_________________________________________________________ NEUROLOGY 2

1.02a STROKE GENERALITIES and MECHANISM 2. Hemorrhagic Stroke – 20%

Dr. John Harold Hiyadan/ January 22, 2018 - What rupture most of the time are the small penetrating
PRELIMS; QUIZ NO. 1 blood vessels
Red bold- emphasized during lecture, Blue italic- Audio, Green-OT/ book
STROKE
Definition of STROKE:
 WHO: It is the sudden onset of focal neurologic
deficits lasting for more than 24 hrs which is vascular
in origin
3 important components
o Sudden onset of focal neurologic deficits 

o >24 hours - 24hrs is proposed to be changed to 1 hr due
to the advent of rtPA, which can lyse clot in 3 hrs 

o Vascular in origin – etiology: problem in the blood vessel Ruptured lenticulostriate arteries causing basal ganglial bleed
not because of a tumor or infection/inflammation in the
brain 
 TYPES OF ISCHEMIC STROKE
 Tissue-based definition (Imaging-based): sudden 1. THROMBOTIC INFARCT
onset of focal neurological deficit, which is vascular in origin  In situ blockade of a medium-sized (secondary to
with evidence of an infarct or hemorrhage in the brain or atherosclerosis) or small-sized artery (lacunar stroke)
spinal cord by neuroimaging (MRI or CT scan) o There is an occlusion of a blood vessel. It originates in
o Difference with WHO definition is “time (>24h)” changed that area itself
with “neuroimaging” o Lacunar stroke: usually due to chronic hypertension or
o CT scan has a very low sensitivity (30%), MRI has a very diabetes
high sensitivity (97%)
- In detecting early infarct, MRI is superior than CT
- If it is a bleed, CT scan is superior than MRI
o Problem in tissue-based definition: Dependent on
neuroimaging
- Early changes (within an hour) cannot be detected
in CT Scan  Negative imaging results  False
Negative Diagnosis of Stroke
- Unavailability of machines in some hospitals
Definition of TRANSIENT ISCHEMIC ATTACK (TIA)
 “mini stroke” 

 WHO: sudden onset of focal neurologic deficit lasting 
for
less than 24 hours, vascular in origin
 Tissue-based definition: sudden onset of focal neurologic
deficit with no evidence of infarct or hemorrhage on
neuroimaging
Epidemiology 2. EMBOLIC INFARCT 

 No.1 cause of disability in the Philippines & worldwide
 - Blockage of an artery by an embolus usually originating
 No.2 leading cause of mortality in the Philippines and from the heart or proximal blood vessel (artery to
worldwide (No. 1 is cardiovascular) 
 artery)
 Stroke remains among the five leading causes of death across - Blood clot doesn’t happen in that blood vessel itself. The clot
every income group in most countries in the last comes from somewhere else
comprehensive review by WHO in 2004. 
 -
2 MAJOR TYPES OF STROKE 2 Types:
 Cardioembolic infarct/stroke
1. Ischemic stroke – 80 % - Blood clot originating from the heart
- MC cause: Non-valvular Atrial Fibrillation
 Artery to artery infarct/stroke
- Ex: Blood clot in carotid artery can be dislodged into MCA
- MC from Carotid artery

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_________________________________________________________ NEUROLOGY 2
TYPES OF HEMORRHAGIC STROKE Reviewing your blood vessel layers, tunica intima, media and
1. INTRACEREBRAL (80%) adventitia, atherosclerosis occurs in the intima.
 Bleed within the brain parenchyma
 Rupture of small penetrating vessels, like in the lacunar
infarct
 MC due to HPN

When we were born, our blood vessels are very clean.

CT Scan: Hyperdense = hemorrhage (hypodense = infarct)

2. SUBARACHNOID (20%)
 Bleed in the subarachnoid 

 Rupture of an aneurysm  blood will collect at the
surface of the brain (subarachnoid space)
 MC non-traumatic cause: usually due to a ruptured saccular Due to environmental and internal factors, atherosclerosis forms.
aneurysm. 
 Environmental and Internal Factors:
 AV malformation is suspected if it occurs in
younger age  Obesity
group (<40y/o) 
  Nutritional factors
 Aneurysms usually rupture beyond the age of 
 40. 
  Inactivity
 Can be caused by AV malformation in younger individuals  Hypertension
 Reduced HDL
 Elevated LDL
 Diseases like DM
 Smoking
 Genetic factors (family history of stroke and dyslipidemia
- Fat streak formation on tunica intima and tunica media starts
by 11 years old
- Formation of atherosclerosis  Narrowing of the lumen 
Cause an occlusion  End result: Stroke or Myocardial
Infarction or ischemic limb
NON MODIFIABLE
 Genetically determined 

 Cannot be changed 

CT Scan: Non- modifiable risk Relative risk
Hyperdense and widened sulci = blood is covering the brain 1. Age Doubles per decade after age 55
Stroke in the young <45y/o
RISK FACTORS FOR STROKE 2. Gender M>F
Female hormones (estrogen) are
protective, but after menopause
(>45y/o), risk is the same

3. Previous stroke 10x

4. Race-ethnicity Blacks > Whites & Asians >
Caucasians
Incidence of hypertension among
Blacks is very high
Probably diet or genetics for Asians
5. Heredity Increased if with family history of
stroke

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_________________________________________________________ NEUROLOGY 2
MODIFIABLE  Nicotine and carbon monoxide decrease oxygen in the brain
 Medical conditions
 and damages blood vessels 

 Result from unhealthy lifestyle  If smokers quit smoking, stroke risk goes down
Medical condition Relative Risk Prevalence significantly from 2 years onward
(RR) (%)
 Passive smoking
Hypertension 4x 35%
o Risk stroke: 1.82x
Diabetes 2x 7.3% o (+) Exposure to environmental tobacco smoke from:
Smoking 1.8x 25% - Household member who had regularly smoked
1.73x 8% cigarette
Coronary Artery
- Co-worker who smoked in the same indoor room
Disease (CAD)
(ex: MI)
NVAF (Non Valvular Atrial 2.6-4.5x 0.5-8.8%
Fibrillation) (age related)
Obesity 1.75-2.37x 17.9%
Dyslipidemia 2x 25%
Physical inactivity 2.7x 25%

HIGH BLOOD PRESSURE


 Increased stroke risk by 3 to 5 times
 Single most important risk factor for stroke HIGH BLOOD CHOLESTEROL 

 Both systolic & diastolic BP are important
 Increases stroke risk by 2 times
Assignment:  Causes formation of plaque in blood in the blood vessels
 Formation of atherosclerosis is multifactorial. Cholesterol
2017 ACC/AHA Hypertension Guidelines
plaques start/ form in injured blood vessels (caused by
Systolic Pressure Diastolic Pressure smoking and hypertension)
(mmHg) (mmHg)
Normal <120 <80 EXCESSIVE ALCOHOL INTAKE
Elevated 120-129 and <80  increase stroke risk up to 4 times
 Hemorrhagic stroke: dose-dependent risk 

Stage 1 130-139 or 80-89
 Cerebral infarction: biphasic effect
Stage 2 140 and > or 90 and > o Protective if moderate up to 2 drinks (2 bottles of beer
Source: http://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/ or 2 shots of whiskey or 2 glasses of 
wine per day)
mon-5pm-bp-guideline-aha-2017 o Increased risk if excessive
‘
NON VALVULAR ATRIAL FIBRILLATION SEDENTARY LIFESTYLE 

 AF increases stroke risk by up to 4.5x  Increased chance of being overweight -> increases stroke
- Almost the same with Hypertension (also in the top list) risk by 1.3x, CVD by 1.5-2.4x 

 Atrial fibrillation and other forms of heart disease causes
blood clot to form in the heart PRACTICE QUIZ:
 Irregularly irregular HR 1. Defined as a suddent onset of focal neurologic
 MC cause of cardioembolic stroke deficit lasting for less than 24 hours.
2. Form of stroke affecting small-sized arteries.
 Causes blood clot to form in the heart to be dislodged in the
3. Most common cause of cardioembolic stroke.
brain, kidneys, and peripheral arteries 4. Most common form of hemorrhagic stroke.
5. What is the leading cause of subarachnoid
DIABETES hemorrhage?
 Increases stroke risk by 2 to 3 times 6. Considered as the single most important risk
factor for stroke.
 Causes neuropathy, vasculopathy, retinopathy 7. Females are generally less prone to stroke
 Vascular complications are secondary to accelerated because of __________________.
atherogenesis, increased platelet aggregation and 8. Risk factor for stroke attributed to
prothrombotic state accelerated atherogenesis, increased platelet
 Recommend long-term, intensified control of glucose, aggregation and a prothrombotic state.
cholesterol, blood pressure which includes behavioral 9. After __ years, people who quit smoking have
significantly decreased risk for stroke.
modification and pharmacologic intervention to prevent
10. Type of stroke most likely to occur in
complication in Type I and Type II diabetes excessive alcohol intake.

SMOKING ---end of trans---

 Any kind of smoking increases stroke risk by 2.5
times

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