ISCHEMIC STROKE PROF.SHKROBOT

Stroke morbidity in different countries per 100 OOO of population Stroke morbidity in different countries Ischemic stroke 1:3,6 Hemorrhagic stroke 1:7

Stroke morbidity per 100 000 of population

Stroke mortality in different countries per 100 000 of population

Mortality from different types of stroke in Ukraine per 100 000 of population

Nowadays

... Every fifth Ukrainian resident will die of stroke ...

Every fifth one will finish his life as depending from others disabled person

DEFINITION STROKE IS RAPIDLY DEVELOPING CLINICAL SIGNS OF FOCAL DISTURBANCE OF CEREBRAL FUNCTION,LASTING MORE THEN 24 HOURS OR LEADING TO DEATH

Classification 3. Haemodynamic 4. Rheologic 5. Lacuna 1. Atherothrombotic 2. Cardioembolic 3. Haemodynamic 4. Rheologic 5. Lacuna

Classification 1. Atherothrombotic - occurs in case of plugging of extracranial or intracranial vessel by atherosclerotic plague 2. Cardioembolic - occurs in case of plugging of extracranial or intracranial vessel by thrombus or embolus from the heart

Classification 3. Hemodynamic - one occurs at angiospasm in case of atherosclerosis, vascular insufficiency, central hemodynamics disorders. 4. Rheologic – occurs in case of disturbance of rheologic blood properties 5. Lacuna-focus of iscemia without meningeal,cortical symptoms

Subtypes of ischemic stroke Atherotrombotic (36%) Cardioembolic (27%) Lacunar (29%) Others and non specified (8%) ? 13

The most common causes of brain infarction Atherosclerotic lesion of MAH Combination of atherosclerosis with hypertension Chronic ischemic heart disease with rhythm disorders

The most common causes of brain infarction Combination of atherosclerosis with diabetes Rheumatism, heart abnormalities (inborn and acquired) Vasculitis

Pathophysiology As a result of brain infarction in case of blood circulation less than 10 ml per 100 g of brain tissue in 1 min zone of focal necrosis is formed.

Pathophysiology Penumbra - during the first 6 hours this zone is surrounded by region with borderline blood circulation (18 – 20 ml per 100 g in 1 min). The neurons within this region are preserved structurally but their function suffers.

Pathophysiology During first 3 – 6 hours we can renew their function, that’s why this period is known as “therapeutic window

Pathophysiology After 6 hours zone of brain infarction is formed completely. Pathobiochemical and pathophysiological changes are observed in penumbra region:

Pathobiochemical and pathophysiological changes One of the main reason of neurons death is accumulation of glutamat brain edema disturbance of synaptic transference

Pathobiochemical and pathophysiological changes the number of intracellular enzymes is increased activation of thrombocytes, microcirculation disorders, ischemia. As a result ruination of neurons occurs.

penumbra

Clinical features of ischemic stroke Acute period of brain infarction is divided into three stages: Precursors Apoplectic stroke Focal signs

Clinical features of ischemic stroke 1. Precursors - transient ischemic attacks in the same region where brain infarction is developed 2. Onset is gradually 3. During several hours focal neurologic symptoms are developed. 4. The prevalence of focal symptoms over the general cerebral ones.

Clinical features of ischemic stroke General cerebral symptoms manifest as: Headache Vomiting Consciousness disorders Focal symptoms depend of localization of the infarction, damaged vessel and state of collateral blood circulation.

Clinical features Atherothrombotic stroke Occur at older age Develop during some ours and days TIA present in anamnesis Developed at night or in the morning time Stenosis and occlusion of MAH at ultrasound examination Decreased of Internal Carotid artery pulsation on the neck

Ischemic stroke Extensive Lacunar 27

Clinical features of cardioembolic stroke 1. Precursors are absent 2. Acute onset at emotional and physician activity 3. General cerebral signs are very intensive: Loss of consciousness, Seizures and psychomotor agitation Severe headache

Clinical features of cardioembolic stroke 4. Embolism of vessels of retina, extremities, other inner organs 5. Embolism of different arteries of the brain 6. Embolism of cortical branches of the brain arteries 7. Maximal neurological deficit at the begining of stroke 8. More often medial cerebral arteries are involved

The reasones of embolism aortal or arterial thrombus thrombus in case of heart abnormalities, such as mitral stenosis, aortal abnormality, rheumatic or bacterial endocarditis, myocardial infarctions, cardiosclerosis, cardiomyopathy.

The reasones of embolism Embolism can occur at thrombophlebitis, lung abscess, malignant tumors, sepsis Fat embolism occurs at bone fractures, after surgery associated with trauma of subcutaneous tissue Gas embolism occurs at surgery on lungs, at pneumothorax

Lacunar stroke

Lacunar stroke

Blood supplying of brain hemispheres А - convex, Б – medial surface, В – frontal section (pink – blood supplying by anterior cerebral artery, blue - middle, yellow – posterior cerebral artery) А Б В

Blood supplying of brain

Territory of Middle cerebral artery

Scheme of middle cerebral artery basin А А – cortical branches on convex surface of hemispheres; 1 – middle cerebral artery; 2 – branches to eye - socket; 3 – frontal branches; 4 – parietal branches; 5 – occipital branches; 6 – temporal branches; Б – central branches. 7 – internal carotid artery; 8 – anterior cerebral artery; 9 – middle cerebral artery; 2 3 1 6 4 5 Б 7 8 10 9 10 - стріарні гілки

Middle cerebral artery distribution basal nuclei internal capsule part of temporal lobe middle and lower parts or anterior and posterior central gyruses opercular region part of parietal lobe gyrus angularis posterior parts of upper and middle frontal gyruses

Focal symptomes of infarction in middle cerebral artery (MCA) 1. Motor disorders – Hemiplegia 2. Sensory disorders - Hemianesthesia 3. Gaze paresis 4. Visual disorders - Hemianopsia

The lesion of the left MCA 1. Aphasia 2. Alexia 3. Acalculia 4. Agraphia

The lesion of the right MCA Apracto – agnostic syndrome Anozognosia Astereognosis Autotopognosia Apraxia

Postischemic cist

Postischemic cist

Postischemic cist

Anterior cerebral artery distribution the cortex of frontal lobe ( superior frontal gyrus ) superior part of anterior central gyrus superior part of posterior central gyrus corpus callosum part of superior parietal lobulus orbital part of frontal lobe lobulus paracentralis

Scheme of anterior cerebral artery basin 1 – posterior communicant artery; 2 – internal carotid artery; 3 – central branch of anterior cerebral artery; 4 – middle cerebral artery; 5 – anterior cerebral artery; 6 – branch of internal carotid artery; 7 – ophthalmic branches; 8 – corpus callosum arteries with cortical branches; 9 – frontal arteries; 10 – parietal branches

Focal symptomes of infarction in anterior cerebral artery (ACA) Spastic hemiparesis with the prevalence in proximal part of upper extremity and distal part of lower extremity Symptoms of oral automatism Psychiatric disorders – frontal mental disorders

Focal symptomes of infarction in anterior cerebral artery (ACA Dysphagia Dysphonia Astasia, abasia Motor aphasia Retention of urine

Posterior cerebral artery distribution occipital lobe posterior part of lower and middle temporal gyruses basal and mediobasal part of temporal lobe deep thalamocollicular branches blood supply thalamus hypothalamus posterior – lower parts of cortex of parietal lobe

Posterior cerebral artery distribution 1.Occipital lobe 2.Posterior part of lower and middle temporal gyruses 3. Posterior –lower part of parietal lobe 4.Thalamus 5.Hypothalamus

Focal symptomes of infarction in posterior cerebral artery (PCA) Hemianopsia Visual agnosia Hemianesthesia Hyperpathia Desorientation in space and time

Postischemic cist

Territory of Vertebral artery

Scheme of vertebral artery basin 1 – internal carotid artery; 2 – anterior artery of choroid plexus; 3 – posterior communicant artery; 4 – posterior cerebral artery; 5 – upper cerebellar artery; 6 – basal artery; 7 – anterior lower cerebellar artery; 8 – posterior lower cerebellar artery; 9 – vertebral artery

Region of vertebral artery Brain stem Oblongate brain Cerebellum Cortex of occipital lobe Part of cervical part of the spinal cord. It can be damaged extra – or intracranialy

Focal symptoms of infarction in vertebral artery In case of extracranial lesion: systemic dizziness Hearing disorders Visual disorders eye movements disorders Vestibular and equilibrium disorders paresis with sensory disturbances in extremities some patients have “ drop- attacks “.

Focal symptoms of infarction in basilar artery loss of consciousness eye movements disorders pseudobulbar syndrome tetraplegia muscle tone disturbance cerebellar symptoms cortical blindness vital functions disorders.

Vertebro – basilar basin infarction Lesion of vertebro – basilar basin arteries cause development of brain stem and occipital lobes infarction

CT - scan Focus of ischemia in right occipital lobe (posterior cerebral artery basin)

Blood supplying of the base of the brain

Diagnostics of Brain Infarction The main peculiarities are: Before stroke period in the previous history ( TIA in anamnesis ) The beginning of the stroke is gradual Data of somatic and neurological status Additional methods of diagnostics

Diagnostics of Brain Infarction Rheologic disturbances Liquor is pellucid, without significant changes. EEG - There is focus of pathologic activity USD finds out occlusion, stenosis of carotid and vertebral arteries CT reveals hypodensive focus on the second day MRI helps to find out small focuses and those, located in the brain stem

Differential diagnosis Traumatic hemorrhage, trauma of brain Myocardial infarction Epilepsy Uremic coma Hyperglycemic coma Hypoglycemic coma Brain tumor with inside hemorrhage

Strokes treatment Nondifferential treatment includes: Prevention and treatment of pulmonary insufficiency Liquidation of heart – vascular disorders Brain edema treatment

Strokes treatment Normalization of water – electrolytes balance and acid – alkali balance Osmosis correction Improving of brain metabolism Liquidation of hyperthermia and other autonomic disorders

Prevention and treatment of pulmonary insufficiency the patient is lying on the bed with his head elevated cleaning of patient’s oral cavity tracheostomia ( at inspiratory muscles paralysis ) in lung edema - oxygen; narcosis, Bobrov’s apparatus, 2 ml 1 % lazix, 2 ml 1 % dimedroli, 2 ml 0.1 % atropini I/m antibiotics are used in order to prevent pneumonia

Elimination of heart – vascular disorders In increased blood pressure we use Clofelini 1 – 3 ml 0.01 % solution i/m, i/v. Dibasoli 3 – 4 ml 1 % solution i/v Droperidoli 1 ml 0.25 % solution i/v Rasedili 1 – 2 ml 0.1 % i/v, I / m, - adrenoblockers ( anaprilini, obzidani, inderali ) peripheral vasodilatators ( Natrii nytroprussidi , appresini ) in combination with euphyllini

In low blood pressure we prescribe Dexamethazoni 4 – 8 mg i/v by drops in physiological solution Prednizoloni 60 – 120 mg i/v by drops in physiological solution In order to improve heart activity we use strofantini, corgliconi, cordiamini

Brain edema treatment Diuretics Corticosteroids Albumini Ganglioblockers 20 % Mannit Manitoli Glycerini Lazix Diakarbi

Normalization of water – electrolytes balance and acid – alkali balance We should estimate patient’s necessity in water according to his secretion, the level of Na in blood, hematocritis An average water necessity is 35 ml per kg, in patients with loss of consciousness it is 50 ml per kg We should correct patient’s hyper- or hyponatriemia, hyper- or hypokaliemia 4 % solution of Na bicarbonates i/v, trisaminum is used at metabolic acidosis. KCl i/v is used at metabolic alkalosis

Osmosis correction Normally blood osmose is within 280 – 295, urine osmose is 600 – 900 moms per liter At stroke usually we have hyperosmose, which manifests as increased hematocritis, hyperagrigation

Improving of brain metabolism Vit E Piracetam Instenon cerebrolysin Nootropil Citikolin Cortexin

Liquidation of hyperthermia and autonomic disorders. analgini 50 % 2.0 aspizoli 0.5 g sibazoni 0.5 % 1 ml haloperidoli 0.5 % 1 ml dimedroli 1 % 2 ml natrii oxybutiras 20 % 10 ml

Differential treatment of brain infarction To renew blood circulation in zone of ischemia To correct rheologic and coagulative properties of blood, to improve microcirculation To prevent disorders of cerebral metabolism To decrease brain edema To treat brain hypoxia

To renew blood circulation in zone of ischemia Actilaza 100 mg I / v by drops every 2 – 3 hours. Inhibitors of glutamat excretion ( difenin, nimotop, MgSO4) are used. Nimotop is used 15 mg in 1500 ml of physiologic solution i/v by drops, or in tablets 30 – 60 mg 4 times per day. In order to improve perfusion we use cavinton 20 mg I /v by drops

To renew blood circulation in zone of ischemia At hyperperfussion we use euphyllini 10 ml 2.4 % solution penthoxiphyllini diuretics (manitol 15 % 100 – 200 ml ) albumini 100 ml I / v

To improve microcirculation Anticoagulative therapy : heparini 5 000 U 4 times per day during 5 – 7 days, the 2 500 U during next 3 –4 days. Fraxiparini is considered to be even more effective Clexane-0.3 twice a day

Antiagregants Penthoxiphyllini 5 – 10 ml 2 % solution I /v by drops during 10 days, then 200 mg 3 –4 times per day up to 1 month. Sermioni 4 mg I / v by drops during 10 days , then 1 tablet 3 times per day up to 1 month. Ticlid 250 mg twice a day. Aspirini 250 mg once a day. Dipiridamoli 1 – 2 ml i/v by drops during 10 days, then 25 mg 2 –3 times per day

Organization of assistance to patients with stroke Primary prevention Secondary prevention Organization of assistance to patients with stroke First aid Rehabilitation

Smoking Risk of recurring stroke in smokers increases in 1.5 times

Weight For all over weighted people is recommended to keep weight index between 18,5 and 24,9 kg/m2 and size of waist not more than 88 sm in women and not more than 102 sm in men (Northern Manhattan Study)

Physical activity Physical exercises for not less than 30min a day are recommended for patients