Types and clinical presentation of stroke

INTRODUCTION

Cerebrovascular disease is caused by one of several pathophysiologic processes involving the blood vessels of the brain. The process may be intrinsic to the vessel, as in atherosclerosis, lipohyalinosis, inflammation, amyloid deposition, arterial dissection, developmental malformation, aneurysmal dilation, or venous thrombosis.¹ The process may originate remotely, as occurs when an embolus from the heart or extra cranial circulation lodges in an intracranial vessel.² The process may result from inadequate cerebral blood flow due to decreased perfusion pressure or increased blood viscosity.³

The process may result from rupture of a vessel in the subarachnoid space or intracerebral tissue. The first three processes can lead to transient brain ischemia (transient ischemic attack [TIA]) or permanent brain infarction (ischemic stroke), while the fourth results in either subarachnoid haemorrhage or an intracerebral haemorrhage (primary haemorrhagic stroke).^4,5

The most important historical item for differentiating stroke subtypes is the pace and course of the symptoms and signs and their clearing. Each subtype has a characteristic course. Intracerebral haemorrhage (ICH) does not improve during the early period; it progresses gradually during minutes or a few hours. Embolic strokes most often occur suddenly.⁶ The deficits indicate focal loss of brain function that is usually maximal at onset. Rapid recovery also favors embolism. Thrombosis-related symptoms often fluctuate, varying between normal and abnormal or progressing in a stepwise or stuttering fashion with some periods of improvement.¹

Penetrating artery occlusions usually cause symptoms that develop during a short period of time, hours or at most a few days, compared with large artery-related brain ischemia, which can evolve over a longer period.

METHODS

This was cross sectional study performed on patients of Department of medicine, Nishtar Hospital Multan, Pakistan. This study was carried on patients of stroke admitted in above mentioned hospital from July 2019 to September 2019.Data was collected from patients after getting their consents.

Inclusion criteria

• • A case of non-traumatic stroke.

Exclusion criteria

• • Patients of traumatic brain injury.
• • Patients with CNS infection such as meningitis.

Total of 122 participants were involved in this study- 66 Male and 56 Female. All patients satisfying inclusion and exclusion criteria were included in study. This was a Cross-sectional study. All patients were subjected to a detailed history and thorough clinical examination after obtaining his/her informed consent. Investigations of CT head, Random blood sugar was done.

RESULTS

There were 66(54.1%) Male and 56(55.9%) Female. There were 74(60.6%) patients who were over the age of 60 years, 16(13.1%) patients were between 50-59 years of age, 12(9.8%) patients were between 40-49 years of age, 10(8.15%) patients were in the age of 30-39 years while 10(8.15%) were between 20-29 years of age (Figure 1).

Out of 66 Males, 44(66%) and 22(18%) had ischemic and haemorrhagic stroke respectively and out of 56 females, 42(34.2) had ischemic stroke while 14(11.5) had haemorrhagic stroke (Table 1). 110(90%) patients suffered stroke in the anterior circulation of brain while posterior circulation was involved in only 12(10%) patients.

Of all the patients (n=76) with ischemic stroke, 50(66%) had history of hypertension and 36(47.4%) had history of Diabetes Mellitus. In patients with haemorrhagic stroke (n=46), 14(30.4%) had diabetes and 34(74%) had history of hypertension (Table 2).

In this study, altered sensorium was present in 45.9% of ischemic stroke patients and 21.3% of haemorrhagic stroke. Vomiting was present only in patients of Haemorrhagic stroke. Hemiplegia (left sided more than right sided) was presented more in patients of ischemic stroke than in haemorrhagic stroke (Table 3).

Of all the patients (n=46) with haemorrhagic stroke, 38(82.6%) had high blood pressure at presentation while there were 32(42%) patients with ischemic stroke (n=76) had high BP. Total of 70(57.4) patients had high BP at presentation (Figure 2).

Hyperglycaemia was present in 44 of ischemic stroke patients and 32 of haemorrhagic patients (Figure 3).

DISCUSSION

Stroke is the second leading cause of death worldwide, and the leading cause of acquired disability in adults in most regions.⁷ Countries of low and middle income have the largest burden of stroke, accounting for more than 85% of stroke mortality worldwide.⁷ Men have a higher prevalence of stroke than women. Prevalence of ischemic stroke is higher than that of haemorrhagic stroke. Early CT scan is necessary to differentiate the two types of stroke that will help guide therapy. The treatment of ischemic stroke is anticoagulants which are contraindicated in haemorrhage that`s why distinction between the two types of stroke is important.

Hypertension is the most prevalent risk factor for stroke, based on data from 30 studies, has been reported in about 64% of patients with stroke.^7,8 Hypertension is associated with both types of these stroke. Consistent with previous studies, this findings showed that hypertension was the most important risk factor for all stroke subtypes. This leads us to believe that hypertension is underdiagnosed and less treated in this study community due to lack of an active screening program, failure to take routine blood pressure measurement, poor medical history taking and poor follow up of the patients.⁷

According to study by Alemayehu et al, infarction is the most common type of stroke events in diabetic individuals (57.7%).⁹ In this study the prevalence of DM was 41%.

Smoking was seen more in patients with ischemic stroke than in hemorrhagic which is consistent with other studies.⁷ The majority of smokers develop stroke due to atherosclerosis and smoking may predispose blood vessels to thrombosis and facilitates platelets aggregation possibly by causing an imbalance between brain vascular coagulation and abnormal fibrinolysis. This might alter the function of blood brain barrier and disrupt normal endothelial cell.

Similar to this finding, study by Kuriakose et al, reported that vomiting favors hemorrhagic stroke. This may be one indicator of stroke diagnosis based on clinical where brain imaging is not available.¹⁰

Hemiplegia was one of the common presentation in this study which is consistent with.¹¹ where patients that suffered from hemiplegic deficit are 58.8%, and those suffered from asphyxia are 16%. Aphasia was one common presentation in this study compared to other previous studies.⁸

Majority of the patients had high blood sugar at presentation. Careful management of hyperglycemia is important in this phase as studies found that hyperglycaemia and diabetes may be associated with an increased incidence of haemorrhagic transformation of ischemic infarcts.^11,12 Other studies, which did not confirm these findings, suggested that admission hyperglycaemia is a marker of extensive brain damage leading to a greater increase in stress hormones resulting in hyperglycemia.^13-15 This hyperglycaemia may be mediated partly by the release of cortisol and norepinephrine.

High blood pressure is common at the onset of stroke. Most of the studies, although not all, have found that high BP in the acute phase of stroke, whether measured as casual or 24 hours ambulatory readings, is associated with a poor outcome,^16-18 and an increased risk of death and dependency.^19-22

The acute hypertensive response seen in stroke has numerous potential causes including: fluctuations in, or elevation of, pre-existing hypertension; infection; pain, for example, due to urinary retention; stress related to hospitalization; activation of cortisol, natriuretic peptide, renin–angiotensin–aldosterone and sympathetic neuroendocrine systems; impaired cardiac baroreceptor sensitivity; and raised intracranial pressure (Cushing's reflex).

CONCLUSION

Stroke is a disabling disease. Two major types of stroke are Ischemic stroke and Haemorrhagic stroke. Ischemic stroke is more common than haemorrhagic stroke. Early symptoms of stroke are hemiparesis/hemiplegia, aphasia and altered sensorium, facial palsy, vertigo and headache. Vomiting favors haemorrhagic stroke. High blood pressure at onset is more common in haemorrhagic stroke. Hyperglycaemia in early phase is a common finding, however further studies should be conducted to assess the effects of high blood glucose on neurons in patients with stroke as it is associated with worse outcomes. Common risk factors associated with stroke are Hypertension, DM and smoking.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Andreucci M, Faga T, Serra R, De Sarro G, Michael A. Update on the renal toxicity of iodinated contrast drugs used in clinical medicine. Drug, Healthcare Patient Safety. 2017;9:25.
2. 2. Rieger J, Sitter T, Toepfer M, Linsenmaier U, Pfeifer KJ, Schiffl H. Gadolinium as an alternative contrast agent for diagnostic and interventional angiographic procedures in patients with impaired renal function. Nephrol Dialys Transplant. 2002 May 1;17(5):824-8.
3. 3. Thomsen HS. Gadolinium-or iodine-based contrast media: which choice?. Acta Radiologica. 2014 Sep;55(7):771-5.
4. 4. Erley CM, Bader BD, Berger ED, Tuncel N, Winkler S, Tepe G, et al. Gadolinium-based contrast media compared with iodinated media for digital subtraction angiography in azotaemic patients. Nephrol Dialys Transplant. 2004 Oct 1;19(10):2526-31.
5. 5. Caplan, LR. Brain embolism. In: Caplan, LR, Hurst, JW, Chimowitz, M, eds. Clinical Neurocardiology. New York: Marcel Dekker; 1999:35-185.
6. 6. Ay H, Furie KL, Singhal A, Smith WS, Sorensen AG, Koroshetz WJ. An evidence‐based causative classification system for acute ischemic stroke. Ann Neurol: Off J Am Neurol Assoc Child Neurol Soc. 2005 Nov;58(5):688-97.
7. 7. O'DonnellMJ X. LiuL. interstroke investigators. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the interstroke study): a case-control study. Lancet. 2010;376:112-23.
8. 8. Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circulation research. 2017 Feb 3;120(3):439-48.
9. 9. Alemayehu CM, Birhanesilasie SK. Assessment of stoke patients: occurrence of unusually high number of haemorrhagic stroke cases in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Clin Med Res. 2013;2(5):94-100.
10. 10. Kuriakose C, Shifafiya MN, Tharakan NS, Sattanathan K, Kumar RS. A prospective study of clinical profile of stroke in a tertiary care hospital. Asian J Pharm Clin Res. 2016;9(3):1-4.
11. 11. Beghi E, Bogliun G, Cavaletti G, Sanguineti I, Tagliabue M, Agostoni F, et al. Hemorrhagic infarction: risk factors, clinical and tomographic features, and outcome A case‐control study. Acta Neurologic Scandinav. 1989 Sep;80(3):226-31.
12. 12. Broderick JP, Hagen T, Brott T, Tomsick T. Hyperglycemia and hemorrhagic transformation of cerebral infarcts. Stroke. 1995 Mar;26(3):484-7.
13. 13. Murros K, Fogelholm R, Kettunen S, Vuorela AL, Valve J. Blood glucose, glycosylated haemoglobin, and outcome of ischemic brain infarction. J Neurologic Sci. 1992 Aug 1;111(1):59-64.
14. 14. Cox NH, Lorains JW. The prognostic value of blood glucose and glycosylated haemoglobin estimation in patients with stroke. Postgrad Medi J. 1986 Jan 1;62(723):7-10.
15. 15. Murros K, Fogelholm R, Kettunen S, Vuorela AL. Serum cortisol and outcome of ischemic brain infarction. J Neurologic Sci. 1993;116(1):12-7.
16. 16. Dandapani BK, Suzuki S, Kelley RE, Reyes-Iglesias Y, Duncan RC. Relation between blood pressure and outcome in intracerebral hemorrhage. Stroke. 1995 Jan;26(1):21-4.
17. 17. Robinson T, Waddington A, Ward-Close S, Taub N, Potter J. The predictive role of 24-hour compared to casual blood pressure levels on outcome following acute stroke. Cerebrovascul Dis. 1997;7(5):264-72.
18. 18. Carlberg B, Asplund K, Hägg E. The prognostic value of admission blood pressure in patients with acute stroke. Stroke. 1993 Sep;24(9):1372-5.
19. 19. Willmot M, Leonardi-Bee J, Bath PM. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension. 2004 Jan 1;43(1):18-24.
20. 20. Tikhonoff V, Zhang H, Richart T, Staessen JA. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol. 2009 Oct 1;8(10):938-48.
21. 21. Keezer MR, Amy YX, Zhu B, Wolfson C, Côté R. Blood pressure and antihypertensive therapy as predictors of early outcome in acute ischemic stroke. Cerebrovasc Diseases. 2008;25(3):202-8.
22. 22. Stead LG, Gilmore RM, Decker WW, Weaver AL, Brown RD. Initial emergency department blood pressure as predictor of survival after acute ischemic stroke. Neurol. 2005 Oct 25;65(8):1179-83.