottingy Chest radiograph and ECGy CT scan


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M anagementy Ischaemic Strokes- Aspirin 300mg and Simvastatin 40mg and

compression stockings if not contra-indicatedy Admission to acute stroke ward, assessment of swallow

reflex, intensive nursing, early physiotherapy, occupationaltherapy and social services need to be instigated


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Complicationsy W ide ranging!


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Complications


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Complications


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Complications


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Complications


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Complications


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Complications


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Complications


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Complications

At 1900 At 2000


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Complicationsy Malnutrition and aspirationy DVT and PEy Falls and fracturey

Epilepsyy Spasticityy Pneumoniay B edsores


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Prognosisy TACS: 60% dead at one year. 20% living independentlyy PACS: 15% dead at one year. 50% living independentlyy Lacunar: 10% dead at one year. 70% living independentlyy

POCS: 20% dead at one year. 60% living independently

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Clinical Presentation and Complications of Stroke