prognosis and management of cerebrovascular accident

1. CEREBROVASCULAR
ACCIDENT
MANAGEMENT AND PROGNOSIS
A.RASAGNA

2. MAJOR SUBTYPES OF
STROKE

3. ISCHEMIC STROKE
MANAGEMENT

4. INVESTIGATIONS
IMAGING STUDIES:
A CT scan of the head (without contrast) should
be performed immediately, before the
administration of aspirin or other antithrombotic
agents, to exclude cerebral hemorrhage.
CT is relatively insensitive to acute ischemic
stroke, and subsequent MRI with diffusion-
weighted sequences helps define the distribution
and extent of infarction as well as to exclude tumor
or other differential considerations.

5.  Imaging of cervical vasculature, by CT
angiography, MR angiography, or conventional
catheter angiography, is indicated as part of a
search to identify the source of the stroke.

6. CT SCAN

7. MRI SCAN

8. LABORATORY AND OTHER STUDIES:
Complete blood count, ESR, blood glucose
determination
Antiphospholipid antibodies
Abnormalities of protein C, protein S, or
antithrombin, or a prothrombin gene mutation -
hypercoaguable disorder
Elevated serum cholesterol and lipids and serum
homocysteine – thrombotic stroke

9.  ECG or continuous cardiac monitoring- recent
MI
 Blood cultures- if endocarditis suspected
 CSF examination if infectious cause suspected
but should be delayed until after CT or MRI to
exclude any risk for herniation

10. TREATMENT
• Management is aimed at minimizing the volume
of brain that is irreversibly damaged, preventing
complications, reducing the patient’s disability
and handicap through rehabilitation and
reducing the risk of recurrent stroke or other
vascular events.

14. • Thrombolysis: i.v. thrombolytic therapy with
recombinant tissue plasminogen activator (rtPA;
0.9 mg/kg to a maximum of 90 mg, with 10%
given as a bolus over 1 minute and the
remainder over 1 hour) is effective in reducing
the neurologic deficit in selected patients without
CT evidence of intracranial hemorrhage.

15. • Aspirin: in the absence of contraindication,
aspirin (300 mg daily) should be started
immediately after an ischemic stroke unless rtPA
has been given, in which case it should be
withheld for at least 24 hours
• Heparin: reduces the risk of early ischemic
recurrence and venous thromboembolism but
first intracranial haemorrhage must be excluded
on brain imaging before considering
anticoagulation

16. • Carotid endareterctomy: patients with carotid
territory ischemic stroke will have a greater than
50% stenosis of the carotid artery on the side of
brain lesion
• Removal of the stenosis has been shown to
reduce the overall risk of recurrence
• Physical therapy
• Early mobilization and active rehabilitation

17. PROGNOSIS
• The prognosis for survival after cerebral
infarction is better than after cerebral or
subarachnoid hemorrhage
• Only proved effective therapy- initiation of
treatment within 3-4.5 hours after stroke onset
• Depends on time that elapses before arrival
• rtPA- 30% more likely to have minimal or no
disability at 3 months
• LOC after infarct- poorer prognosis
• Extent of infarct governs the potential for rehab

18. HEMORRHAGIC
STROKE

19. INTRACEREBRAL
HEMORRHAGE
INVESTIGATIONS:
IMAGING:
•CT scanning (without contrast)- to confirm
hemorrhage and determining the size and site of
the hematomas
•It is superior to MRI for detecting intracranial
hemorrhage of < 48 hours duration
•CT angiography, MR angiography or cerebral
angiography- aneurysm or AVM

21. LABORATORY AND OTHER STUDIES:
•Complete blood count, platelet count, bleeding
time, prothrombin, partial thromboplastin times
•Liver and kidney function tests- predisposing
cause
•Lumbar puncture contraindicated- may precipitate
herniation

22. TREATMENT
Conservative and supportive
•Ventilatory support, blood pressure regulation,
seizure prophylaxis, control of fever, osmotherapy,
and nutritional supplementation
•ICP monitoring
•Ventricular drainage- intraventicular hemorrhage
•Decompression- superficial hematoma in cerebral
white matter exerting a mass effect and causing
incipient herniation

23. • Cerebellar hemorrhage- prompt surgical
evacuation of the hematoma because
spontaneous unpredictable deterioration may
lead to a fatal outcome and because operative
treatment may lead to complete resolution of the
clinical deficit
• Treatment of underlying lesions or bleeding
disorderes

24. PROGNOSIS

25. SUBARACHNOID
HEMORRHAGE
INVESTIGATIONS:
IMAGING:
•CT scan (preferably with CT angiography)
immediately to confirm hemorrhage and to search
for clues regarding source
•Preferable to MRI because it is faster and more
sensitive in detecting hemorrhage in the first 24
hours

26. • Cerebral angiography- source of bleeding
• Bilateral carotid and vertebral angiography are
necessary because aneurysms are multiple
while AVMs may be supplied from several
sources
LABORATORY AND OTHER STUDIES:
• CSF is bloodstained
• ECG evidence of arrhythmias or myocardial
ischemia has been well described
• Peripheral leukocytosis and transient glycosuria

27. TREATMENT
• Nimodipine (30-60 mg iv for 5-14 days, followed
by 360 mg orally for further 7 days) given to
prevent delayed ischemia in acute phase
• Insertion of platinum coils into an aneurysm(via
endovascular technique) or surgical clipping of
the aneurysm neck reduces the risk of both early
and late recurrence
• Coiling is associated with fewer complications
and better outcomes than surgery, now the
procedure of first choice

28. • Arteriovenous malformations can be managed
either by surgical removal, by ligation of the
blood vessels that feed or drain the lesion, or by
injection of material to occlude the fistula or
draining veins.

29. HEMORRHAGIC STROKE PROGNOSIS
• People who suffer ischemic strokes have a much better
chance for survival than those who
experience haemorrhagic strokes.
• Haemorrhagic stroke not only destroys brain cells but
also poses other complications, including increased
pressure on the brain or spasms in the blood vessels,
both of which can be very dangerous.
• Studies suggest, however, that survivors of hemorrhagic
stroke have a greater chance for recovering function
than those who suffer ischemic stroke.

30. PRIMARY AND
SECONDARY PREVENTION
OF STROKE

31. GENERAL PRINCIPLES
• Medical and surgical interventions, as well as
lifestyle modifications, are available for
preventing stroke.
• Identification and control of modifiable risk
factors is the best strategy to reduce the burden
of stroke, and the number of strokes could be
reduced substantially by these means

32. ATHEROSCLEROTIC RISK
FACTORS
• Older age, family history of thrombotic stroke,
diabetes mellitus, hypertension, tobacco
smoking, abnormal blood cholesterol
• hypertension should be controlled
• Statins reduce the risk of stroke even in patients
without elevated LDL or low HDL
• Tobacco smoking discouraged
• Tight control of blood sugar

33. • ANTIPLATELET AGENTS: aspirin, clopidogrel
and the combination of aspirin plus extended-
release dipyridamole – commonly used
• ANTICOAGULATION THERAPY: with a VKA
reduces the risk by 67%

34. TAKE HOME MESSAGE