Dr.
Endang Elisawaty SpS
Introduction
Stroke is the third leading cause of death as
well as the third leading cause of disability
in the United States.
Approximately 700,000 per year and
160,000 fatalities.
Up to 80% of strokes are preventable!
There are numerous missed
opportunities for treatment of stroke!
Time is Brain
Every second 32,000
neurons die
Every minute 1.9 million
neurons die
Every hour 120 million
neurons die
Completed stroke: Loss of
1.2 billion neurons
Blockage of one blood
vessel will cause ischemia
within 5 minutes
Time is Brain
Each minute you
wait, you lose
close to 2 million
brain cells
A pea sized piece
of brain dies for
every 12 minutes
that treatment is
delayed
4
5
DEFINITION
Stroke: Rapid onset of clinical signs of focal or global
disturbance of cerebral function lasting more than
24 hours or leading to death with no apparent
cause other than a vascular lesion
Types of Vascular lesion:
Occlusive
Hemorrhagic
STROKE SUBTYPES
ICH ISCHEMIC
Lacunar small vessel
disease (25%)
Intracerebral
hemorrhage (59%)
Atherothrombotic
disease (25%)
SAH (41%)
Embolism (20%)
Albers GW et al. Chest. 1998;114:683S-698S. Cryptogenic (30%)
Rosamond WD et al. Stroke. 1999;30:736-743.
Result in:
Permanent lack of blood flow to a focal region of
the brain parenchymal changes
ALL lead to INFARCTION
HEMORRHAGIC
Spontaneous rupture of the arterial in or outside
the brain
BRAIN INFARCTION vs HEMORRHAGE
CONCEPT OF STROKE
AS A MEDICAL EMERGENCY :
• Short hospital arrival times are
crucial
• Brief therapeutic window
• Interventional therapy within
Few hours after onset
STROKE
SHOULD BE HOSPITALIZED, Aim to :
Precise diagnosis
Acute interventional therapies
Determination pathogenesis
Treatment in multidisciplinary setting :
acute medical care
Neuro-rehabilitation
AIMS OF TREATMENT
Optimizing the patient’s chance of
surviving
Minimizing the impact of stroke
on the patient and care-givers
The diagnostic process.
1. Is it a stroke?
2. Which part of the brain has the stroke
affected?
3. What pathological type of stroke is it?
4. What disease process caused the
stroke?
5. What are the functional consequences
of the stroke?
RISK FACTORS
Non-modifiable
behavioral risk factor
Increasing Age
Male gender
Race
Family history of stroke
RISK FACTORS
Modifiable behavioral
risk factor
Smoking
Alcohol
Obesity
Physical activity
RISK FACTORS
Treatable vascular risk
factors
Hypertension
DM
Lipids
IHD
Carotid stenosis
TIA/Previous stroke
Peripheral vascular disease
CLINICAL SIGNS AND SYMPTOMS
Sudden weakness affecting one side of the body
Sudden numbness affecting one side of the body
Sudden difficulty speaking or understanding
Sudden difficulty walking
Sudden visual difficulty
Sudden severe headache
VASCULAR DIFFERENCES
A. CAROTID SYSTEM B. VERTEBROBASILAR SYSTEM
Motor dysfunction Motor dysfunction
• Contralateral hemiparesis • Alternating hemiparesis
• Motor cranial nerves and • Motor cranial nerves and
extrimities paresis is
extrimities paresis ipsilateral
contralateral
• Dysarthria
• Dysarthria
Sensory dysfunction
Sensory dysfunction
• Contralateral hemihypesthesia
• Alternating hemihypesthesia
• Cranial nerves and
• Cranial nerves and extremities
extrimitiesypesthesia is ipsilateral
hypesthesia is contralateral
Visual disturbances
Visual disturbances
• Contralateral homonymous
• Homonymous hemianopsia
hemiamianopsia
• Cortical blindness
• Amaurosis fugax ( TIA )
( TIA : blackout )
Higher cortical dysfunction
Others: Loss of balance, Vertigo,
• Aphasia
Diplopia
• Agnosia
Mortality Predictors Include
Stroke severity; but older age,
concomitant medical diseases, and
recurrent stroke are also associated
with poor short-term prognosis.
Condition is worsened by neurological
and medical complications in up to
80% of patients.
Mortality Causes
Week One –
90% of deaths are due directly to the
Infarct (Edema, Extension, Herniation)
Weeks 2-4 –
Pulmonary Embolism is most common
cause of death and risk remains high for 3
months
Weeks 8-12 –
Bronchopneumonia. Later Heart Disease.
Stroke complication
Brain edema
Pneumonia
Urinary Tract Infection
Seizure
Clinical depression
Bedsores
Contractures
Shoulder pain
Deep vein thrombosis
Depresi
Complications post Stroke
Neurologically:
Recurrent Stroke
Seizure
Infection
Urinary tract infection >20%, common
Pneumonia 20%,
with 25% death in first month
Complication of immobility :
Falls
Pressure ulcers
Thromboembolism
Psychological:
Depression
Emotionalism
Anxiety
Confusion
Psychological complications
Acute phase:
Overt sadness 72%
Disinhibition 56%
Lack of adaption 44%
Environmental withdrawal 40%
Crying 27%
Anosognosial passitivity 24%
A third of patient have poor memory or no
memory of event
Stroke location and emotional implication
Strong correlation with aphasia and left
insular location: 66% of these develop
depression later in chronic stage
Acute psychosis seen in left PICA Infarct
Left frontal Stroke, Basal ganglion lesion:
Post Stroke depression 40%
Anxiety disorder 25%
Dysphagia –Impaired Swallowing
The Join Commission Requires
“All patients exhibiting stroke symptoms
are screened for dysphagia prior to receiving
any oral intake of fluids, food, or medication.
Dysphagia –Impaired Swallowing
Affects 37% to 78% of patients with acute stroke.
Associated with increased risk of aspiration, pneumonia, prolonged
hospital stay, disability, and death.
Prevention Plan
Starts in ED –use a validated tool to assess swallow
Assess for possible aspiration
Strict NPO if fail
Consult Speech therapist
Feed only when awake and alert
Elevate HOB upright
Suction available
Avoid rushed or forced feeding
Provide thickened liquid or pureed diet when recommended
by SLT.
Provide frequent oral care.
Pain/Positioning Post Stroke
Stroke patients are at risk for contractures pain and joint damage due to
a paretic limb.
Shoulder pain occurs in up to 80% of pts with arm paresis due to: poor
positioning and traction on arm during transfer
Spasticity occurs in up to 65% of stroke patients
Prevention plan
Early PT/OT consults for splinting to prevent contractures
Position paretic limb
Progressive ROM
Electrical stimulation
Heat
Anti-inflammatory agents or analgesics
Proper handling of paretic extremity
Spasticity treatment-stretching, splinting, and medications.
Botox injections
Oral Baclofen, benzodiazepines
Be Stroke Smart
The 3 R’s of Stroke
Reduce Stroke Risk
Recognize Stroke Symptoms
Respond
When warning signs occur
Stroke is the MOST preventable of all
catastrophic medical conditions
Prevention of Future Stroke
EDUCATE, EDUCATE, EDUCATE!!!
Of the 795,000 stroke that occur each
year, approximately 25% are recurrent
events.
Provide individualized education for each
patient and his/her family
Should ALWAYS include the patient and
family in facilitation of care goals and
options.
Patient Prevention Plan –Education
•Identify patient specific stroke risk factors
•List medications and treatment plan to control
risk factors
•Explain cause of stroke if known
•Review medical, nursing and other therapeutic
interventions to manage the stroke
•Review interventions to prevent another stroke;
Ex; Quit smoking, routine exercise
Stress importance of recognizing signs and
symptoms of stroke
