1. An overview of stroke
Dr Shankar Hippargi
Consultant Emergency Physician
MMHRC

2. An overview of stroke
• Stroke & TIA definition
• Epidemiology
• Classification
• Challenges in India
• Risk factors
• Treatment options

3. Stroke
• Stroke is a syndrome characterised by
rapidly developing clinical signs of focal
(or global) neurological disturbance
lasting 24 hours or longer or leading to
death with no apparent cause other than
vascular origin.
Includes: Excludes:
• Subarchanoid • TIA
hemorrhage • Subdural Hemorrhage
• Tumor or infection
causing hemorrhage
or infarction

4. In stroke "Time lost is brain lost"
• Every second 32,000 neurons die
• In a minute
• 1.9 million neurons die
• Brain loses 14 billion synapses
• 12 KM of myelinated fibers are lost
• The ischemic brain ages 3.6 years each
hour

5. Facts about stroke...
• Globally approximately 20 million people
suffer stroke each year
• Of these 5 million wont survive
• Male : Female = 3 : 1
• Developing countries account for 85%
of stroke related deaths

6. ...Facts about stroke
• Leading cause of functional
impairment
• 20% survivors require institutinal care
• 15-30% permanently disabled
• 50% of stroke victims feel major
stroke is worse than death

7. ...Facts about stroke
• Every 40 seconds, someone in the United
States has a stroke
• Every 4 minutes someone dies of stroke
• Prevalent in 3% of US population
• The incidence is declinng overtime in
developed nations
Circulation- 2011 AHA

8. Indian scenario
• Age-adjusted annual incidence
• 334-424/1,00,000 in urban
community
• 84-262/1,00,000 in rural community
• Relatively more hemorrhagic strokes
(32%)
• 1.2% of all deaths are due to stroke (all
age groups)
* Neurology Asia 2006; 11 : 1 – 4

9. Indian scenario
• 12% of strokes in age <40 years
• Male : Female ratio is 7:1
• With increasing life expectancy & life
style changes, incidence of stroke is
expected to rise in India
* Stroke in India

10. Challenges...
• Lack of organised stroke services in
government sector
• 70% rural population- No access to Rx
• Most stroke care centers are private & in
urban areas
• With infectious diseases still endemic,
non-communicable diseases are given low
priority

11. Median time to arrival to
hospital after stroke onset
• 7.6 hours in urban areas
• Only 25% reached within 3
hours
• Affordability???
• 34 +/- 6 hours rural areas

12. Types of stroke
• 85% are ischemic
• 10% are intracerebral
hemorrhage
• 5% are subarachnoid
hemorrhage strokes

13. Types of stroke
I s c h e m ic H e m o r r h a g ic
85% 15%
L a rg e V e s s e l C a r d io e m b o lic Lacunar O th e r IC H SAH
35% 25% 20% 5% 10% 5%

14. Intra Cerebral Hemorrhage
• Incidence of Hemorrhagic
stroke has increased 18%
in the past 10 years
• Old age
• Anticoagulation
• Antiplatelets
• Thrombolytic therapy

15. Transient Ischemic Attack
• A neurological event with the signs and
symptoms of a stroke, which resolve
completely within 24 hours
• TIAs typically last 2 to 30 minutes and
can produce problems with vision,
dizziness, weakness or trouble speaking
• Mini stroke, Warning stroke

16. TIA
• Short term risk of stroke following TIA is 3-
10% at 2 days, 9-17% at 90 days
• Approximately 1/3 of all strokes are
preceded by a TIA
• Approximately half of all patients who
experience a TIA fail to report it

17. TIA
One third of episodes
characterized as TIAs according to
the classic definition (ie, focal
deficits that resolve within 24
hours) would be considered
infarctions on the basis of
diffusion-weighted MRI findings

18. ABCD2 scoring for TIA
Symbol Clinical feature Criterion Point
A Age >= 60 1
B Blood pressure >= 140/90 mmHg 1
C Clinical features of the TIA unilateral weakness 2
speech disturbance without weakness 1
D1 Duration of symptoms >= 60 min 2
10-59 min 1
<10 min 0
D2 Diabetes diagnosed with diabetes? 1

19. ABCD2 scoring for TIA
ABCD2 Score Risk of stroke in 2 days
0-3 1%
4-5 4%
6-7 8%

20. Mortality
• Every 4 minutes someone dies of stroke
• 1 in every 18 deaths is due to stroke
• Third leading cause of death next to
cardiac problems and cancers
• 30 days mortality decreased significantly
in men (from 23% to 14 %) but not in
women (21% to 20%)

21. Death rate after different
types of stroke
30days 1 year 5 years
Ischemic 10 23 52
stroke
ICH 52 62 70
SAH 45 48 52

22. Risk factors
Non-modifiable: Modifiable:
• Age • Hypertension
• Sex • Diabetes
• Family history • Atrial fibrillation
• Smoking
• Race
• High cholesterol
• Excess Alcohol
• Stress & Depression
• Sedantary life style
• Over weight
• Poor diet

23. Stroke in women
• Women between 45-54 years twice more
likely to have stroke than men
• Lifetime risk of stroke is greater in women
compared with men because of their higher
life expectancy
• 44% increased risk in post-menopausal
women on HRT

24. Stroke in women
• Risk of stroke 2.4 times greater during
pregnancy and until 6 weeks post natal
period
• Stroke is more severe in women, with
30 days case fatality of 24.7%
compared with 19.7% for men*
*Sex Differences in Stroke Epidemiology, AHA journal

25. Stroke in children
• Can occur in-utero, perinatal or later
• Annual incidence 6.4/100000 children
• Prevalence of perinatal stroke 29/100000 live births
• A history of infertility, preeclampsia, prolonged
rupture of membranes, and chorioamnionitis were
found to be independent risk factors
• Cerebral arteriopathy most common cause followed
by Sickle cell disease and Congenital Heart Disease

26. • 12 years old
• Left hemiplegia
• BP 200/120
• GCS 15/15

28. Signs & symptoms of stroke
• Weakness or numbness of arm / leg or both
• Facial muscle weakness
• Difficulty speaking
• Co-ordination problems
• Dizziness
• Visual problems
• Sudden headache
• Altered sensorium / Loss of consciousness

29. EMS

30. Magical agents in ER
• Dextrose
• Adenosine
• Amiadarone
• Calcium Gluconate
• DC shock
• Tissue plasminogen activator
(Altepllase)

31. Recombinant Tissue Plasminogen
Activator- Alteplase
• The only approved durg for treatment of ischemic
stroke
• Should be given within 4.5 hours of onset, earlier
the better
• Category C in pregnancy
• Dosage:
• 0.9 mg/kg (up to a max total dose of 90 mg)
• 10% of the dose given as a bolus over 1 min
• 90% of the dose by infusion over 60 minutes

32. Intra-arterial thrombolysis
• Better rate of recanalization
• Larger therapeutic window
( 6 hours)
• Can be given post-
operatively (except post
craniotomy)
• Lower hemorrhage rate
• Lower dose
• Done by Interventional
Neuroradiologist

33. Mechanical thrombolysis
• 3-8 hours after stroke
• Clot is mechanically
extracted from the blood
vessel
• Done by Interventional
Neuroradiologist

34. Neuro-surgical intervention
• For malignant middle cerebral artery
infarction
• Large IC bleed
• Bleed difficult to reach- Endovascular
treatment

35. Rise of machines
RP 7

36. Rehabilitation
• Will I be able to lead a normal life?
• Stroke recovery is a life time process
• Needs a dedicated team work
• Physiotherapist
• Psychologist
• Occupational therapist
• Speech therapist
• Should be customised to each patient

37. Prevention
• Primary prevention:
• 80% of strokes can be prevented by eating a
healthy diet, regular exercise and avoiding
smoking and excessive consumption of alcohol
• Early recognition & Rx of hypertension
• Anticoagulation for atrial fibrillation
• Secondary Prevention:
• 43% risk of second stroke
• Compliance to medications most important
• Life style modification

38. The Myths & Reality
• Myth: Stroke is unpreventable
• Reality: Stroke is largely preventable
• Myth: Stroke cannot be treated
• Reality: Stroke requires emergency treatment
• Myth: Stroke only strikes the elderly
• Reality: Stroke can happen to anyone
• Myth: Stroke recovery happens only for a few
months following a stroke
• Reality: Stroke recovery continues throughout
life

39. Race Against Time
Thank You