Assessment of
Ischemic vs Hemorrhagic Stroke
Cynthia Bautista, PhD, RN, CNRN
Nursing Brains, LLC
Stroke

In the USA 795,000 new or recurrent
strokes

Represents 4th leading cause of death in
USA
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Ischemic vs Hemorrhagic

Ischemic stroke is 10x more frequent

Hemorrhagic stroke has higher mortality
risk
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Common risk factors
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Ischemic Stroke
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80% of all strokes
Blockage in blood vessel
Fatty deposits lining blood vessel wall
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Thrombosis (50%)
◦ Thrombi formed by plaque
◦ Greater than 50%stenosis

Embolism (30%)
◦ Cardiac emboli
◦ Atrial Fibrillation
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Cryptogenic Stroke
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30% of ischemic strokes
Infarct of undetermined cause
Hemispheral infarction
Average age 58
No risk factors
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Lacunar Stroke
25% of Ischemic strokes
Thrombosis of Lenticulostriate arteries
(small penetrating arteries)
 Predominate in basal ganglia
 Caused by hypertension and diabetes
 No treatment
 Risk factor management
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
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Hemorrhagic Stroke
20% of all strokes
 Rupture of leaking blood vessel

Intracerebral (ICH)
◦ High blood pressure
 Subarachnoid (SAH)
◦ Cerebral Aneurysm
◦ Arterial Venous Malformation
 Intraventricular (IVH)
◦ ICH and/or SAH
 Hemorrhagic transformation of ischemic infarct

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Ischemic Stroke
Risk Factors
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NonModifiable Risk Factors

Age
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Gender
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Race
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Prior Stroke
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Family History
◦ Risk of stroke doubles every decade after 55
◦ 55,000 more women than men have a stroke each year
◦ Men’s stroke incidence rates are greater than women ‘s at
younger ages
◦ African American have almost twice the risk of first ever
stroke compared to whites
◦ 5% chance of stroke/year, 10x higher
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Modifiable Risk Factors

High Blood Pressure
◦ Incidence of stroke increases with severity
◦ Goal ≤ 120/80 with risk factors

Diabetes
◦ Goal of Hgb A1C < 7%
◦ Pre-meal blood glucose 70-130mg/dl
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Modifiable Risk Factors (con’t)
 Tobacco
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use - #1 preventable cause
Ischemic and hemorrhagic stroke
Aggravates atherosclerosis
Raises blood pressure
50% reduction of risk with cessation
Counseling, nicotine products, oral smoking cessation
medications
Implement 5 A’s
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ASK about tobacco use
ADVISE to quit
ASSESS willingness to attempt to quit
ASSIST in the quit attempt
ARRANGE follow-up
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Modifiable Risk Factors (con’t)

Carotid Disease
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Atrial Fibrillation
◦ 50% of all embolic strokes
◦ Anticoagulation reduces risk by 68%

Cardiac Disease
◦ Routine screening
◦ Aggressive treatment

Sickle Cell Disease
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Modifiable Risk Factors (con’t)
High blood Cholesterol
 Poor diet
 Physical Inactivity
◦ Moderate intensity exercise ≥ 30 minutes
most days
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Obesity
◦ Weight reduction
◦ Maintain BMI < 25 kg/m2
◦ Waist circumference <40” men, < 35” women
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Modifiable Risk Factors (con’t)

Alcohol Use
◦ Men no more than 2 drinks/day
◦ Women no more than 1 drink/day
◦ Drink in moderation
 1.5 oz hard liquor
 4 oz wine
 12 oz beer
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Hemorrhagic Stroke
Risk Factors
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NonModifiable Risk Factors

Age

Gender

Race

Prior Stroke

Family History
◦ Risk of stroke doubles every decade after 55
◦ 55,000 more women than men have a stroke each year
◦ Men’s stroke incidence rates are greater than women ‘s at
younger ages
◦ African American have almost twice the risk of first ever
stroke compared to whites
◦ 5% chance of stroke/year, 10x higher
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Modifiable Risk Factors

High Blood Pressure
◦ Incidence of stroke increases with severity
◦ Goal ≤ 120/80 with risk factors
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Modifiable Risk Factors (con’t)
Tobacco
use
#1 preventable cause
◦ Raises blood pressure
◦ 50% reduction of risk with cessation
◦ Counseling, nicotine products, oral
smoking cessation medications
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Modifiable Risk Factors (con’t)

Alcohol Use
◦ Men no more than 2 drinks/day
◦ Women no more than 1 drink/day
◦ Drink in moderation
 1.5 oz hard liquor
 4 oz wine
 12 oz beer
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Modifiable Risk Factors (con’t)

Drug Abuse
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Occurs first time or long-term user
Amphetamines, cocaine, heroin
Hypertension
Intracerebral Hemorrhage
Screen
Rehabilitation
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Ischemic Stroke Presentation
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Left (Dominant Hemisphere)
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Left gaze preference
Right visual field deficit
Right hemiparesis
Right hemisensory loss
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Right (Nondominant Hemisphere)
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Right gaze preference
Left visual field deficit
Left hemiparesis
Left hemisensory loss
◦ Neglect (left hemi-inattention)
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Brainstem Stroke Syndrome
 Decreased consciousness
 Diplopia, dysconjugate gaze, gaze
 Hemiparesis or quadriplegia
 Sensory loss in hemibody or all 4
 Dysarthria
 Dysphagia
 Vertigo, tinnitus
 Nausea/vomiting
 Abnormal respirations
palsy
limbs
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Cerebellum Stroke Syndrome
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Gait ataxia
Limb ataxia
Neck stiffness
Nystagmus
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Warning Signs of Stroke
Think F-A-S-T
 F = FACE numbness or weakness especially
one side of body
 A = ARM numbness or weakness one side of
body
 S = SPEECH slurred or difficulty speaking or
understanding
 T = TIME to immediately call 9-1-1 and note
time symptoms started or last time person was
seen normal
Hemorrhagic Stroke
Presentation
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Hemorrhage Stroke Syndromes
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Decreased level of consciousness
Focal neurological deficits
Headache
Neck pain
Light intolerance
Nausea, vomiting
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Level of Consciousness
Glasgow Coma Scale
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Eye Opening
◦ 4 - Spontaneous
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Motor Response
◦ 6 - Obeys Commands
◦ 3 - To Speech
◦ 2 - To Pain
◦ 1 - None
◦ 5 - Localizes
◦ 4 - Withdraws
◦ 3 - Abnormal Flexion
Verbal Response
◦ 5 - Oriented
◦ 4 - Confused
◦ 2 - Abnormal Extension
◦ 1 -None
◦ 3 - Inappropriate Words
◦ 2 - Inappropriate Sounds
◦ 1 - None
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Warning Signs of Stroke
“Give Me 5”
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Give Me 5 quick stroke check:
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Walk – Is their balance off?
Talk – Is their speech slurred or face droopy?
Reach – Is one side weak or numb?
See – Is their vision all or partly lost?
Feel – Is their headache severe?
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Ischemic Stroke Imaging
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Early CT Finding
Hypodensity
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Infarction – darker area
Obscures gray white matter contrast
Effacement of sulci or
loss of insular ribbon
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Early CT Finding
Hyperdense Middle Cerebral Artery
Sign (HDMCA)
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Observed in 50% MCA occlusions
Development of large infarct
Poor clinical outcomes
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CT Technologies
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CT Angiographey
◦ Details vessels
◦ Large vessel occlusions
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CT Perfusion
◦ Tracks arterial blood in brain
◦ Perfusion maps
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Multimodal CT (CT, CTA, CTP)
◦ Detects absence of hemorrhage
◦ Presence of ischemia
◦ Vascular anatomy/perfusion deficits
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MRI
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Magnetic energy
DWI
◦ Abnormal within 7 minutes of onset
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Gradient Recalled Echo (GRE)
◦ Detects hemorrhage
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Fluid attenuated inversion recovery (FLAIR)
and T2-weighted
◦ Evolving infarction
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Perfusion-weighted Images (PWI)
◦ Abnormal flow
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DWI and PWI
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DWI (Diffusion-Weighted Imaging)
◦ Ischemic region within minutes
◦ Lesion size, site, age
◦ Detects random movements of water protons
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PWI (Perfusion-Weighted Imaging)
◦ Hemodynamic status
◦ Provides information regarding cerebral blood flow
◦ Extremely sensitive to cerebral ischemia
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Same lesion size and location are matched
Larger PWI lesions are mismatched
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Carotid Ultrasound
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Inexpensive, safe
Non-invasive screen
Blood velocity
Patient that cannot receive contrast or MRA
90% sensitivity and specificity
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Digital Subtraction Angiography
(DSA)
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Gold Standard for cerebral vasculature
Degree of stenosis
Provides interventions
◦ Thrombolytics
◦ Thrombectomy
◦ Angioplasty and stenting
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Echocardiogram
Transthoracic
 Noninvasive utilizing
sound waves
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Transesophageal
Combines
ultrasonography &
endoscopy
Image posterior of the heart
Heart structures
Clots, valves, PFO, LV
function
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Hemorrhagic Stroke Imaging
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Early CT Finding
Hyperdensity
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Hemorrhage appears white
Petechial is scattered hyperdense points
Hematoma is solid, homogenously
hyperdense legion
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Predicting ICH Expansion
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Spot sign on CTA
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MRA
Extracranial & intracranial cerebral circulation
abnormalities
 86% sensitivity 98% specificity
 Aneurysm detection 95% sensitivity
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Transcranial Doppler (TCD)
Safe, inexpensive
Flow of blood through arteries of the brain
High frequency sound waves pass through
tissue
 Detects, monitors stenosis, vasospams,
reperfusion
 Concern with
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◦ Velocity of >120
◦ Lindegaard ration > 3
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Stroke Case Studies
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Case Presentation #1
T.E. is a 39 year old Caucasian man who works in
construction. Ten years ago he had a myocardial
infarction, EF 45% with apical akenesis and an
intraventricular thrombus (was on warfarin).
Has a history of TIAs, hypercholesterolemia and
smokes 2-3 packs per day.
He left his house about 8:15PM and was found
lying on the sidewalk. People passing by called 91-1.
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Case Presentation #1 (con’t)
At 8:45 PM T.E. was weak on the RIGHT
side, unable to speak, and had a LEFT gaze
deviation.
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Case Presentation #2
Mr. A. is a 41 year old African American, obese,
male, with hypertension and a history of
CABG 10 years ago. He went to the
bathroom at about 3:55PM. His family heard a
load noise coming from the bathroom. He was
found by his family lying in the shower at 4PM.
He was unable to talk and weak on the
RIGHT side. They called 9-1-1.
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Case Presentation #3
53 year old male (WR) was in a car accident in
which he could not see oncoming traffic. He
was having piercing headache in his right
occiput. He took ASA 325mg with no relief. He
was at work when the symptoms started, went
home, and then was driving to the bank with
his girlfriend when he crashed his car into the
side of the road. His family picked him up and
brought him to the ED.
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Case Presentation #3 (con’t)
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Construction worker
History of diabetes and hypertension
Medications: lisinopril, glipizide, metformin, ASA
Quit smoking 4 years ago
Drinks 6 pack of beer on the weekends
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Case Presentation #3 (con’t)
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Upon arrival to ED …
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NIHSS = 2 (LEFT hemianopsia)
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BP 211/118
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Glucose 247
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Case Presentation #4
MM is a 60 year old female who was at the gym
on an elliptical machine when she experienced
the “worst headache of her life”. She went into
the restroom with her sister where she began to
vomit. Her sister called 9-1-1
She has a history of hypertension and her cousin
died of a ruptured cerebral aneurysm
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Case Presentation #5
D.B. is a 75 year old Caucasian man in good
health. He quit smoking over 30 years ago
and has no family history of stroke. He has
not seen a physician in over 40 years.
He was taking his family to McDonalds for
lunch. After leaving the drive thru window
he began to drive erratically over curbs and
islands. D.B. had a sudden onset of right
facial droop, right arm weakness, and
difficulty speaking.
His daughter got him to stop the car and she
called 9-1-1.
Case Presentation #6
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A 57-year-old female (CB) last spoke to
her relatives on Sunday. She did not
answer her phone on Monday. The
landlady entered her apartment on
Thursday and found her lying face down
on floor of living room covered in vomit
and feces. Landlady called 9-1-1
Case Presentation #6
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Pre Hospital
◦ Vital signs 149/94 – 79 – 20, 99.3, pulse
oxygenation 98%
◦ Not moving right side
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Emergency Room
◦ 162/83 – 87 – 20
◦ Pupils equal react to light
◦ Opens eyes, difficult to remain awake
Case Presentation #6
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History of chronic atrial fibrillation
Coumadin started in 2007
Noncompliant
Sub therapeutic INR
Patient on ASA only
Case Presentation #7
83 year old man (JP) fell at home x2 last
night. He was able to getup on his own
after the first fall, unable to getup after 2nd
fall. According to wife, JP began acting
abnormal (asking strange questions, using
inappropriate words). Wife dragged JP
from living room to bedroom. They slept
together on the floor in the bedroom.
Case Presentation #7 (con’t)
In the morning the wife was unable to
wake JP up and called 9-1-1
 JP had right sided weakness, right facial
droop
 History of TIA, CAD, hypertension
 Pre Hospital

◦ 198/80 – 93 – 20 Pulse oxygenation 95%
Questions????
Cindy Bautista
cabbrain@aol.com