Stroke
The cost of stroke
•1 year after stroke 65%
independent
•Stroke occupied 20% of
acute and 25% of longterm
beds in UK
•Every 34 minutes 1 patient
with stroke is admitted to
hospital in CR
Stroke
Classification
Pathogenesis
Brain vascular territories
Brain arteries
Vascular territories
Medial cerebral artery
Anterior
cerebral
artery
Posterior circulation
Imaging
CT examination
• X rays
• High doses
• Computer
assisted
• Short
examination time
• Without or with
contrast media
CT- ischaemic stroke
• Cardioembolic stroke (AF)
• Fluent aphasia
ICH: CT
Brain-stem haemorrhage
SAH: CT
MRI
• No X rays
• Radio frequency (RF) fields
are used to systematically
alter the alignment of this
magnetization, causing the
hydrogen nuclei to
produce a rotating
magnetic field detectable
by the scanner.
• More information than CT
• much greater contrast
between the different
soft tissues of the
body than computed
tomography
• Longer examination time
• fMR
Ultrasound
•Duplex sonography
•Transcranial doppler
sonography
Angiography
Stroke
Ischaemic (brain
infarction) (80%)
Hemorrhagic
(cerebral
bleeding)
Haematoma
(17%)
SAH (3%)
Ischaemic
stroke
• Stroke is currently the second leading
cause of death in the Western world
• Most frequent cause of the severe
disability among older adults
Incidence (100 tis./year)
Italy (Valle
d´Aosta)
• 289
England
• Newcastle,
Darlington
276
• Oxfordshire
240
(první iktus)
Czech Republic
• ???
• Brno (280-
350)
Prevalence
• Northern England
• 468 / 100 tis.
• Cognitive changes 33%
• Problems with gait 30%
• Speech difficulties 27%
Subtypes of stroke
• Atherotrombotic
• Large artery atherotrombosis
• Cardioembolic infarction
• Lacunar infarction- SAD
LAA
50%
CA
25%
SAD
20%
Others
5%
Tromboembolic stroke
Lacunar
infarction
Small vessel disease
• 9% persons>70 years
• 16,1/12,2 % M/F >75 y
• 5,6x greater risk of Stroke
• (+valvular mitral stenosis = 17x)
Anticoagulation therapy risk reduction 68- 81%
ECG
Holter monitoring
Implantable long-term
device - reveal
Cardiac source of embolism- AF
Signs and symptoms
Brain infarction
Sudden deficit
• Over seconds to minutes
Anterior or posterior circulation
• (The symptoms depend on the area of
the brain affected.)
TIA
Up to 1 hour, mostly minutes-20 min
• Amaurosis fugax
• Crescendo TIA 2 and more= urgeng
situation
Weakness, sensory disorder
Contralaterally
Blurred visoin Speech disorders
Acute headache Vertigo, dizziness
Clinical Presentations of Stroke
Signs and symptoms
Signs and symptoms
Anterior circulation
• Hemiparesis
• Sensory loss
• Aphasia, Apraxia
• Hemianopsia
Posterior circulation
• Vertigo, dizziness
• Drop attack
• Diplopia
• Altered vision
• Cranial nerves
lesions
Primary
prevention
Highlights
• Up to 90% of all strokes are preventable, and
attributable to 10 modifiable risk factors
• Hypertension is ubiquitously the major modifiable
risk factor for stroke,
• accounting for one-third of stroke in developed
countries and two-thirds in
• developing countries
• Optimal stroke prevention requires a harmonious,
integrated approach to educating about stroke risk
and healthy lifestyle behaviors, simple screening and
management of individuals for a history and presence
of modifiable and treatable causal risk factors, and
improving social and environmental factors
Risk factors
Nonmodifiable
Age
Gender
Modifiable
Hypertension
Diabetes
Smoking
Heart
diseases
HLP
High blood
pressure
• The most important risk factor
• Systolic and diastolic BP
• Hypertonics
• SBP 10/DBP 5
• 41% reduction of stroke risk
• (fatal –30%, nonfatal –34%)
• Normotonics
• UKTIA SBP 12 /DBP 5 = -34%
Smoking
• The risk of stroke is approximately 50% higher
in smokers than in non-smokers
• Spousal cigarette smoking also harmful
• The risk increases with the number of cigarettes
smoked per day and is reversible
• Stopping smoking reduces the risk of stroke:
• By approximately 50% within one year
• To normal levels (people who never smoked)
within five years
Other risk factors
DM
Independent risk factor (1.5-
3.0)
• Depends on type and severity
HLP
Statins are more effective for
the primary prevention of
acute coronary syndrome and
MI compared with ischemic
stroke
For every 1-mmol/l reduction
in LDL cholesterol
concentration with statin
therapy, the risk of first stroke
is reduced by about 21%
Other risk factors II
• Oral contraceptives
• Depends on estrogen level
• Low level 1.93
• Higher level 2.75
• Normal BP, non-smoker: 1 stroke per 24 000 cases
• Risk disappears after withdrawal of OC
• 10% of strokes in young women is caused by OC HRT: not
clear…
• Hormone replacement after menopause is not effective in the secondary
stroke prevention in women and may increase mortality after stroke.
Other risk factors III
• Gravidity and
puerperium
• 13x increased risk
• 1 stroke/ 3000
childbirth
Other risc factors- drinking
Alcohol drinking is
related to the
increased incidence of
stroke
In general the more alcohol
that is consumed the greater
the risk for the development
of a stroke
•Chronic intake
•Bing
This is true of both types
of stroke
• Ischemic
• hemorrhagic
Patients with TIA or ischaemic stroke
Stroke
Therapeutical
possibilities
Acute care
Initial
examination
should
include
• Observation of breathing and pulmonary function
• Early signs of dysphagia, preferably with a
validated assessment form
• Evaluation of concomitant heart disease
• Assessment of blood pressure (BP) and heart rate
• Determination of arterial oxygen saturation using
infrared pulse oximetry if available
• Blood samples for clinical chemistry:
• glucose, coagulation and haematology studies
should be drawn, and a venous line inserted
• ECG
New ways in
stroke care
•Concentration
•Stroke units
•Recanalization therapy
•IVT
•Mechanic thrombectomy
•„Time is brain“ concept
•Public education
•Triage and time
management
Stroke unit
BP
• Hypertension
.. Hypotension
• Routine
lowering of
the BP is not
recommended
Glycemia
• Hyperglycemia
increases the
extent of the
brain
infarction and
decreases the
chance of
good result
(mRS 0-1)
BT
• High body
temperature
increases the
extent of the
infarction
Recanalization
• The primary aim of thrombolysis in acute ischemic stroke is recanalization of
an occluded intracranial artery
• Recanalization is an important predictor of stroke outcome as timely restoration
of regional cerebral perfusion helps salvage threatened ischemic tissue
• The time of the recanalization is probably the most important factor
• Recanalization is strongly associated with improved functional outcomes and
reduced mortality.
Battlefield…
Intravenous trombolysis (IVT)
Intravenously administered
recombinant tissue
plasminogen activator (IV-TPA)
0.9 mg/kg (10% bolus, 90% v 60 min.
infusion)
≤ 4,5 hrs
NINDS (1995)…
1996 approved FDA
2002 EMEA
•2003 SUKL
2008 ECASS II- prolongation 4.5
hrs
NINDS tPA, ATLANTIS, ECASS-I, ECASS-II
NNT 5 NNT 20
NNT 5 NNT 20
mRS 0-1/day 90
Treatment Delay tPA (n = 3391) (%) Control (n = 3365) (%)
≤3 h 33 23
>3 and ≤4.5 h 35 30
>4.5 h 33 31
Proportion of Patients Achieving mRS Score of 0 or 1 at 3 to 6 Months
Mechanic thrombectomy
IVT: only in 18% of patients we can find after two hrs. the full
recanalization
Thrombectomy
Increasingly established as an alternative to
lytic therapy
Mechanical clot removing from the
cerebral vessel with the help of a catheter
device
More efficient, particularly in the case of
large or proximal occlusions
Whether (or not) better recanalisation also
means a better result for the patient
is currently being investigated in a number of
international studies
Mechanic thrombectomy
Futile recanalization
Triaging patients with acute ischemic stroke
Management of Acute Ischemic Stroke
The “time is
brain” concept
• It means that treatment of stroke should be
considered as an emergency.
• Avoiding delay should be the major aim in the
prehospital phase of acute stroke care.
• This has far-reaching implications in terms of
recognition of signs and symptoms of stroke by
the patient or by relatives or bystanders, the
nature of first medical contact, and the means of
transportation to hospital.
• Recommendations
• Educational programmes to increase awareness
of stroke at the population level are
recommended
• Educational programmes to increase stroke
awareness among professionals
(paramedics/emergency physicians) are
recommended
Time
• „Time is brain“ concept
• NNT: 2 (90´) →7 (3 hrs.) →14 (3-4,5 hrs.)*
• Obstacles
• Social circumstances
• Time of onset
• Public education
• Increase public awareness
*Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R,
Wahlgren N, Toni D, for the ECASS Investigators.Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New Engl J Med 2008; 359:
1317–1329.
First contact after onset of symptoms
• Recognition of stroke in communities
• Most studies show that only approximately 33-50% of
patients recognize their own symptoms as stroke
• Education
FAST http://www.youtube.com/watch?v=H4-rnEH4Pxo
•Phone contact with the ambulance
• Sustained pressure on the shortening of the onset-to-needle
time
• Measurement, evaluation, benchmarking
• Door-to-needle (DNT)
• Door-to-imaging (DIT)
• Bridging, drip-and-ship…
Triage and time management
Drip-and-ship vs. mothership model
Secondary
prevention
Prevention
• • Up to 90% of all strokes are preventable,
and attributable to 10 modifiable risk
factors.
• • Hypertension is ubiquitously the major
modifiable risk factor for stroke, accounting
for one-third of stroke in developed
countries and two-thirds in developing
countries.
• • Optimal stroke prevention requires a
harmonious, integrated approach to
educating about stroke risk and healthy
lifestyle behaviors, simple screening and
management of individuals for a history and
presence of modifiable and treatable causal
risk factors, and improving social and
environmental factors.
Risk of recurrence
The highest
risk during first
weeks-
months
01
10% during
first year
02
Then 5%
per year
03
Patient, who survives
ischemic stroke
(80%/first month) has
2x greater risk of
death during following
years
04
Antiplatelet drugs
•Acetylsalicylic Acid (ASA)
•COX inhibitor
•Clopidogrel
•Inhibition ADP induced activation of FBG
receptors IIb/IIIa
•More effective than ASA +18% (27 vs 33%)
ASA
Ischemic stroke, HI, vascular death
-27%
30- 1300 mg - 18% reduction of
new stroke episodes during 3 years
Prevention of 40 severe strokes per 1000
treated (2 hemorrhages per 1000 treated)
ASA
• Incidence of bleeding is dose
independent
• GI complications and
discomfort are dose
dependent
• Sufficient recommended
dose= 100 mg
• No reason for primary
prevention
Lipids lowering agents
9014 pts
(HI,AP)
CCH 4-7
mmol/l
6 years
Reduction
23%
All types of stroke (CE 30%,
LAA 17%, SAD 20%)
Atrial Fibrillation
• More than 9% persons >70 years
• 16,1/12,2 % M/F >75 years
• 5,6x higher risk of stroke
• (+rheumatic Mi stenosis = 17x)
• Warfarin / DOAC
• Risk reduction of first and repeated ischemic stroke between 68- 81%
• If Warfarin is contraindicated- ASA
• Oral anticoagulation is not recommended in patients with co-morbid
conditions such as falls, poor compliance, uncontrolled epilepsy, or
gastrointestinal bleeding
• Increasing age alone is not a contraindication to oral anticoagulation
Risk factors
•ASA
•Epistaxis
•Anticoagulation
•Warfarin
•2% of treated patiens
•Risk of bleeding 8-
11x Hypolipidemika
•Thrombolysis
•6,4%
Carotid
endarterectomy
• Atherosclerosis causes plaque to form in
the carotid arteries, usually at the fork
where the common carotid artery divides
into the internal and external carotid artery
• The plaque can build up in the inner
surface of the artery (lumen), and narrow
or constrict the artery
• Pieces of the plaque emboli can break off
and travel up the internal carotid artery to
the brain, where it blocks circulation, and
can cause death of the brain tissue
Carotid
endarterectomy
• NASCET, ECST, VA (sympt.)
• ACAS (asympt.)
• The North American Symptomatic
Carotid Endarterectomy Trial (NASCET)
and the European Carotid Surgery Trial
(ECST)
• Large randomized class 1 studies which
have helped define current indications
for carotid endarterectomy
• The NASCET found that for every six
patients treated, one major stroke
would be prevented at two years (i.e. a
number needed to treat (NNT) of six) for
symptomatic patients with a 70 – 99%
stenosis
Endarterectomy
• Complete internal carotid artery
obstruction (because there is no
benefit to treating chronic
occlusion)
• Previous stroke on the ipsilateral
side with severe deficit
• No point in preventing what has
already happened
Contra-indications
• About 3% of asymptomatic and 6%
of symptomatic patients are
expected to suffer stroke or death
as a result of either the surgery or
carotid stenting
Complications
Take home
message
• Acute therapy
• Thrombolysis
• Stroke unit
• HBP
• Most important treatable risk
factor
• Secondary prevention
• ASA
• AF
• Warfarin / DOAC
• Carotid endarterectomy
• symptomatic stenosis 70-
99%
Rehabilitation
Rehabilitation
The most frequent cause
of disability of adults
10-20% die in acute stage
10% resolve
30% severe deficit
30% rehabilitation
Rehabilitation
• Patients with disabling strokes undergo treatment to help them return to normal
life as much as possible by regaining and relearning the skills of everyday living
• Multidisciplinary
• A team with different skills working together to help the patient.
• Nursing staff
• Physiotherapy
• Occupational therapy
• Speech and language therapy
• Social workers
Rehabilitation
• Rehabilitation process includes
• Nursing
• occupational therapy (OT),
• physical therapy (PT),
• therapeutic recreation (TR),
• speech therapy (or speech language pathology, SLP),
• Psychology and vocational rehabilitation.
Rehabilitation
• OT involves exercise and training to help the
stroke patient relearn everyday activities,
sometimes called the Activities of daily living
(ADLs)
• eating and drinking, dressing, bathing,
cooking, reading and writing, and toileting
• Therapeutic recreation works on several areas
including problem solving, improving
movement and re-entry into the community
through familiar, new, and adaptive leisure
skills
• Speech and language therapy is appropriate
for patients who have problems
understanding speech or written words,
cognitive loss, or problems forming speech
• Speech therapists also assess a person's
ability to safely swallow after a stroke
• Psychologists can assess cognitive function
and teach people with stroke coping strategies
• Vocational rehabilitation can work directly
with a person who has stroke and their
employer to facilitate successful return to
work
Depression after
stroke
•More than 50%
•SSRI antidepressants
Post-stroke pain
• 19-74% of patients
• Brain lesion itself
• Central post-stroke pain' (CPSP)
• 1-8%
• Adrenergic antidepressants, Antiepileptics,
(lamotrigine), GABAergic drugs (gabapentin or
pregabalin)
• Other sources
• Frozen shoulder, spasticity
Incontinence and stroke
•1/3- 2/3 pts in acute stage
•Correlate with severity of the stroke
•Important factor which influences the
overall prognosis
•Infections
•Bedsore (decubitus)
Incontinence and stroke
• Depressed level of consciousness
• Immobility
• Communication problems
• Weakness or clumsiness of UE
• Detrusor instability
• Urinary infection
• Supine position
• Diuretics
Stroke and epilepsy
•2% of patients with stroke have first epileptic
seizure
•Cortical infarction – higher risk
•Risk of epilepsy after first stroke
•5% during first year
•1-2% annually during following years