Transcript Stroke

Cerebrovascular diseases for
rehabilitation students
Said S. Dahbour,MD
Consultant neurologist
Associate professor
Faculty of Medicine
Jordan University
Stroke
Sudden Neurological Deficit Due to
an Occlusion Or Rupture of a
Cerebral Vessel
Public Health Impact Of Stroke In USA
Neurology 1997
550,000 stroke / yr
Incidence •
3,800,000 people alive with stroke
Prevalence •
150,000 stroke related / yr
Mortality •
$20-40 billion per/ yr for stroke
related care.
Cost •
(%)Average Of Estimated Outcome After Ischemic Stroke
50
50
45
40
35
30
25
20
15
10
5
0
Estimated avarage %
39
34
33
%
27
24
20
14
7
Worse
M 30d
M1 y
M 5y
R 1m
10
R1y
R 5y
FD
Poor Q O L
Dementia
Worse= worse during hospitalization, M=mortality, R= recurrence, FD= functional
disability, QOL=quality of life at 6 months, Dem= dementia at 52 months post stroke
Stroke: Estimated Frequency Of Impairment And
Disability Within 2 Weeks. Neurology 1995
Defect
%
Hemiparesis
70-85%
Ambulation
70-80%
Vision perception
60-75%
Activity of daily living: Complete dependence
40-75%
Activity of daily living: Assisted
20-60%
Dysarthria
55%
Sitting balance
45%
Depression
40%
Proprioception
40%
Aphasia
20-35%
Dysphagia
15-35%
Hemineglect
10-35%
Recent memory
10-20%
Modifiable Stroke Risk Factors
Risk Factor
Relative Risk
Prevalence (%)*
Hypertension
Cardiac disease
Atrial fibrillation
Diabetes mellitus
Smoking
Alcohol abuse
Hyperlipidemia
4.0-5.0
2.0-4.0
5.6-17.6
1.5-3.0
1.5-2.9
1.0-4.0
1.0-2.0
25-40%
10-20%
1- 5%
4-8%
20-40%
5 – 30%
6-50%
*Prevalence varies by age, gender, race/ethnicity and definition of the stroke risk factor
Non Modifiable Stroke Risk Factors
Age •
Gender •
Hereditary •
Race- ethnicity •
Occurrence Of Ischemic Stroke In High Risk Patients
Risk
General population, aged 70
Prior MI
Asymptomatic bruit
Non Valvlualr AF(NVAF)
NVAF after TIA or minor stroke
TIA with >70% carotid stenosis
Prior ischemic stroke
Stroke rate
0.6
1.5
1.5
5.0
12.0
13.0
9.0
(%/y)
Stroke Types
Cerebrovascular Diseases
Cerebral Infarction (80%)
Focal/ Multifocal
Arterial
Venous
Cerebral Hemorrhage (20%)
Diffues
Focal/ Parencymal (10%)
Hypertensive
Amyloid
AVM
Hypoxia
Cardiac arrest
Hypoperfusion
Diffuse SAH (10%)
Aneuyrism
AVM
Cerebral Blood Supply
ACA= anterior cerebral artery
MCA= middle cerebral artery
PCA= posterior cerebral artery
ICA= internal carotid artery
ECA= external carotid artery
CCA= common carotid artery
Ant Com= anterior communicating A
Post Com=posterior communicating
SCA=superior cerebellar artery
AICA=anterior inferior cerebellar A
PICA=posterior inferior cerebellar A
Clinical Types of Ischemic Stroke
TIA= Transient Ischemic Attack •
Complete clinical recovery within minutes -24hrs.
RIND= Reversible Ischemic Neurological Deficit •
Clinical almost complete recovery in few days.
Stroke:
Residual variable deficit after months and years
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CT
scan in
Stroke
Common causes of ischemic stroke
Stenosis and Occlusion of Carotid Artery
Thrombosis of intracranial arteries
Anterior cerebral artery
Middle cerebral artery
Posterior cerebral artery
Vertebral artery
Basilar artery
Cardio- cerebral emboli
Small vessel disease ( lacunar infarction)
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Internal Carotid Artery Ischemic stroke
Clinical Manifestations
Ipsilateral (same side) transient blindness •
Contralateral ( opposite side) •
hemiparesis including face and bulbar
hemiparasthesia
visual field deficit
aphasia ( dominant hemisphere)
neglect (non dominant hemisphere)
Variable impairment of consciousness •
Middle and Anterior Cerebral Arteries Occlusion
MCA: Like ICA except •
hemiparesis : Arm >> Leg
ACA:
hemiparesis : Leg >> Arm
Cognitive slowing
Abulia : slow thinking and response
Incontinence
Hemiplegia in stroke •
weakness: Arm flexed, leg extended, foot circumducted
hyper-tonia
hyper-reflexia
leg rotated externally
Babenski sign present
Vertebral and Basilar Ischemia
PCA: •
Visual field disturbance : blind on one side
Thalamic syndrome: pain on opposite side
Basilar artery: •
Impairment of level of consciousness
PCA syndrome on both sides
Crossed hemiplgia
Vertebral artery: •
diplopia
dysarthria
vertigo
deafness
dysphonai
dysphagia
Lacunar Syndromes : 20% of Cerebral
Infarctions
Pure motor stroke: 60% ( internal capsule, pons)
Pure sensory stroke: 10-20% (PVL thalamus)
Dysarthria clumsy hand syndrome:10% (pons)
Sensory-motor stroke: 5%(ventral thalamus and
internal capsule)
Ataxic hemiplegia syndrome with pyramidal
signs : 5% (corona radiata or pons)
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Cardiac Sources of Cerebral Emboli
Mitral stenosis: mural and valvular thrombi
Subacute bacterial endocarditis:vegetations
Valve replacement with thrombus formation
Myocardial infarction with mural thrombi
Ventricular aneurysms with thrombi.
Heart failure (dilated cardiomyopathy)
Arrhythmia : atrial fibrillation
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Stroke Evaluation and Management
History and physical examination
Routine labs
ECG and CXR
Non contrast brain CT scan
Brain MRI/ MRA in selected cases
Supportive care and complication prevention
Rehabilitation: physical, psychological and social
Control of risk factors
Antiplatelet therapy
Surgical or endovascualr theraphy
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ICH Manifestation and Common Sites
Sudden neurological deficit
Headache
Change in level of consciousness
Vomiting
Hypertension on presentation
Use of antiplatelets or anticoagulants
Common sites:
lobar/multilobar
putamen
cerebellar
thalamus
intraventricular
pons
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PREVENTION
Estimated Number Of Strokes Prevented By Risk
Factor Modification. Gorelick PB, Neuroepidemiology 1997
Risk factor
Estimated Estimated Estimated Estimated
% of
relative
population strokes
patients
risk (%)
attributabl prevented
exposed
e risk (%)
Estimated
savings
(billions)
Hypertension 56.2
2.73
49.3
246,500 $ 12.33
Smoking
27.00
1.52
12.3
61,600
$ 03.08
AF
3.98
3.60
9.4
47,000
$ 02.35
Alcohol
7.20
1.68
4.7
23,500
$ 01.18
1.31
20.0
100,000 $ 05.00
Cholesterol 25.00
Atrial fibrillation and Stroke
The most effective strategy in this
subgroup of patients is the use of
warfarin with INR 2-3
Stroke Scales
Glasgow Outcome Scale
Grade Description
Definition
I
Good recovery
Patient can lead an independent life with or
without neurological deficit
II
Moderate disability
Patient has neurological or intellectual
impairment but is independent
III
Severely disabled
Patient conscious but totally dependent on
others to get through daily activities
IV
Vegetative state
V
dead
Modified Rankin Scale
Grade Description
0
No symptoms
1
Minor symptoms that do not interfere with lifestyle
2
Minot handicap, symptoms that lead to some restriction in lifestyle, but do
not interfere with the patients’ ability to look after themselves
3
Moderate handicap, symptoms that significantly restrict lifestyle and
prevent totally independent existence
4
Moderately severe handicap, symptoms that clearly prevent independent
existence although the patient does not need constant care and attention
5
Severe handicap. Totally dependent requiring constant attention day and
night.
Barthel Index
Item
Score
Categories
Bowels
0
Incontinent or needs enemas
5
Occasional incontinence(>1/wk)
10
Continent
0
Incontinent/unable to manage catheter
5
Occasional accidents (<1/day)
10
Continent
0
Needs help with shaving,washing, hair or teeth
5
Independent
0
Dependent
5
Needs some help
10
Independent
0
Dependent
5
Needs some help(cutting, spreading)
10
Independent if food within reach
Bladder
Grooming
Toilet use
Feeding
Barthel Index Continued
Item
Score
categories
Transfer
0
Unable and no sitting balance
5
Needs major help
10
Needs minor help
15
Independent
0
Unable
5
Wheelchair independent indoors
10
Walks with help or supervision
15
Independent but may use aid
0
Dependent
5
Needs some help
10
Independent including fasteners
0
Unable
5
Needs some help or supevions
10
Independent up and down
0
Dependent
5
Independent in bath or shower
Mobility
Dressing
Stairs
Bathing
Total
100
Conclusions
Stroke is a very common and serious disease
It is the leading cause of disability and third leading
cause of mortality in developed countries and quite the
same in other places
Ischemic stroke is much more common than
hemorrhagic stroke
Stroke is basically a preventable rather than treatable
disease
We have to look for risk factors and act before they hit.
Antiplatelets , antithrombotics and thrombolyic Rx in
the appropriate situation are the main stay of
treatment.
Supportive and rehabilitation care play a major role in
the chronic management and care of these patients
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THANK YOU