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ISCHEMIC STROKE
Maria Grace Ang-De Guzman, MD
DEFINITION OF TERMS
Stroke Sudden focal neurologic syndrome due to
cerebrovascular disease
Cerebrovascular disease designates any abnormality of the
brain resulting from a pathologic process of the blood
vessels
Pathologic Processes:
Occlusion of the lumen by embolus or thrombus
Rupture of a vessel
Stroke Deaths > MI Deaths
An altered permeability of the vessel wall
Increased viscosity of other change in the quality of the
blood flowing through the cerebral vessels TYPES OF STROKE
Infarct Blockage of an artery
We don’t use the term “Cerebrovascular Accident
(CVA)” anymore Since it is not an “accident,” we now
call it “Cerebrovascular Disease (CVD)”
Temporal Profile (Clinical Course): Acute, sudden, focal
neurologic deficit arising from pathologic process of the
blood vessels Vascular in nature
Hemorrhagic Rupture of an artery 4. Adolescence and Early Adult Life: Vascular occlusion or
hemorrhage with:
a. Pregnancy and Puerperium
b. Estrogen-related stroke
c. Migraine
d. Vascular malformations
e. Premature atherosclerosis
f. Arteritis
g. Valvular heart disease
Hemorrhagic Stroke Based on the LOCATION
h. Sickle cell anemia
INTRACEREBRAL HEMORRHAGE In the brain
i. Antiphospholipid arteriopathy, plasma C-protein
matter?
deficiency and other coagulopathies
SUBARACHNOID HEMORRHAGE within the
j. Moyamoya, Takayasu disease
subarachnoid space
k. Arterial dissections
l. Amyloid angiopathy
STROKE TYPES IN ASIA
Cerebral Intracranial Hemorrhage 5. Middle Age
Country a. Atherosclerotic thrombosis and embolism
Infarction (%) ICH (%) SAH (%)
China NDA NDA NDA b. Cardiogenic embolism
Hong Kong 70 30 - c. Primary (hypertensive) cerebral heemorrhage
India 70-80 18-20 - d. Ruptured saccular aneurysm
Indonesia 67 26 1 e. Dissecting aneurysm
Malaysia 61 33 3 f. Fibromuscular dysplasia
Philippines 71 19 10
Singapore 70 27 - 6. Late Adult Life
Korea 48 31 18
a. Atherosclerotic thrombotic occlusive disease
Taiwan 61 33 4
b. Embolic occlusive disease
Thailand 70-80 18-20 -
c. Lacunar state
Japan 72 17 8
d. Brain hemorrhage (multiple causes)
e. Multi-infarct dementia
CEREBROVASCULAR DISEASES CHARACTERISTIC OF EACH
f. Binswanger disease
AGE PERIOD
1. Prenatal circulatory diseases leading to:
RISK FACTORS
a. Porencephaly
b. Hydrancephaly Could be classified into: Modifiable or Non-modifiable
c. Hypoxic-ischemic damage
d. Unilateral cerebral infarction Behavior or trait that increases your risk of stroke
The most important of these are hypertension, heart Importance of long-duration cigarette smoking in the
disease, Atrial Fibrillation, Diabetes Mellitus, cigarette development of carotid atherosclerosis has been
smoking & hyperlipidemia documented
Nicotine and CO decrease oxygen in the brain and
Hypertension Long-standing, poorly-controlled damages blood vessels
Heart Disease Coronary Artery Disease, previous If you quit smoking, your stroke risk goes down
attack significantly from 2 years onwards (Kawachi et al, 1993)
Heavy Alcohol Drinking Diabetes Mellitus
Increases stroke risk by 1.5-3x
Others:
Systemic diseases associated with a hypercoagulable Macrovascular Cerebral arteries, Coronary arteries
state Microvascular Arteries going to the foot Prone
Use of birth control pills to diabetic foot
Hypercoaguable State Hematologic problem or Heart Disease
exogenous problem Atrial fibrillation and other forms of heart disease causes
OCPs Make the blood hypercoaguable blood clot to form in the heart
Neoplasms, Malignancies AF increases stroke risk by up to 18x
Hypercholesterolemia
Embolic Strokes:
Causes formation of plaques in the blood vessels
Structural cardiac disease and arrhythmias, particularly
Increases stroke risk by 2x
Atrial Fibrillation (↑’s incidence of stroke about 6x; and by
Heavy Alcohol Intake
18x if there is also rheumatic valvular disease), bacterial
Increases stroke risk by up to 4x
and nonbacterial (marantic) endocarditis and right-to-left
Hemorrhagic strokes Dose-dependent risk
shunts between the cardiac chambers or in the lung
Cerebral infarction Biphasic effect (protective if
Documented the importance of long-duration cigarette
moderate up to 2 drinks BUT increase risk if excessive)
smoking in the development of carotid atherosclerosis
Obesity
Low potassium intake and reduced serum levels of
Physical Inactivity/Sedentary Lifestyle
potassium intake and reduced serum levels of potassium,
Increases chance of being overweight
have been associated with an increased stroke rate in
Increases stroke risk by 1.3x
several studies
Cardiovascular disease by 1.5-2.4x
NON-MODIFIABLE RISK FACTORS Stress and Anger
High intensity stress risk of fatal stroke: 1.5-1.9x
Genetically determined, cannot be changed
Expressed anger risk of stroke: 2x
Relative risk
Trigger hemodynamic, vasoconstrictive and hemostatic
Age – Doubles per decade after age 55
forces leading to atherosclerosis
Gender – Males > Females
Sympathetic arousal and neuroendocrine activation
Previous Stroke – 10x
Heavy Snoring
Race – Ethnicity – Black > White
Heredity Heavy snoring is usually associated with obesity
ARTERIOGRAPHY Anti-Thrombotics
Accurately demonstrates Anti-Hypertensives
stenosis and occlusions of IV fluids, Bed rest
the larger vessels, as well as Close monitoring
aneurysms, vascular Surgery, clipping of aneurysm
malformations, and other
vessel diseases such as SPECIFIC MANAGEMENT – TREATMENT OPTIONS
arteritis and vasospasm Stroke Unit Admission
Conventional dye-injection Anti-Thrombotic Agents:
angiography has been supplanted by magnetic resonance Anti-Platelets (ASA, Clopidogrel, Cilostazol, etc)
angiography (MRA) and venography (MRV) for the Anticoagulants (Heparin, Warfarin, LMWH)
visualization of large intracranial arteries and veins
These have the advantage of safety but do not yet give Used for valvular heart diseases
refined images of the smaller vessels and are not as
accurate as angiography in measuring the severity of Thrombolytic Therapy (r-TPA)
stenosis of a vessel Not as frequently used than anti-platelet and anti-
Spiral CT angiography now offer images of better coagulants
resolution, comparable to conventional arteriograms Aided by MRI or CT Scan
High suspicion for subarachnoid hemorrhage but (-) Hemicraniectomy (surgery) – last option
CT scan Since the blood spills in the subarachnoid
space, you can still get results doing lumbar puncture Subjected to criteria
Grossly bloody or Xanthocromic Contraindicated for lacunar strokes and large MCA
Infarct secondary to infection (Neurosyphillis) CSF strokes
test for Treponema Large strokes those that are within 48 hours
STROKE SYNDROMES
DOMINANT HEMISPHERE NONDOMINANT HEMISPHERE
Majority of right handed
and most left-handed
patients have dominance
Less predictable syndrome
for speech and language MCA STROKE
located in the left Contralateral hemiplegia and hemianesthesia: Arm and face
hemisphere
> leg
Left hemispheres Attention defects:
Deviation of the head and eyes toward side of infarct “gaze
infarction is characterized Extinction and neglect
preference”
by Aphasia (both motor –
Broca’s and sensory –
Behavioral changes: Global aphasia (in dominant hemisphere)
Wernicke’s) and Apraxia
acute confusion and delirium Hemianopsia, hemineglect
MCA STROKE LEFT MIDDLE CEREBRAL ARTERY Cranial nerve deficits and involvement of cerebellum and
3H: neurosensory tracts
Hemiplegia Right sided weakness Diplopia, dysphagia, dysarthria, dizziness, vertigo, ataxia
Hemisensory Right sided numbness Pain and temperature deficits in the face occur on opposite
Homonymous Hemianopsia Preferential gaze to side of the body
the left
WALLENBERG SYNDROME Lateral Medullary
Syndrome
CASE 2: Medulla Supplied by vertebral arteries
68 year old female Lateral Part of Medulla PICA
Woke up with weakness in right leg Cranial Nerve Deficits Diplopia, Dysphagia,
Slight right side weakness leg > arm Dysarthria
Family states she has “impaired judgment and insight”
“Seems like a baby: sucking and grasping”
CASE 4:
55 year old male
Diabetic, hypertensive for 15 years
Sudden onset of being unable to move left side of the body
Able to talk Language and speech intact
Sensation intact
LACUNAR INFARCTION
Lesion of small penetrating branch
arteries in to BG, thalamus, pons,
internal capsule
“Pure strokes”
ACA STROKE Motor, sensory, ataxic
hemiparesis
Weakness of the leg
Usually result in hemiparesis of
+/- proximal muscle weakness in the upper extremities
face, arm and leg
Affect frontal lobe: impaired judgment and insight, change
Lack of impairment of consciousness, aphasia, or visual
in affect
disturbances
Presence of primitive grasp and suck reflexes
More common in blacks and history of HTN, DM
Language impairment (common finding)
60% of patients with lacunar infarctions will be independent
at 1 year following stroke
Here, the location of the lesion is on the leg. Based on
anatomy and knowledge on the homunculus, the lower
Pure Motor + Intact Language LACUNAR INFARCTION
extremities are in the territory of ACA.
Pure Motor: Basal Ganglia
Primitive reflexes are usually inhibited by the frontal
Pure Sensory: Thalamus
lobe, when there is ischemia, these reflexes becomes
Diameter: 1-2 cm
uninhibited and reappear.
Pathophysiology: Lipohyalinosis/Fibrinoid deposits
ACA Territory Supplies the basal and medial aspects
NOT ATHEROSCLEROSIS
of the cerebral hemispheres and extends to the
Clues:
anterior 2/3 of parietal love.
(-) Aphasia
(-) Homonymous Hemianopsia
CASE 3: Awake/Alert
77 year old male
Sudden onset of dizziness
CASE 5:
Double vision
85 year old female
On examination, has pain and temperature deficit on half
In ICU, post-repair of ruptured abdominal aortic artery
of face and on opposite side of body
aneurysm
GCS 15
VERTEBROBASILAR SYSTEM
Heterogeneous syndromes and presentations
WATERSHED INFARCTION
Occurs in vulnerable
areas supplied by distal
distribution cerebral
arteries during periods
of hypotension
Infarction between the
ACA and MCA presents
with hemiparesis and
hemianesthesia,
predominantly in the leg
Dominant hemisphere infarctions: decrease in verbal ability
with preserved comprehension
Infarction involving the posterior watershed area presents
with homonymous hemianopia +/- hypoesthesia in the face
and legs