Stroke

[Audio] Stroke Khazaei Mojtaba , MD, associated professor of neurology . Hamedan Medical University , Neurovascular specialist.

[Audio] Learning Objectives By the end of this session, students should be able to: Define stroke and distinguish ischemic vs hemorrhagic types. Describe risk factors and pathophysiology. Understand acute clinical presentation and stroke syndromes. Outline the diagnostic workflow (CT/MRI, labs, vascular imaging). Explain acute management including thrombolysis and thrombectomy. Summarize secondary prevention strategies. Understand basic epidemiology including Iranian stroke data..

[Audio] Definition of Stroke Stroke is a sudden loss of neurological function caused by an interruption of blood supply to the brain. Two main types: Ischemic stroke (≈85%) Due to vessel occlusion → reduced cerebral blood flow. Hemorrhagic stroke (≈15%) Due to vessel rupture → intracerebral or subarachnoid bleeding. TIA (Transient Ischemic Attack): Focal neurological deficit lasting <1 hour with no infarction on imaging..

[Audio] Epidemiology 1. Incidence and Epidemiologic Burden in Iran Current estimates suggest that the annual incidence of stroke in Iran ranges between 150–200 per 100,000 population, placing the country among the highest-burden regions in the Middle East and higher than many Western countries (e.g., Western Europe ~100–150 per 100,000). This elevated incidence is partly attributed to: Higher prevalence of hypertension, diabetes, and metabolic syndrome Younger population structure with emerging vascular risk Gaps in national stroke registry systems leading to regional variability Differences in access to acute stroke centers.

[Audio] Etiologic Stroke Distribution in Iran Based on your center’s data and available Iranian studies, the etiologic breakdown is as follows: • Large-Vessel Atherosclerotic Stroke: ~20% This proportion is comparable to many Western cohorts (15–25%). However, Iran tends to have: Earlier onset of extracranial carotid atherosclerosis Higher prevalence of intracranial atherosclerotic disease (ICAD) compared to Europe Strong association with poorly controlled hypertension & hyperlipidemia.

[Audio] Etiologic Stroke Distribution in Iran • Cardioembolic Stroke: ~30% This is slightly higher than Western figures (20–25%) and reflects: Increasing prevalence of atrial fibrillation (often undiagnosed or undertreated) Presence of rheumatic valvular disease in certain regions Lower anticoagulation adherence.

[Audio] Etiologic Stroke Distribution in Iran • Cryptogenic Stroke: ~20% This percentage is in line with global estimates (20–30%). Contributing factors include: Limited prolonged cardiac monitoring Underdiagnosis of paroxysmal AF Variability in access to high-resolution imaging.

[Audio] Lacunar / Small-Vessel Stroke: ~20–30% This proportion is similar to global trends (15–30%) but tends to be on the higher side in Iran. Reasons include: Very high prevalence of long-standing hypertension High burden of diabetes mellitus Delayed control of vascular risk factors.

[Audio] Comparison With Western and Regional Patterns Comparison With Western and Regional Patterns Etiology Iran Western Countries Middle East Region Large Vessel ~20% 15–25% ~20–30% Cardioembolic ~30% 20–25% ~25–35% Cryptogenic ~20% 20–30% 20–30% Lacunar 20–30% 15–25% 20–35%.

[Audio] Interpretation and Clinical Implications High cardioembolic proportion (~30%) → Emphasizes the need for wider AF screening, especially prolonged Holter monitoring and better anticoagulation strategies. Significant small-vessel stroke burden (20–30%) → Reinforces importance of strict hypertension and diabetes control at the community level. Large-vessel atherosclerosis at 20% → Indicates the need for: nationwide smoking cessation efforts earlier screening for carotid and intracranial stenosis consistent use of statins and lifestyle modification Cryptogenic stroke (~20%) → May decrease with improved diagnostic workup such as long-term cardiac monitoring, TEE, and advanced vascular imaging..

[Audio] Summary for Presentation Iran’s stroke incidence is high (150–200/100,000), above many developed nations. Etiologic distribution is balanced and reflects a combination of: Atherosclerotic disease (20%) Cardioembolism (30%) Cryptogenic causes (20%) Small-vessel disease (20–30%) Clinical practice should prioritize AF detection, vascular risk factor control, and early carotid/intracranial imaging..

[Audio] Pathophysiology schemic stroke Occlusion of artery → drop in perfusion → energy failure Ion pump dysfunction → cytotoxic edema Glutamate excitotoxicity → neuronal death Ischemic core: irreversible damage Penumbra: hypoperfused but salvageable tissue → target for reperfusion therapy.

[Audio] Hemorrhagic stroke Vessel rupture → hematoma expansion Mass effect + increased ICP → secondary injury.

[Audio] Stroke Risk Factors Non-modifiable Age Sex Genetics Ethnicity Modifiable Hypertension (most important) Diabetes Hyperlipidemia Smoking Atrial fibrillation Obesity Physical inactivity Carotid disease Heavy alcohol use.

[Audio] Clinical Presentation Common symptoms Hemiparesis / hemisensory loss Aphasia or dysarthria Visual field defects Vertigo / ataxia Difficulty walking Sudden severe headache (SAH).

[Audio] FAST: Face drooping Arm weakness Speech difficulty Time to call emergency services.

[Audio] Stroke Syndromes Middle Cerebral Artery (MCA) Contralateral weakness (arm > leg) Aphasia (dominant hemisphere) Neglect (non-dominant) Anterior Cerebral Artery (ACA) Leg > arm weakness Abulia Urinary incontinence Posterior Circulation Vertigo, ataxia Diplopia Dysarthria Crossed signs LOC (basilar occlusion).

[Audio] Diagnostic Workflow Time is brain → Treat stroke as a medical emergency. Immediate steps ABCs Blood glucose Rule out mimics (seizure, migraine, hypoglycemia).

[Audio] Imaging Non-contrast CT → rule out hemorrhage Door-to-CT target: ~20 minutes CT angiography → detect large-vessel occlusion MRI DWI → most sensitive for ischemia Perfusion imaging → identify penumbra.

[Audio] Labs CBC Coagulation Electrolytes Glucose Cardiac enzymes.

[Audio] Acute Treatment 1) IV Thrombolysis (Alteplase / tPA) Standard window: 0–4.5 hours Exclude bleeding on CT Dose: 0.9 mg/kg (10% bolus, 90% infusion) Outcomes: Mortality after tPA ≈ 1% (My center data) Symptomatic ICH ≈ 6% My center metrics (Hamadan): Door-to-CT: 20 min Door-to-Needle: 60 min.

[Audio] Mechanical Thrombectomy Indications: Large-vessel occlusion (ICA / MCA M1 / Basilar) Perform within 0–6 hours, selected patients up to 24 hours Methods: Aspiration thrombectomy (≈90% at My center) Stent-retriever + aspiration Intra-arterial thrombolysis (up to 20 mg) My center: Door-to-groin time: 120 min Combined IV tPA + thrombectomy is the protocol if within window Direct thrombectomy when IV tPA window has passed.

[Audio] Post-Stroke Management In-hospital care BP control Fever control Maintain oxygenation DVT prophylaxis Swallow test Monitor for complications Rehabilitation Start early Multidisciplinary team Improves functional recovery.

[Audio] Follow-up My center uses: mRS at discharge mRS at 3 months mRS at 6 months Yearly follow-up.

[Audio] Secondary Prevention Ischemic Stroke Antiplatelets (ASA, clopidogrel) Anticoagulation for AF Statins Blood pressure control Diabetes control Smoking cessation Weight and diet management.

[Audio] Hemorrhagic Stroke BP control Reversal of anticoagulants Neurosurgical evaluation Manage ICP.

[Audio] Than you for your attention. Than you for your attention.