1. Strokes

2. 185,000 recurrent strokes every year
Stroke Facts
610,000 new strokes every year
185,000 recurrent strokes every year
Leading cause of disability, cognitive impairment, and death
In 2012 = cost $71.5 billion (US)

3. Where We’re Headed
By 2030 ~ 4% of the US population over the age of 18 is projected to have had a stroke
Total annual costs of stroke are projected to increase to $ billion by 2030, an increase of 129%

9. Intracerebral Hemorrhage Subarachnoid Hemorrhage
Three Stroke Types
Ischemic
Stroke
Clot occluding
artery
85%
Intracerebral Hemorrhage
Bleeding
into brain
10%
Subarachnoid Hemorrhage
Bleeding around brain 5%

11. ISCHEMIC STROKES

12. Etiology of Ischemic Strokes
LARGE VESSEL THROMBOTIC (aka Clots)
Blood vessel injury
Stasis/turbulent blood flow
Hypercoagulable state
Blood vessel injury
HTN, Atherosclerosis, Vasculitis
Stasis/turbulent blood flow
Atherosclerosis, A. fib., Valve disorders
Hypercoagulable state
Increased number of platelets
Cancer etc

13. Etiology Of Ischemic Stroke:
LARGE VESSEL EMBOLIC (aka clots from somewhere else):
The Heart
Arterial Circulation
(artery to artery emboli)
Venous Circulation
(vein to artery emboli)
The Heart
Arterial Circulation
(artery to artery emboli)
Venous Circulation
(vein to artery emboli)

14. Aphasia (speech /language)
Broca’s
Expressive aphasia
I understand you but I can’t talk
Wernicke’s
Receptive aphasia
I can talk but I don’t understand you

15. SMALL VESSEL (<1.5cm) Risk Factors HTN HLD DM Tobacco Use
Etiology of Stroke
SMALL VESSEL (<1.5cm)
Risk Factors
HTN
HLD DM
Tobacco Use
Sleep apnea

16. Intracranial Hemorrhages
(Brain bleed)

17. Cocaine and amphetamine use Etc
Etiology of ICH
Traumatic
Spontaneous
Hypertensive
Rupture of aneurysm
Bleeding into tumor
Cocaine and amphetamine use
Etc

19. Spontaneous rupture of a small artery deep in the brain
Hypertensive ICH
Spontaneous rupture of a small artery deep in the brain
Typical clinical presentation
Patient typically awake and often stressed, then abrupt onset of symptoms
Basal Ganglia
Cerebellum
Pons

21. Cerebral Hemorrhage
JPG

23. Cerebellar Hemorrhage

24. Subarachnoid Hemorrhage
“Worst headache of my life”
Altered Mental Status
Photophobia
Nuchal rigidity
Seizures
Nausea and vomiting

25. Subarachnoid Hemorrhage

26. Subacute (4 days) Infarction
Acute (4 hours)
Infarction
Subacute (4 days) Infarction R L

27. Have to use within 3 hours
tPa
Facts
Contraindications
“clot buster”
Have to use within 3 hours
Recent Major bleeding
Seizures
High high BP (>185)
Recent Surgery

28. Blood Pressure Management
The goal is to maintain cerebral perfusion!!
Higher than normal BPs can be okay!
Blood Pressure Management
For the most part, ICH stroke guidelines recommend using IV medications to lower SBP < 160 while still maintaining adequate MAP and CPP
Ischemic strokes are a bit trickier to manage. One must keep in mind that the patient’s blood pressure will lower on its own by approximately 25 – 30 % within the first 24 hours.
Furthermore aggressive treatment of hypertension in ischemic strokes has been shown to worsen neurological function by reducing perfusion pressure
Castillo and collegues performed a study in that showed that a drop in either SBP or DBP > 20 points were associated with higher rates of mortality and larger volumes of infarctions. They also noted that early administration of antihypertensinve medications to patients with SBP > 180 was associated with an increased risk of death.
**** CHHIPS trial ***
According to the guidelines, sbp should be reduced by 15 – 25% within the first day as excessively high blood pressures are associated with an increased risk of hemorrhagic conversion.

29. BP and acute ischemic stroke Relationship
Penumbra
Core
Clot in Artery
Penumbra is the area “at risk”
BP increase is an effort to provide more blood to the penumbra
Lowering BP starves penumbra, worsens outcomes

30. Preventing Strokes Healthy Diet Healthy Weight Exercise No Smoking
Limit Alcohol

31. Preventing Strokes Check Cholesterol Control Blood Pressure
Manage Diabetes
Manage Heart Disease
Take Your Medicines!