Neurosurgery-Stroke

Haybusak university 5th year medicine dr. Avet Petrosyan

By:Hanoon Alsana

Sergio Mogalyan10.03.2017

DEF IN IT ION

• Stroke is defined by the World Health Organization as a clinical syndrome consisting of ‘rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin’.

CL ASS IF ICAT ION OF STROKE

Hemorrhagic (20% of Strokes)

Thrombotic 50%

Embolic 30%

Intracerebral Hemorrhage

15%

Subarachnoid Hemorrhage

5%

Ischemic (80% of Strokes)

Each year nearly 800,000 people have a new or recurrent strokeA stroke happens every 40 secondsStroke is the fifth leading cause of death in the U.SEvery 4 minutes someone dies from strokeUp to 80 percent of strokes can be preventedStroke is the leading cause of adult disability in the U.S

ST R O K E BY N U M B E R S

T Y P E S O F S T R O K E

80% Ischemic

20 % hemorrhagic

EVALUAT ION OF STROKE

• 1.    symptoms • 2.    Localize of lesion• 3.   type of stroke• 4.    cause• 5. The clinical assessment

THE MAIN SYMPTOMS

INVEST IGAT IONS

• full blood count, serum electrolytes, renal function tests, cardiac enzymes, and coagulation studies

• Blood sugar• An electrocardiogram (ECG) : arrhythmias and

myocardial infarction• Echocardiography : valve disease and intra-

cardiac clot

NEUROIMAG ING

• Brain CT scan: sensitive to the intracranial blood

• MRI: better at detecting posterior fossa lesions Pons or cerebellum

• carotid ultrasound• doppler ultrasound: speed and direction of

the blood stream

PO O R P RO G N O ST IC FAC TO RS

• Accompanying fever

• Hypotension and severe hypertension• Low oxygen saturation• Hyperglycaemia and hypoglycemia• heart failure• severity of hemiparesis

M A N AG EM ENT: A I RWAY A N D V EN T I L AT ION

• Foreign Bodies, dentures, tongue• Indications for intubation:- hypoxia (pO2 <60 mm Hg or PCO2 >50 mm

Hg) - risk of aspiration with or without impairment of arterial oxygenation

• elective tracheostomy: after 2 weeks of prolonged coma or pulmonary complications

MANAGEMENT:VOLUME STATUS

• Hypovolemia has been associated with worse outcome and increased mortality in acute ischemic stroke

• Isotonic saline, typically 3 litres per day is given• Do not give hypotonic solution, eg 5% Dextrose

in water, as it may worsen cerebral oedema

MANAGEMENT:TEMPERATURE

• Fever worsens outcome:• 1. increased metabolic demands• 2.enhanced release of neurotransmitters

• for every 1°C rise in temp, risk of poor outcome doubles

• Greatest effect in the first 24 hours

• Treat aggressively with acetaminophen

M AN AG EM EN T:BLO O D P RESSU RE

• lowering of blood pressure by approximately 15 percent during the first 24 hours after stroke onset is suggested

1.    Labetalol IV2.    Nicardipine infusion  3. oral agents (captopril, calcium channel blockers)

• Systolic blood pressure > 185 and diastolic > 110 is a contraindication for thrombolysis

M AN AG EM EN T: BLO O D PRES SU RE

Reducing formation of brain edema

lessening hemorrhagic transformation

preventing early recurrent stroke

MANAGEMENT:GLYCAEMIC CONTROL

Hyperglycemia may augment brain injury by several mechanisms including:

• increased tissue acidosis• free radical generation• increased blood brain barrier permeability

MANAGEMENT:GLYCAEMIC CONTROL

• Hypoglycemia- Hypoglycemia can cause focal neurologic deficits mimicking stroke

• Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients withacute ischemic

stroke

ANT I COAGUL ANTS

• Heparin 5,000 units 12 hourly(or 8hrly)• unfractionated heparin may be considered

for prevention of DVT in patients with intracerebral hemorrhage

ANT IPL ATELET AGENTS

• Aspirin prevent risk of recurrent by 13%

• Aspirin –within 48hrs – reduce risk of mortality/ disability in ischemic stroke

• Anti-platelets contraindicated in hemorrhagic stroke

Tissue Plasminogen Activator TPA< first three hours following the onset of symptomsContraindicated in hemorrhagic stroke

T H R O M BO LY T I C S

M ED IC AL CO M PL ICAT IO N S O F ST RO K E

• 85% of patients with stroke • 50% of mortality after the first week of stroke• the most important causes of mortality in the

early period following a stroke are cardiac (arrhythmias, myocardial infarction), infections (pneumonia, urosepsis), and venous thrombo-embolism (pulmonary embolus)

MEDICAL COMPL ICAT IONS IN HOSP ITAL IZEDPAT IENTS WITH STROKE

Complications of Immobility• Deep vein thrombosis/pulmonary embolism• Falls• Pressure sores or ulceration Infections• Chest infection- aspiration pneumonia• Urinary tract infection

MEDICAL COMPL ICAT IONS IN HOSP ITAL IZEDPAT IENTS WITH STROKE

Pain• Shoulder pain in the weak limb• Central post-stroke pain Neuropsychiatric Disturbances• Depression, anxiety ,Emotional incontinence• Acute confusional states (delirium) Miscellaneous• Cardiac complications (arrhythmia, myocardial

ischemia)• Gastrointestinal complications( bleed,

Constipation)• Sleep apnea

SURG ICAL MANAGEMENT

• Ischemic stroke: A) endovascular interventions: angioplasty and

stenting B) carotid endarterectomy C) bypass surgery

• Hemorrhagic stroke: Surgical evacuation of hematoma

SURG ICAL MANAGEMENT

SURG ICAL MANAGEMENT

• Subarachnoid hemorrhage: Clipping and coiling of aneurysm

• Cerebral edema Decompressive craniectomy

SURG ICAL MANAGEMENT

• Intra ventricular hemorrhage /acute hydrocephalus: Ventricular drainage

SURG ICAL MANAGEMENT

VENTRICLES

ventricles catheter

what type of stroke?

what type of stroke?

thank you…