Ischemic Stroke

Peng BinPeng Bin

Department of Department of

Neurology,Peking Union Neurology,Peking Union

Medical College HospitalMedical College Hospital

What do we need to know……

Definition and classificationDefinition and classification

Vascular anatomyVascular anatomy

MechanismMechanism

Clinical featuresClinical features

Diagnosis and differentiate diagnosisDiagnosis and differentiate diagnosis

TreatmentTreatment

Definition

Stroke:Stroke:

World Health Organization (WHO) has defined stroke World Health Organization (WHO) has defined stroke

as “rapidly developing clinical signs of focal (at times as “rapidly developing clinical signs of focal (at times

global) disturbance of cerebral function, lasting more than global) disturbance of cerebral function, lasting more than

24 hours or leading to death with no apparent cause other 24 hours or leading to death with no apparent cause other

than that of vascular origin.” than that of vascular origin.”

Ischemic stroke:Ischemic stroke:

deprivation of blood flow to an area of the brain, generalldeprivation of blood flow to an area of the brain, generally as a result of thrombosis, embolism, or reduced blood pressure.y as a result of thrombosis, embolism, or reduced blood pressure.

------OnsetOnset : Rapidly : Rapidly

------SymptomSymptom: Focal or global : Focal or global

cerebral dysfunctioncerebral dysfunction

------DurationDuration: More than 24 hours: More than 24 hours

------Vascular originVascular origin: :

Classification of Ischemic Stroke

Atherothrombotic cerebral infarctionAtherothrombotic cerebral infarction

Cerebral embolismCerebral embolism

Lacunar infarctionLacunar infarction

Cerebral watershed infarctionCerebral watershed infarction

Vascular Anatomy

The brain is perfused by the carotid The brain is perfused by the carotid

and vertebral arteriesand vertebral arteries

---Anterior circulation : carotid ---Anterior circulation : carotid

artery ,etcartery ,etc

---Posterior circulation: vertebrobasilar ---Posterior circulation: vertebrobasilar

artery.artery.

How does it happen?

Clinical manifestations

Ischemic syndromes of specific Ischemic syndromes of specific

vessels depend onvessels depend on

----- the site of the occlusion ----- the site of the occlusion

----- the presence of previous brain ----- the presence of previous brain

damagedamage

----- collateral circulation----- collateral circulation

MCA

ACA

PCA

Example

Internal carotid artery Internal carotid artery

occlusion(MCA+ACA)occlusion(MCA+ACA)

* * SymptomaticSymptomatic

--Contralateral hemiparesis--Contralateral hemiparesis

--Hemianesthesia --Hemianesthesia

--Hemianopia --Hemianopia

**AsymptomaticAsymptomaticMCA

ACA

Asymptomatic

Diagnosis

Onset Onset

Causes or risk factorsCauses or risk factors

Clinical featuresClinical features

---Stroke syndromes---Stroke syndromes

TestsTests

---Brain CT scan---Brain CT scan

---Brain MRI---Brain MRI

---TCD,CTA or DSA---TCD,CTA or DSA

Differentiate Diagnosis

Intracerebral hemorrhageIntracerebral hemorrhage

General Management

Standard frequency of observations Standard frequency of observations

and monitored parametersand monitored parameters

Deep vein thrombosis (DVT) Deep vein thrombosis (DVT)

prophylaxisprophylaxis

Treatment of increased blood sugar Treatment of increased blood sugar

levels (BSL)levels (BSL)

Treatment of increased temperatureTreatment of increased temperature

Treatment of increased blood pressure Treatment of increased blood pressure

(BP)(BP)

Specific treatment

Thrombolytic therapy Thrombolytic therapy

--Intravenous thrombolytic --Intravenous thrombolytic

therapy with rt-PAtherapy with rt-PA

--Intraarterial thrombolytic --Intraarterial thrombolytic

therapytherapy

Inclusion CriteriaInclusion Criteria

--Patient or family are able to indicate consent--Patient or family are able to indicate consent

--Age --Age >> 18 18

--Onset of stroke symptoms defined, and --Onset of stroke symptoms defined, and

within within 4.5 hours4.5 hours of commencement of infusion of commencement of infusion

--Moderate to severe neurological deficit --Moderate to severe neurological deficit

(NIHSS (NIHSS >> 7 and < 25) 7 and < 25)

Exclusion CriteriaExclusion Criteria

----TimeTime of onset unknown, patient awoke with of onset unknown, patient awoke with

deficitdeficit

Antiplatelet therapyAntiplatelet therapy

AnticoagulationAnticoagulation

--Indications :--Indications : Atrial fibrillation Atrial fibrillation

(chronic or paroxysmal) (chronic or paroxysmal)

--Contraindications--Contraindications

Secondary PreventionSecondary Prevention

Specific Interventions

Carotid endarterectomyCarotid endarterectomy

Angioplasty/stentingAngioplasty/stenting : Extracranial : Extracranial

(carotid) and intracranial (carotid) and intracranial

Rehabilitation

After class

Definition and vascular anantomyDefinition and vascular anantomy

Diagnosis and treatmentDiagnosis and treatment

Suggested readingsSuggested readings

---Cerebralvascular disease 4---Cerebralvascular disease 4thth

editonediton

---Merrit’s Handbook of Neurology---Merrit’s Handbook of Neurology

Thanks!