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Hello everyone. Good evening. I just wanted to check. Can you hear me? Ok. Hello. I just wanted to check the sound if everything is being heard. Ok, before I start. So if anyone is there, can you just let me know through the chat whether you can hear me just? Ok, great. Thank you so much for the confirmation. So we're gonna start now. Um My name is uh Linta Dema and I'm one of the upcoming Neurology Registrars and an academic clinical fellow in Neurology at Sheffield teaching hospitals. And today we're going to be discussing the management of stroke and we're gonna go through the evidence based approach to stroke patients. So we're gonna start off with what is stroke? Essentially. It, it is a clinical syndrome which consists of a rapidly developing clinical signs, either focal or global if the patients present with a comatose state and that causes a disturbance of cerebral function, but it is known to last more than 24 hours and in some cases can lead to death with no apparent cause that we can identify other than a vascular origin. And there are two main types of stroke classification. It's either ischemic, which is uh 87% of all the stroke cases that we see versus hemorrhagic, which is about 13% of all the cases that we see. And it's important for you to know the details about uh stroke work up and the pathophysiology and how to approach it because it is critical for reducing the morbidity and mortality of patients. Now, from an epidemiological perspective, around 1005, 50 100 people have a stroke in the UK each year and about 50,000 of these die every year. And currently, about 20% of all acute hospital beds are being occupied by stroke patients and all the long term beds, about 25% of them are stroke patients. Uh So there is a burden on the patients health, there is a burden on the health care uh because of uh stroke and its implications, short term and long term. And that's why it's important for you to understand that time is brain and each minute uh which stroke is untreated that basically equals 1.9 million neurons dying. So, we usually are very efficient in assessing the patient and then assessing whether they would be suitable for management that being thrombolysis or thrombectomy, which we will discuss a bit later today. But it's important to make decisions as quick as we possibly can rule out all the contraindications and move forward because we're saving more tissue as we go when we do make these decisions precisely but with less time spent on them. And it's estimated that the cost of stroke in England is around 8 billion per year. So you can see all the implications of stroke as a disease on the patient, on the healthcare system and financially and on the patients long term. So it's very important to know and to follow up with the evidence based management for stroke. Now, there are modifiable and nonmodifiable risk factors that we can work with and modifiable risk factors are things like hypertension, diabetes, smoking, which are very well known to be associated with increased risk of diabetes. And then there are nonmodifiable risk factors such as age, gender or family history of previous strokes. Now we identified or categorized the stroke as either ischemic or hemorrhagic. Now, for each of those, there are different ways that they can present or different pathophysiology. So, for example, the ischemic stroke can either be thrombotic in nature or embolic in nature. And we're gonna discuss that now, in the next slide. However, the hemorrhagic stroke, you'll find that it's either presenting as an intracerebral or tissue hemorrhage or subarachnoid hemorrhage. And obviously, depending on which brain region are affected by either an ischemic stroke or hemorrhagic stroke, you'll see different impact on different functions and the functional outcome of patients accordingly. So essentially, this just summarizes the characteristics of these different stroke subtypes. So for example, the intracerebral hemorrhage, we'll notice that it's more gradual progression from minutes to hours in patients. While subarachnoid hemorrhage, it's usually abrupt onset, sudden severe headache and it can cause focal brain dysfunction. And it's less common than uh with other types. And the risk factors for bleeding generally include hypertension, which is a very well known and associated risk factor with um, uh intracerebral and subarachnoid hemorrhage trauma, uh illicit drug use like amphetamine and cocaine and vascular malformations that previously maybe were not known as they did not present. Um And we'll find that there is more likelihood in certain ethnicities just uh such as uh Africans or Asians than in whites to have intracerebral hemorrhages, uh in subarachnoid hemorrhage. Uh, you'll find that risk factors are mainly related to amphetamine and cocaine use and uh bleeding diastases. Now, for the ischemic, um uh stroke subtypes in the thrombotic subtype, you have a stuttering progression. There are periods of improvements in between and um the lacus, they develop over hours or at most, over days and the large arteries, uh uh large artery ischemia may evolve over longer periods and the risk factors are the vascular risk factors. So, smoking diabetes and, and usually men are more, more uh affected than women uh with thrombotic uh strokes and they may have a history of previous tia that led to the development of uh thrombotic uh uh stroke. Now, the embolic stroke, it presents as a sudden onset and uh there is a deficit maximal at the time of onset. And you, you can find that sometimes the the symptoms that they present with may improve quickly, um they have the same risk factors. Um but as you know, emboli are more likely to develop when patients have heart disease, like valvular heart disease, atrial fibrillation, endocarditis that puts them at a higher risk of forming emboli and then throwing emboli into the brain. And this is just to show you the differences between all these different subtypes of stroke. So we can see on the left hand side with the ischemic stroke, we have uh the thrombotic type. It's a blood clot forming locally in the brain and consequently, it blocks the blood flow. Embolic is a blood clot that forms in the body and then travels through the bloodstream until it reaches the brain where it blocks the artery uh in the hemorrhagic. On the right side, you can see that the intracerebral hemorrhage, it's a bleeding that occurs within the brain tissue. However, the subarachnoid is the one that occurs in the subarachnoid space. And this summarizes to you the different vascular territories for the cerebral circulation. So the most important ones to know are the anterior cerebral artery, which you can see it's basically covering the frontal, medial part uh of the frontal lobe. And then you have the middle cerebral artery which encompasses a large area from the frontal parietal and temporal lobes. And then we have the posterior cerebral artery in blue, which covers the occipital and the parietal lobe and then goes on to cover the brainstem. And then we have um uh smaller arteries uh like medial lenticular artery, which you see here, the basal ganglia is covered by the medial lenticular striae as well as the lateral lenticular striate arteries. And these are very sensitive to high BP as well. And with high BP, there is higher risk of uh strokes in these areas. And these are very important for localization purposes, which we're gonna discuss now to know what does each of these areas present in terms of function. So, you know, by examination which area is affected. So we have the Oxford try uh classification or.