Management of Cerebrovascular Accidents

APPROACH TO AND MANAGEMENT
OF CEREBROVASCULAR ACCIDENTS
Dr. Mohsina Syed
Assistant Professor
Neurology
Hamdard University
DEFINITION
• Acute stroke is defined as clinical syndrome of rapid appearance

(over minutes) of a focal deficit of brain function lasting more
than 24 hours or leading to death with no apparent cause other
than a vascular one.
TYPES
Ischemic Stroke
 Thrombotic
 Embolic
 Lacunar
 TIA
Hemorrhagic Stroke
 Intracerebral Hemorrhage
 Subarachnoid Hemorrhage
Risk factors Non Modifiable
• Age: The risk of stroke doubles with every decade after the age of
55 years
• Sex: Male>Female
• Race and ethnicity: higher in African Americans and Hispanics >
Caucasians
• Stroke related mortality is higher in African American population
• Asian population has an increased risk of hemorrhagic stroke
subtype compared to Caucasians
• Family history: inherited susceptibility, inherited predisposition to

risk factors
Modifiable Risk Factors
• Hypertension
• Smoking
• Diabetes Mellitus
• Carotid disease
• Cardiac disease: Atrial Fibrillation, Myocardial infarction secondary to
coronary artery disease
• Dyslipidemia or hyperlipidemia (high cholesterol, high LDL, low HDL)
• Obstructive sleep apnea
• Obesity
• Lack of exercise
• Poor diet
• Alcohol abuse
• Hyperhomocysteinemia
• Sickle cell disease
• Oral Contraceptive pills
Etiology
Embolism Prothrombotic states

• Atrial fib • Hemostatic regulatory protein
• Sinoatrial D/O abnormalities
• Recent MI • Antiphospholipid antibodies
• Endocarditis
• Cardiac tumors
• Valvular D/O
• Patent foramen ovale
• Carotid/basilar artery stenosis
• Atherosclerotic lesions
• Vasculitis
• When the arteries that branch from the internal carotid artery are
blocked, which of the following is the most common symptom?
• A. Blindness in both eyes
• B. Dizziness and vertigo
• C. Paralysis in one arm or leg
• D. Weakness in both sides of the body
Stroke Symptoms
• SUDDEN numbness or weakness of face, arm

or leg
• SUDDEN confusion, trouble speaking or

understanding.
• SUDDEN trouble with vison.
• SUDDEN trouble walking, dizziness, loss of

balance or coordination.
Investigations
• The purpose of investigations in both stroke and TIA is:

• confirm vascular nature of the lesion
• distinguish cerebral infarction from hemorrhage
• identify the underlying vascular disease and its risk factors
• Further investigations indicated only :

• if nature of stroke uncertain
• young patients (unlikely to have atherosclerotic disease)
Initial evaluation
• Cardiac monitoring, pulse-ox, ECG
• CT Scan Brain Plain
• CBC, PT, PTT
• Blood glucose, serum electrolytes
• Cardiac markers, ABG’s
• Blood alcohol level, Toxicology screen

Neuroimaging
• CT or MRI should be performed urgently in all patients.

• CT
• exclude non-stroke lesions (e.g. subdural hematomas, tumors) and
demonstrate intracerebral hemorrhage immediately.
• changes in cerebral infarction may be absent in the first few hours after
symptom onset.
• An immediate CT scan is essential if the patient has abnormal

coagulation, a progressing deficit or suspected cerebellar hematoma, or
if thrombolysis is planned.
• MRI
• detects infarction earlier than CT and is more sensitive for strokes
affecting the brainstem and cerebellum.
• Diffusion-weighted imaging (DWI) MR can identify infarcted areas
within a few minutes of onset
• Carotid Dopplers U/S
• Echocardiography
• MRI & Angiogram Brain
• CT Angiogram Brain
• HbA1C, FLP
• Routine bloods (for polycythemia, infection, vasculitis,
thrombophilia, syphilitic serology, clotting studies, autoantibodies,
lipids)
Stroke Management
• Stroke is medical emergency and should be managed in specialized

stroke unit by a multidisciplinary team.
• Management is aimed at:
● Minimizing the volume of brain that is irreversibly damaged.
● Preventing complications.
● Reducing disability and handicap through rehabilitation.
● Reducing the risk of recurrent episodes.
• Thrombolysis
• IV thrombolysis with recombinant tissue plasminogen activator (rt-PA)
within 4.5 hours of stroke onset.
• Aspirin
• Aspirin (300 mg daily) should be started immediately after an ischemic
stroke unless rt-PA has been given, in which case it should be withheld for
at least 24 hrs.
• Statin
Blood Glucose If blood glucose ≥ 11.1 mmol/L, use
insulin
Temperature If pyrexial, investigate and treat cause

but give antipyretics early
Pressure Areas treat infection

Maintain nutrition
provide a pressure-relieving mattress
turn immobile patients regularly
Incontinence Ensure patient is not constipated or in

urinary retention.
Avoid catheterization unless retention or
incontinence is
threatening pressure areas
DVT prophylaxis DVT stockings

Management of Hemorrhagic Stroke
Mass effect / Obstructive insertion of a ventricular drain and/or

hydrocephalus decompressive surgery
Cerebral edema Anti edema agents (Mannitol)
Raised ICP artificial ventilation and/or surgical

decompression
Coagulation abnormalities Correct coagulation abnormalities by

(oral anticoagulants) FFPs, Vitamin K, cryoprecipitate.
Management of SAH
• CT scan
• CSF should be obtained by LP atleast 12 hrs after symptom onset,
in order to detect blood and xanthochromia
• Nimodipine (30–60 mg IV) is given to prevent vasospasm
• Endovascular insertion of coils into an aneurysm or surgical

clipping of the aneurysm neck reduces recurrence.
Complications
• Aspiration Pneumonia
• Urinary infection
• DVT
• Pulmonary Embolus
• Shoulder subluxation
• Depression
• Malnourishment
• Pressure sores
• Falls
• Seizures
Is Stroke preventable?
Prevention
• Primary prevention
• Secondary prevention
Primary Prevention
• Primary prevention starts at the level of the physician playing the

role of the primary care and occasionally at the level of the
cardiologist and the stroke neurologist
• Key is identification of underlying risk factors and modification

and treatment of modifiable risk factors
Primary Prevention Elements
• Establishing good medical history and family history
• Identifying the patient’s vascular risks
• Exam elements which are key: pulse (rate and establishing how
regular), blood pressure, carotid auscultation (bruits), cardiac
auscultation (murmurs and abnormal rhythm), symmetry and
detection of pulses, diabetic peripheral changes
Secondary prevention
• The average risk of a further stroke is 5–10% within the first week
of a stroke or TIA, 15% in the first year and 5%/year thereafter.
• Daily low dose aspirin prevents the risk of early recurrence of
ischemic stroke in future and improves long-term outcome
• Control BP with antihypertensive medication.
• Lipid lowering agents to control dyslipidemia.

• Control diabetes with anti diabetic medications.
• Treatment of other causative factors to reduce the risk of future

attacks.
• For patients with atrial fibrillation, the risk can be reduced by

~60% by oral anticoagulation to achieve an INR of 2–3
Carotid Endarterectomy & angioplasty
• Patients with a carotid territory ischemic event and > 70% carotid
artery stenosis on the side of the brain lesion have a higher risk of
stroke recurrence.
Secondary prevention in hemorrhagic stroke
• Secondary prevention in hemorrhagic stroke is the treatment of

cause.
• Hypertension
• Bleeding disorders
• Aneurysms
• Avm
• 50 years old hypertensive male came to Emergency department with
sudden onset right sided weakness for 2 hours. On examination his BP
was 200/110 mmHg, pulse 100 b/min, regular, and there was right
hemiplegia with upper motor neuron signs. His CT Brain was normal. You
are considering this patient for TPA.
• Which of the following is a contraindication to TPA in this patient?.
• A. Head trauma 2 years back
• B. Major surgery in last 9 months
• C. BP > 200/110
• D. Platelet count of 120,000

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APPROACH TO AND MANAGEMENT

• Acute stroke is defined as clinical syndrome of rapid appearance

• Family history: inherited susceptibility, inherited predisposition to

Embolism Prothrombotic states

• SUDDEN numbness or weakness of face, arm

• SUDDEN confusion, trouble speaking or

• SUDDEN trouble with vison.

• SUDDEN trouble walking, dizziness, loss of

• The purpose of investigations in both stroke and TIA is:

• Further investigations indicated only :

• Cardiac monitoring, pulse-ox, ECG

• CT Scan Brain Plain

• CBC, PT, PTT

• Blood glucose, serum electrolytes

• Cardiac markers, ABG’s

• Blood alcohol level, Toxicology screen

• CT or MRI should be performed urgently in all patients.

• An immediate CT scan is essential if the patient has abnormal

• Stroke is medical emergency and should be managed in specialized

Temperature If pyrexial, investigate and treat cause

Pressure Areas treat infection

Incontinence Ensure patient is not constipated or in

DVT prophylaxis DVT stockings

Mass effect / Obstructive insertion of a ventricular drain and/or

Cerebral edema Anti edema agents (Mannitol)

Raised ICP artificial ventilation and/or surgical

Coagulation abnormalities Correct coagulation abnormalities by

• Nimodipine (30–60 mg IV) is given to prevent vasospasm

• Endovascular insertion of coils into an aneurysm or surgical

• Primary prevention starts at the level of the physician playing the

• Key is identification of underlying risk factors and modification

• Establishing good medical history and family history

• Identifying the patient’s vascular risks

• Control BP with antihypertensive medication.

• Lipid lowering agents to control dyslipidemia.

• Treatment of other causative factors to reduce the risk of future

• For patients with atrial fibrillation, the risk can be reduced by

• Secondary prevention in hemorrhagic stroke is the treatment of

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