Stroke

Introduction

Stroke is synonyms to: Brain attack, Cerebrovascular disease, and Apoplexy.
It is a condition resulting from disruption of blood supply to brain cells (either occlusion (infarction) or blood vessel rupture (haemorrhage).
There should be pathological and/or radiological demonstration of the lesion.
The disability may result in death.
The duration of disability is no longer
critical and acute stroke is now referred to as “Brain Attack” because the longer brain cells are deprived of blood, the bigger the size of brain cells affected and the more severe the damage or disability.

Clinical features

Classical stroke:

  • Sudden motor weakness of one side of the body but could be bilateral, with/without speech, visual and sensory impairment
  • Subarachnoid haemorrhage:
    • Severe headache, neck stiffness and positive Kernig’s sign
  • Stroke-in-evolution:
    • Gradual onset of deficit with progression
  • Mass lesion:
    • Sudden rise in intracranial pressure
    • Loss of consciousness, respiratory
      changes, pupillary changes
  • Sudden death
  • Lacunar syndrome:
    • Incomplete deficits: speech defects with clumsy hand involvement
  • Dementia:
    • Pure motor and/or pure sensory deficits
    • Arises from small, recurrent strokes resulting in cognitive impairment and functional dependence

Differential diagnoses

  • Brain tumour
  • Subdural haematoma
  • Brain abscess
  • Meningitis/encephalitis
  • Cerebral malaria
  • Migraine headache
  • Multiple sclerosis
  • Metabolic derangements e.g. hypoglycaemia, hyperosmolar non ketotic coma

Complications

Short and Long term

  • Tentorial herniation with coning and Cardiac arrhythmias death
  • Depression
  • Epilepsy
  • Demential
  • Parkinsonism
  • Hyperglycaemia
  • Sepsis
  • Pneumonia
  • UTI
  • Decubitus ulcers
  • Deep vein thrombosis
  • Contractures

Investigations

  • Neuro-imaging with CT scan/MRI to determine stroke type and choice of management
  • Lumbar puncture for CSF analysis in suspected subarachnoid haemorrhage
  • Electrocardiography
  • Echocardiography
  • Carotid Doppler ultrasound study
  • Cerebral angiography
  • Full Blood Count with differentials
  • Random blood glucose
  • Urea, Electrolytes and Creatinine
  • Chest radiograph
  • HIV screening

Management

Treatment objectives

  • Restore cerebral circulation
  • Limit disability
  • Treat identified risk/predisposing factors
  • Reduce raised intracranial pressure
  • Treat complications (if any)

Non-drug treatment

  • Attention to calories, fluid balance
  • Physiotherapy for passive muscle exercises
  • Nursing care (frequent turning and bladder care) to prevent decubitus ulcers and urinary tract infection
  • Rehabilitation

Drug treatment

Cerebral decompression if there is evidence of raised intracranial pressure

  • 20% mannitol 250 mL repeated every 12 hours for 4-6 doses.

And/OR

  • Furosemide 40 mg every 8 hours by slow intravenous injection for 6 doses

And/Or:

  • Thrombolysis with tissue plasminogen activator (Atelpase) – if patient is brought to medical attention within 4½ hours and CT scan did not show haemorrhage or big infarct, no previous bleeding and BP not severely elevated
  • Treat underlying conditions such as diabetes mellitus, hypertension, and thrombosis.
  • Treat hyperglycaemia with Insulin
  • Treat seizures with Intravenous Diazepam
  • Treat fever with antipyretics and
    antibiotics if infection is suspected

For subarachnoid haemorrhage:

  • Nimodipime is recommended for the control of BP and to prevent vasospasm
  • Use of antacids to prevent and treat stress ulcers.
  • Use of anti-epileptic drugs to prevent seizures in the acute phase

Notable adverse drug reactions, caution

  • Rebound cerebral oedema when mannitol is discontinued
  • Thrombolytic agents: bleeding tendencies
  • Diazepam by the intravenous route must be administered slowly to avoid respiratory depression and laryngeal spasm

Prevention

Treat/control known risk factors.

  • Hypertension
  • Diabetes mellitus
  • Cardiac diseases
  • Hyperlipidaemia
  • Obesity
  • Smoking
  • Excessive alcohol consumption
  • Give low dose aspirin (acetylsalicylic acid) to patients at risk if tolerated