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Updated: 6/18/2021

Stroke

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  • summary
    • Stroke is an acute onset of focal neurologic deficits resulting from diminished blood flow or hemorrhage in the brain. 
    • Diagnosis is made clinically with specific and thorough neurological examination. 
    • Treatment is emergent medical management and possible surgical management depending on underlying cause. 
  • Epidemiology
    • incidence
    • risk factors include
      • diabetes
      • smoking
      • atrial fibrillation
      • cocaine
  • Etiology
    • Two forms
      • diminished blood flow (ischemic stroke)
      • hemorrhage (hemorrhagic stroke)
    • Pathophysiology
      • etiology include
        • 35% - atherosclerosis of the extracranial vessels (carotid atheroma)
        • 30% -cardiac and fat emboli, endocarditis
        • 15% - lacunar
          • occur in areas supplied by small perforating vessels and result from
            • atherosclerosis
            • hypertension
            • diabetes
        • 10% - parenchymal hemorrhage
        • 10% - subarachnoid hemorrhage
    • Watershed occurs at areas at border of two arterial supplies
      • often follow prolonged hypotension
    • TIA is charcaterized by transient neurologic deficits for less than 24 hours (usually less than 1 hr.)
  • Presentation
    • Edema occurs 2-4 days post-infarct.
    • Watch for symptoms
      • decorticate (cortical lesion): flexion of arms
      • decerebrate (midbrain or lower lesion): extension of arms
      • Symptoms of various strokes
      • Carotid/Ophthalmic
      • Amaurosis fugax (monocular blind)
      • MCA
      • Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia.
      • ACA
      • Leg paresis, hemiplegia, urinary incontinence
      • PCA
      • Homonynmous hemianopsia
      • Basilar Art
      • Coma, cranial nerve palsies, apnea, drop attach, vertigo
      • Lacunar stroke
      • Silent, pure motor or sensory stroke, dysarthria (clusy hand syndrome), ataxic hemiparesis.
    • Other stroke syndromes
      • lateral medullary infarct (Wallenburg syndrome)
        • loss of pain and temp on ipsilateral face and contralateral body, vestibulocerebellar impairment, Horner's syndrome
  • Imaging
    • CT without contrast
      • indicated for acute presentation
      • important to diagnose as ischemic or hemorrhagic
    • MRI
      • indicated for subacute
      • vascular studies of intra and extracranial vessels
  • Studies
    • Labs
      • should include coagulation studies
      • lumbar puncture to r/o encephalitis
    • Echo
      • to check for mural thrombus, rule out endocarditis
    • EEG to rule out seizure
  • Differential
    • Brain tumor, epi / subdural bleeds, brain abscess, endocarditis, multiple sclerosis, metabolic (hypoglycemia), neurosyphillis
  • Treatment
    • Nonoperative
      • thrombolytics
        • indications
          • for occlusive disease
        • modalities
          • give IV tPA if within 3-4.5 hours
          • can consider intra-arterial thrombolysis in select patients (major MCA occlusion) up to 6 hours after onset of symptoms
      • warfarin/aspirin therapy
        • indications
          • for embolic disease and hypercoagulable states give warfarin / aspirin once the hemorrhagic stroke has been ruled out
      • anti-hypertensive medications
        • do not overtreat hypertension. Allow BP to rise to 200/100 to maintain perfusion
    • Operative
      • thrombectomy
        • indications
          • within 6 hours in an ischemic stroke with a proximal cerebral arterial occlusion, compared to alteplase alone, improved reperfusion, early neurological recovery, and functional outcome.
      • endarterectomy
        • indications
          • if corotid > 70% occluded
  • Prognosis, Prevention, and Complications
    • Less than 1/3 achieve full recovery
    • For embolic disease give warfarin / aspirin for prophylaxis
    • Carotid endarterectomy if stenosis is > 70%. Contraindicated if vessel is 100% occluded.
    • Manage hypertension

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