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Hi, everyone. Welcome to this talk on ischemic stroke. As a part of a series of lectures for MLA revision, we will be covering the presentations, diagnostics and management of ischemic stroke. Starting with the case presentation, we have a 70 year old male presenting to A&E with sudden onset left sided body weakness for sudden onset limb weaknesses. The first thing to think about is stroke. Other causes can be hypoglycemia which can cause neurological symptoms, hemiplegic migraine which can present with upper motor weakness as an aura or to paralysis, which is neurological condition experienced by people with epilepsy leading to weakness in or part of the body. Ischemic stroke occurs in around 85% of all stroke cases and present acutely with rapid onset neurological defect depending on the affected regions. However, symptoms do overlay across regions. Strokes of the anterior circulation include the anterior cerebral artery, middle cerebral artery lacuna or small deep infarcts and striatal capsule infarcts which are infarcts of the called the nucleus putamen and anterior limb of the internal capsule. These present with mostly higher cerebral dysfunction such as dysphasia, difficulty swallowing, sensory with or without unilateral motor defects and homonymous visual field defect, posterior circulation includes posterior cerebral artery cerebellar and brainstem. In vals strokes in these areas present with similar symptoms from anterior circulation. In facts with the additions of dizziness slash vertigo dysarthria, which is difficulty speaking due to weak muscles, unilateral limb weaknesses, ataxia, ga's palsy, which means cannot move both eyes in the same direction and visual problems. Vinosum means impairment of recognizing visually presented objects. Ischemic stroke is mostly due to disrupted blood flow to intracranial artery leading to deprivation of oxygen and nutrients to the vascular territory. This leads to possible cellular death if circulation is not reestablished in time. Main causes of ischemic stroke include embolism via atrial fibrillation which causes stasis of blood and increasing chance of clotting fat emboli air emboli and endocarditis which forms vegetation. Other causes include thrombosis by atherosclerosis and arterial dissection. Risk factors include old age, male hypercholesterinemia, hypertension, smoking, poor diet, diabetes, atrial fibrillation and previous history. Some of which are also cardiovascular risk factors. Initial diagnosis of stroke, ischemic stroke include fast, it stands for face, arms, speech and time often used in the community. Uh We then exclude hypoglycemia which which can cause neurological problems. And rosia is a scoring system used in the emergency room. Non contrast. CT is used to confirm the diagnosis of stroke and determine its nature of ischemic or hemorrhagic. A thrombectomy which means the removal clot is indicated an enhanced CT scan will be performed. A CT perfusion scan can also be offered to show the area which are worth salvaging such as the uh see the penumbra in the middle picture. Ischemic stroke management has three major parts. Firstly, initial management is done with hemorrhage, hemorrhagic stroke excluded. And then we give aspirin 300 mgs, then control BP, control glucose and refer to the stroke team who will perform A N I HSS score uh to assess neurological impact. Secondly, intravenous or intraarterial thrombolysis is done. Uh This is done within 4.5 hours after onset. Given that a possible hemorrhagic stroke is ruled out. Thirdly. Mechanical thrombectomy may also be done depending on the time the patient presents if presentation is within six hours after onset, thrombectomy is given with IV thrombolysis for acute ischemic stroke, meaning no hemorrhagic potential with occlusion of proximal anterior circulation, which is determined via CTA or MRA imaging. If patient presents within 6 to 24 hours after onset, thrombectomy is given for ischemic stroke. Given ruling out hemorrhagic stroke with occlusion of proximal anterior circulation with potential salvaging of the brain determined by aceto perfusion or diffusion weighted MRI scans. If patient presents 24 hours within onset thrombectomy is given with IV thrombolysis for ischemic stroke with occlusion of proximal posterior circulation and potential of salvaging of the brain. After stroke has been treated, supportive management is given to minimize the risk of future strokes clip which is antiplatelet statin with dyslipidemia and uh antihypertensives and lifestyle management. It is legal to drive within one month of getting a stroke and you need to inform the DL after one month to report any persisting problems on the left. We can see a picture of mechanical thrombectomy on the right. It is a decompressive craniectomy procedure which is only used in certain cases such as a large middle cerebral artery. In fact, going back to the case, the patient has a past history of hypertension and previous tia, you examine him and he has weakness in his left arm and visual disturbances with sensations intact. Do they investigate using a non contrast CT scan to summarize ischemic stroke is is more common than hemorrhagic stroke with risk factors including old age, male hypertension smoking, previous cardiovascular history, hypercholesterinemia presentations usually depend on the areas affected and neurological symptoms are likely diagnosis is fast fras noncontrast management. Uh is IV thrombolysis mechanical thrombectomy and supportive treatment. Along with the initial management we've discussed um to make this powerpoint use the nice guidelines and also radio um P. Thank you for listening.
