1. ISCHEMIC STROKE
PROF.SHKROBOT

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

3. Stroke morbidity
per of population

4. Stroke mortality in different countries
per of population

5. Mortality from different types of stroke in Ukraine
per of population

6. Nowadays

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

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

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

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

11. 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

12. 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

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

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

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

16. 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.

17. 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.

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

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

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

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

22. penumbra

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

24. 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.

25. 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.

26. 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

27. Ischemic stroke
Extensive
Lacunar 27

28. 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

29. 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

30. 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.

31. 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

32. Lacunar stroke

33. Lacunar stroke

35. 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

36. Blood supplying of brain

37. Territory of Middle cerebral artery

38. Scheme of middle cerebral artery basinА
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

39. 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

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

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

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

43. Postischemic cist

44. Postischemic cist

45. Postischemic cist

46. 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

47. 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

48. 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

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

50. 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

51. 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

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

53. Postischemic cist

54. Territory of Vertebral artery

55. 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

56. 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

57. 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 “.

58. 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.

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

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

61. Blood supplying of the base of the brain

62. 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

63. 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

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

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

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

67. 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

68. 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

69. 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

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

71. 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

72. 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

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

74. 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

75. 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

76. 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

77. 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

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

79. 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

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

81. Smoking
Risk of recurring stroke in smokers increases in 1.5 times

82. 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)

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