Overview of Ischemic and Hemorrhagic Stroke | Clinical Neurology
Overview of Ischemic and Hemorrhagic Stroke | Clinical Neurology
This video “Overview of Ischemic and Hemorrhagic Stroke” is part of the Lecturio course “Clinical Neurology” ► WATCH the complete course on http://lectur.io/clinicalneuro
► LEARN ABOUT:
► causes of ischemic and hemorrhagic strokes
► diagnostic tests used in the evaluation of a patient with stroke
► risk factors for ischemic stroke
► treatment modalities used in the treatment of stroke
► THE PROF:
Roy Strowd is the Assistant Dean of Undergraduate Medical Education at the Wake Forest Baptist Medical Center, where he co-directs the Neurofibromatosis and Tuberous Sclerosis Clinics. He is a researcher for the Adult Brain Tumor Consortium (ABTC) and Alliance for Clinical Trials in Neuro-Oncology.
► LECTURIO is your single-point resource for medical school:
Study for your classes, USMLE Step 1, USMLE Step 2, MCAT or MBBS with video lectures by world-class professors, recall \u0026 USMLE-style questions and textbook articles. Create your free account now: http://lectur.io/medicalpremium
► INSTALL our free Lecturio app
iTunes Store: https://app.adjust.com/z21zrf
Play Store: https://app.adjust.com/b01fak
► SUBSCRIBE to our YouTube channel: http://lectur.io/subscribe
► WATCH MORE ON YOUTUBE: http://lectur.io/playlists
► LET’S CONNECT:
• Facebook: https://www.facebook.com/lecturio.med…
• Instagram: https://www.instagram.com/lecturio_me…
#medicaleducation #medicalstudents #clinicalneurology
Content
0.806 -> Let's now do a quick summary of ischemic stroke and hemorrhagic stroke.
5.746 -> We're going to hit the highlights for the causes,
8.188 -> the diagnostic workup and treatment for each of these two major types of stroke.
12.81 -> In subsequent lectures, we'll dive deep in to each of these.
16.074 -> Here, we're going to go some tables that hit the highlights.
19.528 -> When I think about ischemic stroke, I think of five major causes.
24.217 -> We can see ischemia or a blood clot reduction in blood flow
29.301 -> to a part of the brain from thromboembolism,
32.068 -> intracranial atherosclerosis, lacunar infarcts, watershed ischemia,
38.123 -> and embolism or cardio embolism,
40.69 -> and those five causes are what we evaluate in patients
43.558 -> or the clinical vignettes when we're evaluating for an ischemic stroke.
48.202 -> As we look at those, the different types of stroke lead to different symptom presentations
53.658 -> and size of lesions on CT scans and MRI scans.
58.555 -> Our embolic strokes, cardioembolic strokes and thromboembolic strokes
63.467 -> result from a blood clot either in the heart or the carotid arteries
67.652 -> that dislodges and travels up to the brain.
70.931 -> Those are typically larger clots and they lodge in larger blood vessels.
75.91 -> We often see larger territory strokes on imaging,
78.888 -> larger territory of stroke in terms of the patient's symptoms and exam findings,
83.792 -> and this large territory ischemic lesions tip us off to be worried about an embolic phenomenon,
90.185 -> and you can see that here in this large territory.
93.01 -> Atherosclerotic disease are hardening of the blood vessels.
96.716 -> Plaques, atherosclerotic plaques or atheroma, that form on the blood vessels,
101.552 -> can form anywhere in the cerebrovascular system,
104.787 -> out in the distal blood vessels, or the medium sized blood vessels
108.588 -> or even the proximal major blood vessels in the brain.
112.434 -> So we can see strokes of any sizes that we tend to see moderate territory strokes
116.842 -> in the anteroposterior circulation, anywhere in the brain,
120.17 -> and so atherosclerosis is a common risk factor
122.8 -> we're evaluating an etiology we would be considering.
126.378 -> Lacunar strokes are small vessel strokes.
129.823 -> A lacuna is an island, and this is an island of stroke deep in the brain,
134.261 -> often in the subcortical gray matter or sometimes white matter tracks.
138.502 -> These small strokes form on small blood vessels, the perforators.
143.511 -> We think about the thalamus stripe perforators
146.258 -> and other small vessels in and around the brain that can lead to lacunar strokes.
150.889 -> And long standing hypertension is an important risk factor that we'll talk about.
154.568 -> And then the last type of stroke is the watershed stroke.
157.344 -> This doesn't come from a blood clot, it's the one ischemic stroke
160.518 -> that's not from a clot in the blood vessel, but from reduced blood flow.
164.626 -> And we see this in areas where vascular blood beds are collateralizing,
169.131 -> so it's at those collateral watershed territories
172.576 -> in between major vessels that are supplying the brain.
176.442 -> When we think about the diagnostic workup, we're working up each of those major causes.
181.638 -> We'll do carotid ultrasounds to look at the blood vessels
186.015 -> going to the brain or transcranial doppler to look at the blood vessels within the brain.
190.892 -> Transthoracic echo cardiography is done to evaluate the heart
194.438 -> and look for a patent Foramen Ovale, as well as blood testing like a thyroid study
198.813 -> and EKGs to look for paroxysmal atrial fibrillation.
202.392 -> Stroke risk factor modification is important and we evaluate cholesterol.
206.785 -> low density and high density lipoprotein,
209.911 -> as well as hemoglobin A1c which are important risk factors for the development of stroke.
214.413 -> And rehab is critically important for recovery for any patient who's had a stroke
218.866 -> and that includes physical, occupational, speech therapy and aggressive rehab.
223.453 -> So those are the types of diagnostic test
225.127 -> and management that we'll do to help patients evaluate the cause of their strokes
229.958 -> and begin their recovery process.
232.478 -> Ultimately, treatment is critical and we want to prevent the next stroke.
236.235 -> Primary prevention of stroke is to prevent the stroke before it's occurred,
240.013 -> and secondary prevention is to prevent the next stroke once one has.
244.155 -> We think about antiplatelet agents like aspirin, Plavix, Aggrenox.
248.23 -> We'll learn about each of those.
249.951 -> We also think about anticoagulation, Coumadin, Lovenox,
253.562 -> and some of the direct oral anticoagulant medications or antithrombotic medications.
259.54 -> What about the a hemorrhagic stroke?
262.198 -> What's the sort of summary, the things we should consider
264.839 -> when we're thinking about hemorrhagic stroke?
267.447 -> Well, again, just as there's five causes of an ischemic stroke there are five causes
271.762 -> that I want you to think about for hemorrhagic stroke.
275.484 -> Hypertensive hemorrhage is the most common cause of hemorrhagic stroke.
279.56 -> Hemorrhagic transformation of ischemic stroke
282.565 -> is something we'll talk about in greater detail in understanding when that may occur,
286.989 -> but hemorrhage can happen after an ischemic stroke.
289.885 -> Certain brain tumors, brain metastases, as well as primary gliomas can hemorrhage.
294.47 -> Vascular malformations in the brain including arteriovenous malformations
299.089 -> and aneurysms can burst and bleed.
302.131 -> And then amyloid angiopathy is a degenerative condition.
305.548 -> Patients can develop amyloid dementia
308.104 -> and we also can see leaking of the blood vessels in that condition,
311.962 -> and a risk of lobar hemorrhage.
313.971 -> Again, when we think about the types of hemorrhagic stroke,
317.889 -> there are two basic types of hemorrhagic stroke,
320.276 -> there's intracerebral or intraparenchymal hemorrhage and subarachnoid hemorrhage.
325.584 -> The hypertensive hemorrhage, the hemorrhagic transformation of a stroke,
329.366 -> the tumors, and the amyloid angiopathy,
332.097 -> those four causes all present with intraparenchymal or intracerebral hemorrhage.
337.519 -> Aneurysms, are the etiology that really present with subarachnoid hemorrhage,
342.984 -> those two causes of intracerebral, excuse me, those two causes of hemorrhagic stroke.
348.561 -> What do we do from a diagnostic standpoint for hemorrhagic stroke
352.128 -> is quite different from that for the ischemic stroke.
354.959 -> With ischemic strokes we're looking why the clot may be there.
358.303 -> With hemorrhage, it's happened and we're making sure it doesn't get worse.
362.431 -> Patients undergo a non-contrast head CT somewhere between 6 and 24 hours
367.867 -> to make sure the bleeding isn't expanding
369.702 -> and the patient doesn't require further intervention.
372.332 -> MRI may be considered if we're looking for a tumor.
375.392 -> Vascular imaging or angiography, some type of non-invasive or invasive angiography,
380.869 -> can look for a vascular lesion, and we look to manage blood pressure
384.473 -> to reduce the risk of further expansion of that hemorrhage.
388.814 -> And then treatments are also very different.
390.805 -> So when we juxtapose the treatment for ischemic stroke and hemorrhagic stroke,
394.261 -> with ischemic stroke we're adding antiplatelets and anticoagulants;
398.05 -> with hemorrhagic stroke we're taking those away.
400.482 -> There's nothing we can do to stop that hemorrhage that's occurred,
403.467 -> but we want to prevent its expansion.
406.276 -> We hold the anti-thrombotic, we stop anticoagulants.
409.543 -> We don't use those for prophylaxis for patients who are in the hospital
413.494 -> and we would use things like sequential compression devices as you see here.
417.399 -> And some patients may develop seizures,
419.239 -> so we're managing those potential side effects particularly in seizures,
422.658 -> excuse me, in hemorrhage, that involve the outer cortical surface in gray matter.
426.985 -> So this important summary gives us an idea of the things we need to be thinking about,
430.807 -> and we'll dive in to greater detail into each of these details.
Source: https://www.youtube.com/watch?v=E8gctxjBCtA