strokestrokeis the clinical term for acute loss of is the clinical term for acute loss of circulation to an area of the brain, circulation to an area of the brain, resulting in ischemia and a resulting in ischemia and a corresponding loss of neurologic corresponding loss of neurologic functionfunction. . Classified as either Classified as either hemorrhagic or ischemichemorrhagic or ischemic, ,

strokes typically manifest with the acute strokes typically manifest with the acute onset of focal neurologic deficits, such as onset of focal neurologic deficits, such as weakness, sensory deficit or speech weakness, sensory deficit or speech difficultiesdifficulties . .

Ischemic strokes have a heterogeneous Ischemic strokes have a heterogeneous group of causes, including thrombosis, group of causes, including thrombosis, embolism, and hypoperfusion, whereas embolism, and hypoperfusion, whereas hemorrhagic strokes can be either hemorrhagic strokes can be either intraparenchymal or subarachnoidintraparenchymal or subarachnoid

PathophysiologyPathophysiology

The brain is the most metabolically The brain is the most metabolically active tissue in the bodyactive tissue in the body . .

While representing only 2% of the While representing only 2% of the body's mass, it requires 15-20% of body's mass, it requires 15-20% of the total resting cardiac output to the total resting cardiac output to provide the necessary glucose and provide the necessary glucose and oxygen for its metabolismoxygen for its metabolism . .

Ischemic strokes result from events that Ischemic strokes result from events that limit or stop blood flow, such as limit or stop blood flow, such as embolism, thrombosis in situ, or embolism, thrombosis in situ, or relative hypoperfusionrelative hypoperfusion . .

As blood flow decreases, neurons cease As blood flow decreases, neurons cease functioning, and irreversible neuronal functioning, and irreversible neuronal ischemia and injury begin at blood flow ischemia and injury begin at blood flow rates of less than 18 mLrates of less than 18 mL//100 mg100 mg//minmin

Ischemic cascadeIschemic cascade

The processes involved in stroke injury at The processes involved in stroke injury at the cellular level are referred to as the the cellular level are referred to as the ischemic cascadeischemic cascade . .

Within seconds to minutes of the loss of Within seconds to minutes of the loss of glucose and oxygen delivery to neurons, glucose and oxygen delivery to neurons, the cellular ischemic cascade beginsthe cellular ischemic cascade begins..This is a complex process that begins with This is a complex process that begins with cessation of the electrophysiologic cessation of the electrophysiologic function of the cellsfunction of the cells . .

The resultant neuronal and glial injury The resultant neuronal and glial injury produces edema in the ensuing hours to produces edema in the ensuing hours to days after stroke, causing further injury to days after stroke, causing further injury to the surrounding neuronal tissuesthe surrounding neuronal tissues

Ischemic penumbraIschemic penumbra

An acute vascular occlusion produces An acute vascular occlusion produces heterogeneous regions of ischemia in the heterogeneous regions of ischemia in the dependent vascular territorydependent vascular territory . .

The quantity of local blood flow is comprised The quantity of local blood flow is comprised of any residual flow in the major arterial of any residual flow in the major arterial source and the collateral supply, if anysource and the collateral supply, if any . .

Regions of the brain without significant flow Regions of the brain without significant flow are referred to collectively as the core, and are referred to collectively as the core, and these cells are presumed to die within these cells are presumed to die within minutes of stroke onsetminutes of stroke onset . .

Zones of decreased or marginal perfusion are Zones of decreased or marginal perfusion are collectively called the ischemic penumbracollectively called the ischemic penumbra . .

Tissue in the penumbra can remain viable for Tissue in the penumbra can remain viable for several hours because of marginal tissue several hours because of marginal tissue perfusion, and currently studied perfusion, and currently studied pharmacologic interventions for pharmacologic interventions for preservation of neuronal tissue target this preservation of neuronal tissue target this penumbrapenumbra

Mechanisms of strokeMechanisms of stroke

--Embolic strokesEmbolic strokes

Emboli may either be of cardiac or Emboli may either be of cardiac or arterial originarterial origin. . Cardiac sources Cardiac sources include:atrial fibrillation, recent include:atrial fibrillation, recent myocardial infarction myocardial infarction ((1-3% of all 1-3% of all acute myocardial infarctions acute myocardial infarctions [[AMIsAMIs])]), , prosthetic valves, native valvular prosthetic valves, native valvular disease, endocarditis, mural thrombi, disease, endocarditis, mural thrombi, dilated cardiomyopathy, or patent dilated cardiomyopathy, or patent foramen ovale allowing passage of foramen ovale allowing passage of venous circulation embolivenous circulation emboli . .

Arterial sources are atherothrombolic or Arterial sources are atherothrombolic or cholesterol emboli that develop in the cholesterol emboli that develop in the arch of the aorta and in the arch of the aorta and in the extracranial arteries extracranial arteries ((ie, carotid and ie, carotid and vertebral arteriesvertebral arteries). ). Embolic strokes Embolic strokes tend to have a sudden onset, and tend to have a sudden onset, and neuroimaging may demonstrate neuroimaging may demonstrate previous infarcts in several vascular previous infarcts in several vascular territoriesterritories

--Thrombotic strokesThrombotic strokes

Thrombotic strokes include largeThrombotic strokes include large--vessel vessel strokes strokes ((70%70%) ) and smalland small--vessel or lacunar vessel or lacunar strokes strokes ((30%30%)) . .

They are due to in situ occlusions, They are due to in situ occlusions, characteristically on atherosclerotic characteristically on atherosclerotic lesions in the carotid, vertebrobasilar, and lesions in the carotid, vertebrobasilar, and cerebral arteries, typically proximal to cerebral arteries, typically proximal to major branchesmajor branches. . Thrombogenic factors Thrombogenic factors include injury to and loss of endothelial include injury to and loss of endothelial cells exposing the subendothelium and cells exposing the subendothelium and platelet activation by the subendothelium, platelet activation by the subendothelium, activation of the clotting cascade, activation of the clotting cascade, inhibition of fibrinolysis, and blood stasisinhibition of fibrinolysis, and blood stasis

Thrombotic strokes are thought to originate on Thrombotic strokes are thought to originate on ruptured atherosclerotic plaquesruptured atherosclerotic plaques . .

Intracranial atherosclerosis may be the cause in Intracranial atherosclerosis may be the cause in patients with widespread atherosclerosispatients with widespread atherosclerosis..In other patients, especially younger patients, other In other patients, especially younger patients, other causes should be considered, including causes should be considered, including coagulation disorders coagulation disorders ((eg, antiphospholipid eg, antiphospholipid antibodies, protein C deficiency, protein S antibodies, protein C deficiency, protein S deficiencydeficiency)), sickle cell disease, fibromuscular , sickle cell disease, fibromuscular dysplasia, arterial dissections, and dysplasia, arterial dissections, and vasoconstriction associated with substance abusevasoconstriction associated with substance abuse

--Lacunar strokeLacunar stroke

Lacunar strokes represent 20% of all ischemic Lacunar strokes represent 20% of all ischemic strokesstrokes . .

They occur when the penetrating branches of They occur when the penetrating branches of the middle cerebral artery the middle cerebral artery ((MCAMCA)), the , the lenticulostriate arteries, or the penetrating lenticulostriate arteries, or the penetrating branches of the circle of Willis, vertebral branches of the circle of Willis, vertebral artery, or basilar artery become occludedartery, or basilar artery become occluded . .

Causes of lacunar infarcts include Causes of lacunar infarcts include microatheroma, lipohyalinosis, fibrinoid microatheroma, lipohyalinosis, fibrinoid necrosis secondary to hypertension or necrosis secondary to hypertension or vasculitis, hyaline arteriosclerosis, and vasculitis, hyaline arteriosclerosis, and amyloid angiopathyamyloid angiopathy . .The great majority are related to hypertensionThe great majority are related to hypertension . .Of all stroke types, lacunar strokes have the Of all stroke types, lacunar strokes have the best prognosisbest prognosis

--Watershed infarctsWatershed infarcts

These infarcts, also known as border These infarcts, also known as border zone infarcts, develop from relative zone infarcts, develop from relative hypoperfusion in the most distal hypoperfusion in the most distal arterial territories and can produce arterial territories and can produce bilateral symptomsbilateral symptoms. . Frequently, Frequently, these are associated with surgical these are associated with surgical proceduresprocedures . .

FrequencyFrequency

Approximately 750,000 strokes occur Approximately 750,000 strokes occur each year, approximately 500,000 each year, approximately 500,000 are ischemic strokesare ischemic strokes..

stroke isstroke is the third leading cause of the third leading cause of death and the leading cause of adult death and the leading cause of adult disabilitydisability..

MortalityMortality//MorbidityMorbidity

Stroke is the third leading cause of death in the Stroke is the third leading cause of death in the United following cardiac diseases and cancerUnited following cardiac diseases and cancer--related deathsrelated deaths. . Approximately 29% of Approximately 29% of patients die within 1 year following a stroke; patients die within 1 year following a stroke; this percentage rises in patients older than 65 this percentage rises in patients older than 65 yearsyears . .

Stroke is the leading cause of disability in the Stroke is the leading cause of disability in the United States; 31% of stroke survivors need United States; 31% of stroke survivors need help in taking care of themselves after a help in taking care of themselves after a stroke, 20% need some type of assistance for stroke, 20% need some type of assistance for walking, and 16% need to be placed in some walking, and 16% need to be placed in some form of institution providing assisted livingform of institution providing assisted living . .

At least one third of stroke survivors have At least one third of stroke survivors have depressiondepression

RaceRace

stroke has a higher incidence in the stroke has a higher incidence in the black population than in the white black population than in the white populationpopulation

In black males, the incidence is In black males, the incidence is approximately 93 per 100,000, with approximately 93 per 100,000, with a death rate of approximately 51%a death rate of approximately 51%..

In black females, incidence is 79 per In black females, incidence is 79 per 100,000 with a death rate of 39.2%100,000 with a death rate of 39.2%..

Young blacks have a 2-3 times greater risk Young blacks have a 2-3 times greater risk of ischemic stroke than the white of ischemic stroke than the white population of the same age, and they are population of the same age, and they are 2.5 times more likely to die of stroke2.5 times more likely to die of stroke . .

White males have a stroke incidence of 62.8 White males have a stroke incidence of 62.8 per 100,000, with death being the final per 100,000, with death being the final outcome in 26.3% of cases, compared with outcome in 26.3% of cases, compared with women who have a stroke incidence of 59 women who have a stroke incidence of 59 per 100,000 and a death rate of 39.2%per 100,000 and a death rate of 39.2%Hispanics have a lower overall incidence of Hispanics have a lower overall incidence of stroke than whites and blacks but more stroke than whites and blacks but more frequent lacunar strokes and stroke at an frequent lacunar strokes and stroke at an earlier ageearlier age

SexSex In patients younger than 60 years, the incidence of In patients younger than 60 years, the incidence of

stroke is greater in males stroke is greater in males ((3:2 ratio)3:2 ratio) ) )

AgeAgeStroke can occur in patients of all ages, including Stroke can occur in patients of all ages, including childrenchildrenRisk of stroke increases with age, especially in Risk of stroke increases with age, especially in patients older than 64 years, in whom 75% of all patients older than 64 years, in whom 75% of all strokes occurstrokes occur

HistoryHistory

The American Stroke Association advises The American Stroke Association advises the public to be aware of the symptoms of the public to be aware of the symptoms of strokestroke. . These symptoms are as followsThese symptoms are as follows

11--Sudden numbness or weakness of face, arm, Sudden numbness or weakness of face, arm, or leg, especially on one side of the bodyor leg, especially on one side of the body

22--Sudden confusion, difficulty in speaking or Sudden confusion, difficulty in speaking or understandingunderstanding

33--Sudden deterioration of vision of one or both Sudden deterioration of vision of one or both eyeseyes

44--Sudden difficulty in walking, dizziness, and Sudden difficulty in walking, dizziness, and loss of balance or coordinationloss of balance or coordination

55--Sudden, severe headache with no known Sudden, severe headache with no known causecause

Focus medical history on identifying Focus medical history on identifying risk factors for atherosclerotic and risk factors for atherosclerotic and cardiac disease, including cardiac disease, including hypertension, diabetes mellitus, hypertension, diabetes mellitus, tobacco use, high cholesterol, and a tobacco use, high cholesterol, and a history of coronary artery disease, history of coronary artery disease, coronary artery bypass, or atrial coronary artery bypass, or atrial fibrillationfibrillation

Consider stroke in any patient presenting with acute Consider stroke in any patient presenting with acute neurological deficit or any alteration in level of neurological deficit or any alteration in level of consciousnessconsciousness..

Common signs of stroke include the followingCommon signs of stroke include the following::

11--Acute hemiparesis or hemiplegiaAcute hemiparesis or hemiplegia

22--Complete or partial hemianopia, Complete or partial hemianopia, monocular or binocular visual loss, or monocular or binocular visual loss, or diplopiadiplopia

33--Dysarthria or aphasiaDysarthria or aphasia

44--Ataxia, vertigo, or nystagmusAtaxia, vertigo, or nystagmus

55--Sudden decrease in consciousnessSudden decrease in consciousness

In younger patients, elicit history of In younger patients, elicit history of trauma, coagulopathies, illicit drug trauma, coagulopathies, illicit drug use use ((especially cocaineespecially cocaine)), migraines, , migraines, or use of oral contraceptives or overor use of oral contraceptives or over--thethe--counter medications counter medications ((especially especially those containing those containing phenylpropanolaminephenylpropanolamine

If the patient is a candidate for If the patient is a candidate for thrombolytic therapy, a thorough thrombolytic therapy, a thorough review of the inclusion and exclusion review of the inclusion and exclusion criteria from the NINDS trial must be criteria from the NINDS trial must be performedperformed. . The exclusion criteria The exclusion criteria largely focus on identifying risk of largely focus on identifying risk of hemorrhagic complication associated hemorrhagic complication associated with thrombolytic usewith thrombolytic use . .

Physical examination is directed Physical examination is directed toward 5 major areastoward 5 major areas::

((11 ) )assessing the airway, breathing, assessing the airway, breathing, and circulation and circulation ((ABCsABCs)) , ,

((22 ) )defining the severity of the patient's defining the severity of the patient's neurologic deficitsneurologic deficits,,

((33 ) )identifying potential causes of the identifying potential causes of the stroke stroke ((44) ) identifying potential stroke identifying potential stroke mimics, andmimics, and

((55 ) )identifying comorbid conditionsidentifying comorbid conditions

11--Vital signsVital signs

22--Head, ears, eyes, nose, and throat examinationHead, ears, eyes, nose, and throat examination

33--CardiacCardiac: : Cardiac arrhythmias, such as atrial Cardiac arrhythmias, such as atrial fibrillationfibrillation

44--ExtremitiesExtremities: : Carotid or vertebrobasilar Carotid or vertebrobasilar dissections, and less commonly, thoracic aortic dissections, and less commonly, thoracic aortic dissections, may cause ischemic strokedissections, may cause ischemic stroke

55-The neurologic examination must be thorough.-The neurologic examination must be thorough.

A directed and focused examination can be A directed and focused examination can be performed in minutes and not only provides performed in minutes and not only provides great insight into the potential cause of the great insight into the potential cause of the patient's deficits, but also helps determine the patient's deficits, but also helps determine the intensity of treatment requiredintensity of treatment required..

A very useful tool in measuring neurological A very useful tool in measuring neurological impairment is the National Institutes of impairment is the National Institutes of Health Stroke Scale Health Stroke Scale ((NIHSSNIHSS)) . .

This scale can be used easily, is reliable and This scale can be used easily, is reliable and valid, provides insight to the location of valid, provides insight to the location of vascular lesions, and can be correlated with vascular lesions, and can be correlated with outcome in patients with ischemic strokeoutcome in patients with ischemic stroke . .

It focuses on 6 major areas of the neurologic It focuses on 6 major areas of the neurologic examinationexamination::

((11 ) )level of consciousness, level of consciousness, ((22) ) visual function, visual function, ((33) ) motor function, motor function, ((44) ) sensation and sensation and neglect, neglect, ((55) ) cerebellar function, and cerebellar function, and ((66) ) languagelanguage

Risk factors for ischemic stroke Risk factors for ischemic stroke comprise both modifiable and comprise both modifiable and nonmodifiable characteristicsnonmodifiable characteristics . .

Identification of risk factors in each Identification of risk factors in each patient can uncover clues to the patient can uncover clues to the cause of the stroke and the most cause of the stroke and the most appropriate treatment planappropriate treatment plan

Nonmodifiable risk factors includeNonmodifiable risk factors include::

age, race, sex, ethnicityage, race, sex, ethnicity , ,

history of migraine headaches, sickle history of migraine headaches, sickle cell disease, fibromuscular dysplasia, cell disease, fibromuscular dysplasia, and hereditory diseasesand hereditory diseases..

Modifiable risk factors include the followingModifiable risk factors include the following::

11--Hypertension Hypertension ((the most important risk factor)the most important risk factor)22--Diabetes mellitusDiabetes mellitus

33--Cardiac disease:Cardiac disease: atrial fibrillation, valvular diseaseatrial fibrillation, valvular disease , ,

mitral stenosis, structural anomalies allowing right mitral stenosis, structural anomalies allowing right toto

left shunting, such as a patent foramen ovale, atrialleft shunting, such as a patent foramen ovale, atrial and ventricular enlargementand ventricular enlargement

44--HypercholesterolemiaHypercholesterolemia55--Transient ischemic attacks Transient ischemic attacks ((TIAs)TIAs)

66--Carotid stenosisCarotid stenosis77--HyperhomocystinemiaHyperhomocystinemia

88--Lifestyle issuesLifestyle issues 99--Excessive alcohol intake, tobacco use, illicit drug Excessive alcohol intake, tobacco use, illicit drug

useuse , , obesity, physical inactivityobesity, physical inactivity

1010--Oral contraceptive useOral contraceptive use

Lab StudiesLab Studies::

11--Glucose and Electrolyte disorders Glucose and Electrolyte disorders tests: Hypoglycemia is the most tests: Hypoglycemia is the most common electrolyte abnormality that common electrolyte abnormality that produces stroke like symptomsproduces stroke like symptoms. . It is It is easily corrected, and correction leads easily corrected, and correction leads to rapid resolution of symptomsto rapid resolution of symptoms . .

Hyperglycemia and uremia should be Hyperglycemia and uremia should be considered carefully as the cause of considered carefully as the cause of ongoing mental and physical deficitsongoing mental and physical deficits . .

22--Complete blood countComplete blood count: : provides key provides key information regarding hemoglobin and information regarding hemoglobin and hematocrit, thus evaluating for anemia hematocrit, thus evaluating for anemia and possible deficiencies in oxygenand possible deficiencies in oxygen--carrying capacitycarrying capacity. . Additionally, sickle Additionally, sickle cell disease, polycythemia, and cell disease, polycythemia, and thrombocytosis increase the risk for thrombocytosis increase the risk for strokestroke..

–33--Prothrombin time Prothrombin time ((PTPT) ) and activated and activated partial thromboplastin time partial thromboplastin time ((aPTTaPTT) ) teststests : :

–many patients with acute stroke are on many patients with acute stroke are on anticoagulants, such as heparin or warfarinanticoagulants, such as heparin or warfarin. . Treatment decisions, such as thrombolytic Treatment decisions, such as thrombolytic use, require data on coagulation statususe, require data on coagulation status . .

–An elevated international normalized ratio An elevated international normalized ratio ((INRINR) ) may preclude patients from receiving may preclude patients from receiving thrombolyticsthrombolytics

44--Cardiac enzymesCardiac enzymes: : Not infrequently Not infrequently patients with acute stroke also patients with acute stroke also experience acute myocardial ischemiaexperience acute myocardial ischemia . .

In addition to ECG findings, increased In addition to ECG findings, increased cardiac enzymes might suggest cardiac enzymes might suggest concomitant cardiac injuryconcomitant cardiac injury..

55--ArterialArterial blood gas blood gas ((ABGABG) ) analysisanalysis : :

In patients with suspected hypoxemia, In patients with suspected hypoxemia, ABG will define the severity of ABG will define the severity of hypoxemia and may detect acidhypoxemia and may detect acid--base base disturbancesdisturbances

66--Additional laboratory tests may Additional laboratory tests may include rapid plasma reagent include rapid plasma reagent ((RPRRPR)), , toxicology screen, fasting lipid toxicology screen, fasting lipid profile, sedimentation rate, profile, sedimentation rate, pregnancy test, antinuclear antibody pregnancy test, antinuclear antibody ((ANAANA)), rheumatoid factor and , rheumatoid factor and homocysteinehomocysteine..

77--In select patients with possible In select patients with possible hypercoagulable states, protein C, hypercoagulable states, protein C, protein S, antithrombin III, and Factor V protein S, antithrombin III, and Factor V Leiden testing may be requiredLeiden testing may be required. . These These blood abnormalities mainly contribute blood abnormalities mainly contribute to venous thrombosis but may be to venous thrombosis but may be relevant in patients with cardiac shunts relevant in patients with cardiac shunts or cerebral venous thrombosesor cerebral venous thromboses

88--The anticardiolipin antibody and the The anticardiolipin antibody and the lupus inhibitor, both antiphospholipid lupus inhibitor, both antiphospholipid antibodies, correlate with arterial antibodies, correlate with arterial stroke, as well as with deep venous stroke, as well as with deep venous thrombosis, pulmonary embolism, thrombosis, pulmonary embolism, myocardial infarction, and myocardial infarction, and miscarriagemiscarriage

Imaging StudiesImaging Studies

CT is the most commonly used form of neuroimaging CT is the most commonly used form of neuroimaging in evaluation of patients with apparent acute strokein evaluation of patients with apparent acute stroke . .

Noncontrast CT is very sensitive in detecting Noncontrast CT is very sensitive in detecting intracerebral and subarachnoid hemorrhage, as well intracerebral and subarachnoid hemorrhage, as well as subdural hematomasas subdural hematomas..

–Although CT is not very sensitive for early Although CT is not very sensitive for early ischemia ischemia ((<6 h<6 h)), several findings can suggest , several findings can suggest ischemic changes relatively early in the time ischemic changes relatively early in the time course of strokecourse of stroke . .

–Loss of the grayLoss of the gray--white matter interface, loss of white matter interface, loss of sulci, and loss of the insular ribbon are subtle sulci, and loss of the insular ribbon are subtle signs of early ischemiasigns of early ischemia

Early mass effect and areas of Early mass effect and areas of hypodensity suggest irreversible injury hypodensity suggest irreversible injury and identify patients at higher risk of and identify patients at higher risk of hemorrhage if given thrombolyticshemorrhage if given thrombolytics . .

Significant hypodensity on the baseline Significant hypodensity on the baseline scan should prompt the physician to scan should prompt the physician to question the time of onsetquestion the time of onset . .

Hypodensity in an area greater than one Hypodensity in an area greater than one third of the MCA distribution is third of the MCA distribution is considered by some a relative considered by some a relative contraindication for thrombolyticscontraindication for thrombolytics

A dense MCA sign suggests a clot in the A dense MCA sign suggests a clot in the MCAMCA. . These patients are at risk for These patients are at risk for significant hemispheric strokessignificant hemispheric strokes. . Some Some authorities believe that these patients authorities believe that these patients may benefit most from aggressive may benefit most from aggressive thrombolytic therapy, including intrathrombolytic therapy, including intra--arterial therapies, but this has not been arterial therapies, but this has not been specifically proven in doublespecifically proven in double--blind blind randomized trialsrandomized trials..

CT scan may demonstrate other causes of CT scan may demonstrate other causes of the patient's symptoms, including the patient's symptoms, including neoplasm, epidural and subdural neoplasm, epidural and subdural hemorrhage, aneurysm, abscess, hemorrhage, aneurysm, abscess, arteriovenous malformation, and arteriovenous malformation, and hydrocephalushydrocephalus

MRI MRI ((MRAMRA) ) is a major advance in the is a major advance in the neuroimaging of strokeneuroimaging of stroke. . MRI not only MRI not only provides great structural detail but provides great structural detail but also can demonstrate impaired also can demonstrate impaired metabolismmetabolism....

DiffusionDiffusion--weighted MRI weighted MRI ((DWDW--MRIMRI) ) can detect areas can detect areas of ischemic brain injury earlier in the evolution of ischemic brain injury earlier in the evolution of ischemia than standard T1of ischemia than standard T1//T2-weighted MRI T2-weighted MRI images or CT scan by detecting changes in images or CT scan by detecting changes in water molecule mobilitywater molecule mobility

Perfusion-weighted MRI Perfusion-weighted MRI ((PWPW--MRIMRI) ) uses injected uses injected contrast material to demonstrate areas of contrast material to demonstrate areas of decreased perfusiondecreased perfusion . .

These sequences in combination with DWThese sequences in combination with DW--MRI MRI yields areas of diffusionyields areas of diffusion--weighted weighted imagingimaging//perfusionperfusion--weighted imaging weighted imaging ((DWDW--MRIMRI//PWPW--MRIMRI) ) mismatch, theoretically mismatch, theoretically identifying potentially salvageable tissuesidentifying potentially salvageable tissues

MRAMRA: : This noninvasive technique This noninvasive technique demonstrates vascular anatomy and demonstrates vascular anatomy and occlusive disease of the head and neck occlusive disease of the head and neck without the need for contrast materialwithout the need for contrast material

EchocardiographyEchocardiography: : Transthoracic Transthoracic echocardiography echocardiography ((TTETTE) ) and and transesophageal echocardiography transesophageal echocardiography ((TEETEE) ) are useful tools in evaluating patients with are useful tools in evaluating patients with possible cardiogenic sources of their possible cardiogenic sources of their strokestroke . .

TEE is more sensitive than TTE and can TEE is more sensitive than TTE and can evaluate the aortic arch and thoracic aorta evaluate the aortic arch and thoracic aorta for plaques or dissectionsfor plaques or dissections

ECGECG: : Stroke and cardiovascular disease Stroke and cardiovascular disease share many risk factorsshare many risk factors. . ECG may ECG may demonstrate cardiac arrhythmias, such as demonstrate cardiac arrhythmias, such as atrial fibrillation, or may indicate acute atrial fibrillation, or may indicate acute ischemiaischemia. . All patients with stroke should All patients with stroke should have an ECG as part of their initial have an ECG as part of their initial evaluationevaluation

Chest radiography should be performed Chest radiography should be performed when clinically indicatedwhen clinically indicated

Digital subtraction angiography is Digital subtraction angiography is considered the definitive method for considered the definitive method for demonstrating vascular lesions, demonstrating vascular lesions, including occlusions, stenoses, including occlusions, stenoses, dissections, and aneurysmsdissections, and aneurysms . .

Carotid duplex scanning is one of the Carotid duplex scanning is one of the most useful tests in evaluating most useful tests in evaluating patients with strokepatients with stroke . .

ManagementManagement

We should decide from the history, duration of We should decide from the history, duration of onset and clinical presentation wither the onset and clinical presentation wither the case is anterior circulation (contralateral case is anterior circulation (contralateral hemiparesis, dysphasia, apraxia, agnosia, hemiparesis, dysphasia, apraxia, agnosia, preserved consciousness and visual field preserved consciousness and visual field defect) or posterior circulation (vertigo, defect) or posterior circulation (vertigo, ataxia, dysphagia, diplopia, disturbed level ataxia, dysphagia, diplopia, disturbed level of consciuosness, crossed hemiparesis and of consciuosness, crossed hemiparesis and bilateral presentation) because if we bilateral presentation) because if we received the patient within 160mins or less received the patient within 160mins or less and there is no contraindications for and there is no contraindications for thrombolytic therapy we decide this line of thrombolytic therapy we decide this line of

treatment accordinglytreatment accordingly . .

Blood pressure managmentBlood pressure managment

Candidates for fibrinolysisCandidates for fibrinolysis

PretreatmentPretreatmentSBP >185 or DBP >110 mm HgSBP >185 or DBP >110 mm Hg Labetalol 10-20 mg IVP 1-2 doses orLabetalol 10-20 mg IVP 1-2 doses orEnalapril 1.25 mg IVPEnalapril 1.25 mg IVP

PosttreatmentPosttreatment DBP >140 mm HgDBP >140 mm Hg Sodium nitroprusside Sodium nitroprusside ((0.5 mcg0.5 mcg//kgkg//minmin

SBP >230 mm Hg or DBP 121-140 mm HgSBP >230 mm Hg or DBP 121-140 mm Hg Labetalol 10-20 mg IVP and consider labetalol Labetalol 10-20 mg IVP and consider labetalol infusion at 1-2 mginfusion at 1-2 mg//min or nicardipine 5 mgmin or nicardipine 5 mg//h IV h IV infusion and titrateinfusion and titrate

SBP 180-230 mm Hg or DBP 105-120 mm HgSBP 180-230 mm Hg or DBP 105-120 mm HgLabetalol 10 mg IVP, may repeat and double every Labetalol 10 mg IVP, may repeat and double every

10 min up to maximum dose of 150 mg10 min up to maximum dose of 150 mg

Noncandidates for fibrinolysisNoncandidates for fibrinolysis

DBP >140 mm HgDBP >140 mm HgSodium nitroprusside 0.5 mcgSodium nitroprusside 0.5 mcg//kgkg//min; may reduce min; may reduce approximately 10-20%approximately 10-20%

SBP >220 orSBP >220 or DBP 121-140 mm Hg orDBP 121-140 mm Hg or MAP >130 mm HgMAP >130 mm HgLabetalol 10-20 mg IVP over 1-2 min; may repeat and double Labetalol 10-20 mg IVP over 1-2 min; may repeat and double every 10 min up to maximum dose of 150 mg or nicardipine every 10 min up to maximum dose of 150 mg or nicardipine 5 mg5 mg//h IV infusion and titrateh IV infusion and titrate

SBP< 220 mm Hg orSBP< 220 mm Hg orDBP 105-120 mm Hg orDBP 105-120 mm Hg or MAP <130 mm HgMAP <130 mm HgAntihypertensive therapy indicated only if AMI, aortic Antihypertensive therapy indicated only if AMI, aortic dissection, severe CHF, or hypertensive encephalopathy dissection, severe CHF, or hypertensive encephalopathy presentpresent

If a case of anterior circulation and candidate If a case of anterior circulation and candidate for thrombolytic therapy (onset less than for thrombolytic therapy (onset less than 160mins)160mins)

CT scan , no hemorrhageCT scan , no hemorrhage

Carotid Doppler, patent carotid arteriesCarotid Doppler, patent carotid arteries

IV infusion of Altiplase 0.9mg/kg not exceed IV infusion of Altiplase 0.9mg/kg not exceed 90mg90mg

10%10% pulse IV and 90% IV infusion over 1 hourpulse IV and 90% IV infusion over 1 hour

Discharge patient to the ICU for close Discharge patient to the ICU for close monitoringmonitoring

Start heparine in the second day with Start heparine in the second day with antiplateletantiplatelet

If there is underlying embolic source If there is underlying embolic source long term anticoagulant +/- long term anticoagulant +/-

antiplatelet +/- lipid-lowering agentantiplatelet +/- lipid-lowering agent

If a case of posterior circulation and candidate If a case of posterior circulation and candidate for thrombolytic therapy (onset within for thrombolytic therapy (onset within 160mins and in some studies less than 5 160mins and in some studies less than 5 hours)hours)CT, no hemorrhageCT, no hemorrhageSend patient to Cath labSend patient to Cath lab . .Angiography to the posterior circulationAngiography to the posterior circulation If no thrombus go out and keep patient on If no thrombus go out and keep patient on heparineheparine . .

If there is thrombus Insitu infusion of AltiplaseIf there is thrombus Insitu infusion of Altiplase

Discharge patient to the ICU for close Discharge patient to the ICU for close monitoringmonitoring

Start heparine in the second day with Start heparine in the second day with antiplateletantiplatelet

If there is underlying embolic source If there is underlying embolic source long term anticoagulant +/- long term anticoagulant +/- antiplatelet +/- lipid-lowering agentantiplatelet +/- lipid-lowering agent

If the patient is not a candidate for If the patient is not a candidate for thrombolytic therapy thrombolytic therapy

• Keep on Antiplatelet (Asprine, Clopidogrile Keep on Antiplatelet (Asprine, Clopidogrile and Amibexicam)and Amibexicam)

• Maintain BP (as above) and Blood VolumeMaintain BP (as above) and Blood Volume• In case of underlying embolization In case of underlying embolization

heparine for 5-7days and long term heparine for 5-7days and long term Warfarine with PT INR followup (range 2.5-Warfarine with PT INR followup (range 2.5-4)4)

• Heparine use is contraversy?? In case of Heparine use is contraversy?? In case of thrombotic stroke.thrombotic stroke.

--Blood glucoseBlood glucose

Treat hypoglycemia with D50Treat hypoglycemia with D50

Treat hyperglycemia with insulin if Treat hyperglycemia with insulin if serum glucose >200 mgserum glucose >200 mg//dLdL

--Cardiac monitorCardiac monitor

Continuous monitoring for ischemic changes Continuous monitoring for ischemic changes or atrial fibrillationor atrial fibrillation

Intravenous fluidsIntravenous fluids--

Avoid D5W and excessive fluid administrationAvoid D5W and excessive fluid administration

IV isotonic sodium chloride solution at 50 IV isotonic sodium chloride solution at 50 mLmL//hh

--Oral intakeOral intakeNPO initially; aspiration risk is great, avoid NPO initially; aspiration risk is great, avoid oral intake until swallowing assessedoral intake until swallowing assessed

--Oxygen Supplement if indicatedOxygen Supplement if indicated

--TemperatureTemperature Avoid hyperthermia, oral or rectal Avoid hyperthermia, oral or rectal acetaminophen as neededacetaminophen as needed

--Diet therapyDiet therapy--Treat hyperlipidemiaTreat hyperlipidemia

--PhysiotherapyPhysiotherapy--Treat convulsion, Fever, depression and Treat convulsion, Fever, depression and

complicationscomplications--Steroid when indicated (increase ICP, large Steroid when indicated (increase ICP, large

infarction with midline shift on CT, CVT infarction with midline shift on CT, CVT induced infarction and acute bacterial induced infarction and acute bacterial

induced infarctioninduced infarction . .

Contraindication of thrombolytic therapyContraindication of thrombolytic therapy::

11--Onset more than 160minsOnset more than 160mins22--age less than 18yage less than 18y

33--TIA or minor stokeTIA or minor stoke 44--large infarction or Hm strokelarge infarction or Hm stroke..

5-DBP 120Hg or SBP 220Hg5-DBP 120Hg or SBP 220Hg6-IC surgery 3months ago6-IC surgery 3months ago7-Major surgery 3wks ago7-Major surgery 3wks ago8-Previous ICH8-Previous ICH9-Diabetic retinopathy9-Diabetic retinopathy10-Low platelet10-Low platelet11-Sugar less than 60mg or more than 200mg11-Sugar less than 60mg or more than 200mg12-Bleedind tendency12-Bleedind tendency13-morbid case13-morbid case14-prolonged PT or PTT14-prolonged PT or PTT