DIAGNOSIS AND INITIAL TREATMENT
OF STROKE
Linda Suryakusuma Department of Neurology
Faculty of Medicine
Background
• In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention
• Despite declining stroke mortality rates, the global burden of stroke is increasing
• A more comprehensive approach to primary prevention of stroke is required that targets
people at all levels of risk and is integrated with prevention strategies for other diseases that
Epidemiology
• Stroke is the second leading cause of death and third leading cause of DALYs lost
worldwide
Definition
• The traditional definition of stroke is clinical
and based on the sudden onset of loss of focal neurological function due to infarction or
haemorrhage in the relevant part of the brain, retina, or spinal cord. (WHO 1970)
• Stroke is distinguished from transient
Updated Definition
• An updated definition of stroke is an acute episode of focal dysfunction of the brain,
retina, or spinal cord lasting longer than 24h,
or of any duration if imaging (CT or MRI) or
autopsy show focal infarction or haemorrhage relevant to the symptoms
• TIA has been redefined as focal dysfunction of less than 24h duration and with no imaging
Diagnosis of Stroke
• Typical symptoms of stroke: - Sudden unilateral weakness - Numbness
- Visual loss - Diplopia
- Altered speech - Ataxia
• The Face Arm and Speech Test (FAST) or the Recognition of Stroke in the Emergency Room (ROSIER) is sensitive and specific
• Non-contrast cranial CT scan is very sensitive for fresh intracranial haemorrhage but not sensitive for recent, small or posterior fossa ischaemic stroke
• Diffusion-weighted MRI detects acute brain ischaemia in about 90% of patients with
• About 20-25% of patients presenting with a stroke syndrome have a stroke mimic; most commonly seizures, syncope, sepsis,
peripheral vestibulopathy, and toxic or metabolic encephalopathy
• The diagnosis of stroke is most difficult in the initial hours, particularly if the onset is
uncertain, the features are atypical or
changing, the patient is unwell or agitated,
Subtypes of stroke
• Clinical ischaemis stroke syndromes include TACS, PACS, LACS, and POCS
• Pathologic subtypes comprise ischaemic
stroke (cerebral, retinal, and spinal infarction) and haemorrhagic stroke (ICH and SAH)
• The proportions of pathological and
Arterial teritories
Types of Stroke
Ischemic Stroke- 88% Embolic (24%) :
Blood clot forms somewhere in the
body and travels to the brain
Thrombotic (61%) :
• The thrombus itself can occlude blood flow
Haemorrhagic stroke
Haemorrhagic stroke is classified according to its anatomical site (85-95% supratentorial: 50-75% deep and 25-40% lobar) or presumed
aetiology (30-60% hypertension, 10-30% cerebral amyloid angiopathy, 1-20%
Risk Factors
• Hypertension
• Hypercholesterolaemia
• Carotid stenosis
• Atrial fibrillation
• Cigarette smoking
• Alcoholism
• Diabetes Mellitus
• Environmental air pollution
• Childhood health
circumstances and fitness
• Poor nutrition
• Physical inactivity
• Obesity
• Blood pressure variability
• Sleep-disordered breathing
• Chronic inflammation
• Chronic Kidney Disease
• Migraine
• Hormonal contraception
• Psychosocial stress
• Depression
Prognosis after stroke and TIA
• Case fatality rates after all stroke are about 15% at 1 month, 25% at 1 year and 50% at 5 years
• Case fatality rates after ICH are 55% at 1 year and 70% at 5 years
• The risk of recurrent stroke without treatment is 10% at 1 week, 15% at 1 month and 18% at 3
months ABCD score
• With appropriate treatment, the risk is 80% lower
Specific Treatment
For Acute Ischaemic Stroke
• Intravenous alteplase (rtPA) 0.9 mg/kg,
administered within 4.5 hours of ischaemic stroke, increases the odds of no significant
disability (mRS 0-2) at 3-6 months by a third and does not affect mortality, despite increasing the odds of symptomatic intracerebral haemorrhage
• Using a lower dose of alteplase (0.6 mg/kg)
Specific Treatment
For Acute Haemorrhagic Stroke
• Intensive blood pressure reduction within 3-6 h of onset of ICH to a systolic target of lower than 140 mmHg may not be safe for all patients, nor more effective in reducing death and disability, compared to a systolic target of lower than 180 mmHg
General Treatment
of Acute Stroke
• Stroke-unit care
• Review by a stroke consultant within 24h of admission
• Nutrition screening and formal swallow assessment within 72h
• Antiplatelet therapy
• Adequate fluids and nutrition in the first 72h
• Crystalloids fluids
Preventing and Managing
Complications
• Cerebral oedema can be a secondary
consequence of a large area of brain infarction
• Early decompressive hemicraniectomy for malignant MCA infarction significantly
decreases 12 month mortality, death or severe disability, but is associated with
non-significantly higher major disability among survivors compared with conservative
• The trade-off between improved survival at the expense of substantial disability is greater for patients older than 60 years than for those of a younger age
• The optimum criteria for patient selection, timing of surgery, and acceptable degree of disability in survivors remain undefined
Preventing recurrent ischaemic stroke
of arterial origin
• Urgent initiation of effective secondary
prevention after TIA and minor ischaemic stroke can reduce the risk of early recurrent stroke by 80%
• Immediate aspirin, 160-300 mg a day, reduces the rate and severity of early recurrent stroke by at
least half within the first 6-12 weeks
• The most effective combination is aspirin and
clopidogrel in Chinese patients with acute TIA or minor ischaemic stroke, who are at low risk of haemorrhagic complications
• Effective long-term antiplatelet regimens for preventing recurrent stroke include aspirin 75-150 mg a day and/or clopidogrel 75 mg a day
• Anticoagulation in acute ischaemic stroke does not reduce early recurrent stroke, mortality or death or dependency compared with control,
• Stenting of recently symptomatic
atherosclerotic intracranial stenosis and
• Sustained lowering of blood pressure by 5 mmHg systolic and 2.5 mmHg diastolic
reduces recurrent stroke by about 20%
• The optimal targe blood pressure might be 120-128 mmHg systolic and 65-70 mmHg diastolic after lacunar stroke
• Visit-to-visit blood pressure variability is reduced in a dose-dependent fashion by
• Lowering of LDL cholesterol concentration by about 1 mmol/L (38 mg/dL) with statins
reduces the risk of recurrent stroke by about 12%
• More intensive lowering of LDL cholesterol concentration is associated with further
• Long-term intensive glucose lowering does not reduce non-fatal stroke risk compared with
standard care in patients with type 2 diabetes
• Insulin sensitivity can be improved by exercise, diet, weight reduction and peroxisome
proliferator-activated receptor γ agonists (pioglitazone)
Preventing recurrent ischaemic stroke
of cardiac origin
• In patients with atrial fibrillation, oral
anticoagulation with vitamin K antagonists, such as warfarin, to maintain an INR of 2.0-3.0,
decreases the odds of recurrent stroke by two-thirds
• The four direct oral anticoagulants that inhibit
thrombin (dabigatran) and factor Xa (rivaroxaban) reduce recurrent stroke and systemic embolism by about a sixth, without increasing major
• The optimal time to start oral anticoagulation in acute cardioembolic stroke is uncertain, but probably between 4-14 days after stroke
Recovery and rehabilitation
• Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and functional activity level
• Stroke survivors and their caregivers should be encouraged to join their local stroke support organisation
• Support and advice from organisations and from other stroke patients and their family can reduce social isolation and depression and improve
