4. stroke- investigations and management

SITI MARIAM BINTI MOHD HAMZAH
STROKE
Investigations and Management

 aims of investigation is to confirm the vascular nature of the lesion,
distinguish cerebral infarction from hemorrhage and identify the
underlying vascular disease and risk factors.
INVESTIGATIONS

 Risk Factors Analysis
 Initial investigation of all patients with stroke includes a range of simple blood
tests to detect common vascular risk factors and markers of rarer causes,
an ECG and brain imaging.

 Neuroimaging
 Either CT or MRI should be performed in all patients with acute stroke
 CT is the most practical and widely available method of imaging
the brain
 It will usually exclude non-stroke lesions, including subdural haematomas and brain
tumours, and will demonstrate intracerebral hemorrhage within minutes of stroke onset
 However, especially within the first few hours after symptom onset, CT changes in
cerebral infarction may be completely absent or only very subtle.
 Changes often develop over time, but small cerebral infarcts may never show up on CT
scans.
 Even in the absence of changes suggesting infarction, abnormal perfusion of brain tissue
can be imaged with CT after injection of contrast media

 MRI is more sensitive than CT in detecting strokes affecting the brain
stem and cerebellum, and unlike CT, can reliably distinguish haemorrhagic
from ischemic stroke even several weeks after the onset
 MRI is not widely available because scanning time are longer and it cannot
be used in some individuals with contraindications; pacemakers

 Vascular Imaging
 Many ischaemic strokes are caused by atherosclerotic thromboembolic
disease of the major extracranial vessels.
 Detection of extracranial vascular disease can help establish why the patient
has had an ischaemic stroke and may, in highly selected patients, lead on to
specific treatments including carotid endarterectomy to reduce the risk of
further stroke

 Cardiac Investigations
 app. 20% of ischemic strokes are due to embolism from the heart.
 Atrial fibrillation, prosthetic heart valves, other valvular abnormalities and recent MI
 Transthoracic or transoesophageal echocardiogram can be useful
 To confirm the presence of a clinically apparent cardiac source
 To identify an unsuspected source such endocarditis, atrial myxoma and intracardiac
thrombus
 Such findings may lead on to specific treatment

 is aimed at minimizing the vol. of brain that is irreversibly damaged,
preventing complications, reducing the patient’s disability and
handicap through rehabilitation, and reducing the risk of recurrent
episodes.
 Primary prevention and secondary prevention
 Primary prevention is to treat the factors
 Secondary prevention is to avoid the reoccurrences of the stroke
MANAGEMENT (ischemic stroke)

 Early admission of patients has been shown to reduce both mortality
and residual disability amongst survivors.
 Consideration of a patient’s rehabilitation needs should commence at
the same time as acute medical management.
SUPPORTIVE CARE

 Intravenous thrombolysis with recombinant tissue plasminogen
activator(rt-PA) increases the risk of hemorrhagic transformation of
the cerebral infarct with potentially fatal results.
 However if given within 3 hours of symptom onset to highly selected
patients, the hemorrhagic risk is offset by an improvement in overall
outcome
THROMBOLYSIS

 In the absence of
contraindications, aspirin (300mg
daily) should be started
immediately after ischaemic stroke
unless rt-PA has been given, in
which case it should be withheld
for at least 24 hours.
 Aspirin reduces the risk of early
recurrence; it may be given by rectal
suppository or by nasogastric tube in
dysphagic patients
ASPIRIN

 A small proportion of patients with a TIA will have a greater than
50% stenosis of the carotid artery on the side of the brain lesion.
 Such patients have a greater than average risk of stroke recurrence.
 The effectiveness of surgery is greatest for those with severe
stenoses (70-90%) and in those in whom surgery can be performed
within the first couple of weeks after TIA or ischemic stroke.
CAROTID ENDARTERECTOMY & ANGIOPLASTY

 For patient taking VKAs, rapid reversal of coagulopathy can be
achieved by infusing prothrombin complex concentrates which can be
administered quickly, followed by fresh-frozen plasma and vitamin K
 If ICH is ass. with thrombocytopenia, transfusion of fresh platelets is
indicated.
 Tissue surrounding hematomas is displaced and compressed but not
necessarily infarcted. Major improvement commonly occurs as the
hematoma is reabsorbed and the adjacent tissue regains its function.
 Surgical evacuation may be undertaken for cerebellar hemisphere
hematomas >3cm diameter in selected patients
ACUTE MANAGEMENT-INTRACEREBRAL HEMORRHAGE

 If ICP is low, place a ICP monitor. Further hyperventilation and
osmotic therapy can be tailored to the patient to keep cerebral
perfusion pressure above 60 mmHg.
 If ICP is found to be high, CSF can be drained from the ventricular
space and osmotic therapy continued
 Persistent or progressive elevation in ICP may prompt surgical evacuation of
the clot
 Alternately if ICP become normal or mildly elevated, induced hyperventilation
can be reversed and osmotic therapy tapered.
ICP is often normal even with large intraparenchymal hemorrhages

 Rehabilitation should be structured to provide as much practice as
possible within the first six months after stroke
 For patients undergoing active rehabilitation,
 as much physical therapy should be provided as possible with a minimum of
one hour active practice per day at least five days a week
 As much therapy for dysphagia or communication difficulties should be
provided as they can tolerate
 Patients should be mobilized as early and as frequently as
possible
REHABILITATION

• Davidson’s principles & practice of medicine 21st ed
• Harrison’s principle of internal medicine 18th ed
• Clinical Practice Guidelines; Management of Ischaemic Stroke 2nd ed 2012
• Clinical Guidelines for Stroke Management 2010; stroke foundation
THANK YOU

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