STROKE

Hawler Medical University

College of Medicine
Community Health

Prepared by:
Hawraz Faris Saadi
BSN, Master Student
Introduction

Neurological deficit of cerebrovascular cause that

persists beyond 24 hours or is interrupted by death
within 24 hours.
Stroke is the third most common cause of death and
the second most common cause of neurologic
disability after Alzheimer's disease.
Type of Stroke

1. Ischemic stroke
2. Hemorrhagic stroke

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Ischemic stroke

 In an ischemic stroke, blood supply to part of the

brain is decreased, leading to dysfunction of the
brain tissue in that area, its about 80% of stroke
There are four reasons:
1) Thrombosis
2) Embolism
3) Systemic hypoperfusion
4) cerebral venous sinus thrombosis

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Ischemic stroke Cont.

 Stroke without previous reasons is termed

"cryptogenic" (of unknown origin), this
constitutes 30-40% of all ischemic strokes

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Hemorrhagic stroke

 Is a bleeding into brain tissue or meningeal spaces

, its about 20% of strokes.
 There are two main types of hemorrhagic stroke:
1) Cerebral hemorrhage
2) Subarachnoid hemorrhage

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Types of hemorrhagic stroke

1) Cerebral hemorrhage (also known as intracerebral

hemorrhage), which is basically bleeding within the
brain itself (when an artery in the brain bursts,
flooding the surrounding tissue with blood).
2) Subarachnoid hemorrhage which is basically bleeding
that occurs outside of the brain tissue but still within
the skull, and precisely between the arachnoid mater
and pia mater.

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Signs and symptoms

 Stroke symptoms typically start suddenly, over

seconds to minutes, and in most cases do not
progress further. The symptoms depend on the
area of the brain affected. The more extensive
the area of the brain affected, the more functions
that are likely to be lost.

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1. Early recognition

 Various systems have been proposed to increase

recognition of stroke.
 Different findings are able to predict the presence or
absence of stroke to different degrees.
 Sudden-onset face weakness, arm drift and abnormal
speech are the findings most likely to lead to the correct
identification of a case.

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2. Subtypes

If the area of the brain affected contains one of the three

prominent central nervous system pathways—the
spinothalamic tract, corticospinal tract, and dorsal column
symptoms may include:
a) hemiplegia and muscle weakness of the face
b) numbness
c) reduction in sensory or vibratory sensation
d) initial flaccidity

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2. Subtypes Cont.

If the cerebral cortex is involved, can produce the following

symptoms:
a) aphasia (difficulty with verbal expression, auditory
comprehension, reading and writing)
b) dysarthria (motor speech disorder resulting from
neurological injury)
c) apraxia (altered voluntary movements)
d) visual field defect
e) memory deficits (involvement of temporal lobe)
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3. Associated symptoms

a) Loss of consciousness
b) Headache
c) vomiting usually occur more often in hemorrhagic stroke
than in thrombosis because of the increased intracranial
pressure from the leaking blood compressing the brain.
d) If symptoms are maximal at onset, the cause is more
likely to be a subarachnoid hemorrhage or an embolic
stroke

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Risk Factors

Non Modifiable Modifiable

Age High Blood pressure
Gender (Male < Female) Cigarette smoking
Race Polycythaemia
Heredity Excessive alcohol intake
Previous Vascular event Diabetes mellitus
Heart Diseases (HF)
Hyperlipidemia 11/9/2017 14
AHA GUIDELINES FOR PRIMARY
PREVENTION OF
CARDIOVASCULAR
DISEASES AND STROKE

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1. RISK ASSESSMENT

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A. Risk factor screening

Goal: Adults should know the levels and significance of risk

factors as routinely assessed by their primary care provider.
Recommendations :
1) Risk factor assessment in adults should begin at age 20 y.
2) Family history of CHD should be regularly updated.
3) Smoking status, diet, alcohol intake, and physical activity
should be assessed at every routine evaluation.

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A. Risk factor screening Cont.

4) Blood pressure, body mass index, waist circumference, and

pulse ,should be recorded at each visit (at least every 2 y).
5) Fasting serum lipoprotein profile (or total and HDL
cholesterol if fasting is unavailable) and fasting blood
glucose should be measured according to patient’s risk for
hyperlipidemia and diabetes, respectively (at least every 5
y; if risk factors are present, every 2 y).

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B. Global risk estimation

All adults 40 y of age should know their absolute risk of

developing CHD.
Goal: As low risk as possible.
Recommendations :
1) Every 5 y (or more frequently if risk factors change),
adults, especially those >40 y of age or those with >2 risk
factors, should have their 10-y risk of CHD assessed
with a multiple risk score
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B. Global risk estimation Cont.

2) Risk factors used in global risk assessment include age, sex,

smoking status, systolic (and sometimes diastolic) blood
pressure, total (and sometimes LDL) cholesterol, HDL
cholesterol, and in some risk scores, diabetes.
3) Persons with diabetes or 10-y risk > 20% can be considered
at a level of risk similar to a patient with established
cardiovascular disease (CHD risk equivalent). Equations for
calculation of 10-y stroke risk are also available.

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2. RISK INTERVENTION

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A. SMOKING

Goal:
Complete cessation. No exposure to environmental tobacco
smoke.
Recommendations :
1) Ask about tobacco use status at every visit.
2) In a clear, strong, and personalized manner, advise every
tobacco user to quit.

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A. SMOKING Cont.

3) Assess the tobacco user’s willingness to quit. Assist by

counseling and developing a plan for quitting.
4) Arrange follow-up, referral to special programs, or
pharmacotherapy.
5) Urge avoidance of exposure to secondhand smoke at work
or home

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B. BLOOD PRESSURE CONTROL

Goal:
I. <140/90 mm Hg
II. <130/85 mm Hg if renal insufficiency or heart failure is
present
III. <130/80 mm Hg if diabetes is present

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B. BLOOD PRESSURE CONTROL Cont.

Recommendations :
1) Promote healthy lifestyle modification. Advocate weight
reduction; reduction of sodium intake; consumption of
fruits, vegetables, and low-fat dairy products; moderation
of alcohol intake; and physical activity in persons with BP
of >130 mm Hg systolic or 80 mm Hg diastolic.
2) For persons with renal insufficiency or heart failure,
initiate drug therapy if BP is > 130 mm Hg systolic or 85 mm
Hg diastolic (>80 mm Hg diastolic for patients with
diabetes).
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B. BLOOD PRESSURE CONTROL Cont.

3) Initiate drug therapy for those with BP >140/90 mm Hg if 6

to 12 months of lifestyle modification is not effective,
depending on the number of risk factors present. Add BP
medications, individualized to other patient requirements
and characteristics (e.g, age, race, need for drugs with
specific benefits).

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C. DIETARY INTAKE

Goal: An overall healthy eating pattern.

Recommendations :
1) Advocate consumption of a variety of fruits, vegetables,
grains, low-fat or nonfat dairy products, fish, legumes,
poultry, and lean meats.
2) Match energy intake with energy needs and make
appropriate changes to achieve weight loss when indicated.

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C. DIETARY INTAKE Cont.

3) Modify food choices to reduce saturated fats (< 10% of

calories), cholesterol (< 300 mg/d), and trans-fatty acids b
substituting grains and unsaturated fatty acids from fish,
vegetables, legumes, and nuts.
4) Limit salt intake to < 6 g/d.
5) Limit alcohol intake (<2 drinks/d in men, <1 drink/d in
women) among those who drink.

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D. PHYSICAL ACTIVITY

Goal: At least 30 min of moderate-intensity physical activity on

most days of the week.
Recommendations :
1) If cardiovascular, respiratory, metabolic, orthopedic, or
neurological disorders are suspected, or if patient is
middle-aged or older and is sedentary, consult physician
before initiating vigorous exercise program..

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D. PHYSICAL ACTIVITY Cont.

2) Moderate-intensity activities are equivalent to a brisk walk

(15–20 min per mile).
3) Additional benefits are gained from vigorous-intensity
activity for 20–40 min on 3–5 d/wk.
4) Recommend resistance training with 8–10 different
exercises, 1–2 sets per exercise, and 10–15 repetitions at
moderate intensity > 2 d/wk.
5) Flexibility training and an increase in daily lifestyle
activities should complement this regimen.
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E. WEIGHT MANAGEMENT

Goal:
Achieve and maintain desirable weight (body mass index 18.5–
24.9 kg/m2). When body mass index is >25 kg/m2, waist
circumference at iliac crest level < 40 inches in men, < 35
inches in women.

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E. WEIGHT MANAGEMENT Cont.

Recommendations :
Initiate weight-management program through caloric
restriction and increased caloric expenditure as appropriate.
For overweight/obese persons, reduce body weight by 10% in
first year of therapy.

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F. DIABETES MANAGEMENT

Goal: Normal fasting plasma glucose (< 110 mg/dL) and near
normal HbA1c (< 7%).
Recommendations :
1) Initiate appropriate hypoglycemic therapy to achieve near-
normal fasting plasma glucose or as indicated by near-
normal HbA1c.
2) First step is diet and exercise.
3) Second-step therapy is usually oral hypoglycemic drugs.
4) Third-step therapy is insulin.

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Secondary prevention
1) Secondary prevention must be seen as a continuation of
primordial prevention and primary prevention, It forms
an important part of an overall strategy.
2) The aim of secondary prevention is to prevent the
recurrence and progression of Stroke.
3) Despite advances in treatment

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Tertiary prevention
1. To prevent complication
2. Rehabilitations
a) Motor-skill exercises. These exercises can
help improve your muscle strength and
coordination. You might have therapy to
strengthen your swallowing

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Tertiary prevention Cont.
b) Mobility training :You might learn to use
mobility aids, such as a walker, canes,
wheelchair or ankle brace
c) Constraint-induced therapy. An unaffected
limb is restrained while you practice moving
the affected limb to help improve its
function.

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Tertiary prevention Cont.
d) Range-of-motion therapy. Certain exercises
and treatments can ease muscle tension
(spasticity) and help you regain range of
motion.
e) Functional electrical stimulation. Electricity
is applied to weakened muscles, causing them
to contract.

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Tertiary prevention Cont.
f) Robotic technology. Robotic devices can
assist impaired limbs with performing
repetitive motions,
g) Therapy for cognitive disorders.
Occupational therapy and speech therapy can
help you with lost cognitive abilities, such as
memory, processing, problem-solving, social
skills, judgment and safety awareness.
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Tertiary prevention Cont.
h) Therapy for communication disorders.
Speech therapy can help you regain lost
abilities in speaking, listening, writing and
comprehension.
i) Alternative medicine. Treatments such as
massage, herbal therapy, acupuncture and
oxygen therapy are being

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References

1. Nicki R., Brian R., Stuart H., (2010) Davidson’s Principles and Practice of
Medicine.
2. Park K. (2015) Park’s textbook of preventive and social medicine.
3. http://professional.heart.org/professional/index.jsp
4. http://www.strokesocietyphil.org/files/chapter-3.pdf
5. http://www.stroke.org/understand-stroke/what-stroke
6. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke-
rehabilitation/art-20045172