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Snapshot
  • A 60-year-old woman presents with acute onset of right facial weakness. Past medical history is significant for hypertension and type II diabetes mellitus. Non-contrast head CT is performed, which is negative for blood. (ischemic stroke)
Introduction
  • Acute onset of focal neurologic deficits resulting from
    • diminished blood flow (ischemic stroke)
    • hemorrhage (hemorrhagic stroke)
  • Risk factors include diabetes, smoking, atrial fibrillation, and cocaine
  • Etiology include
    • 35% - atherosclerosis of the extracranial vessels (carotid atheroma)
    • 30% -cardiac and fat emboli, endocarditis
    • 15% - lacunar
    • 10% - parenchymal hemorrhage
    • 10% - subarachnoid hemorrhage
  • Lacunar infarcts occur in areas supplied by small perforating vessels and result from
    • atherosclerosis
    • hypertension
    • diabetes
  • 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 
    • cerebellar: ataxia, nystagmus, abnormal finger-nose and heel-shin 

      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-Clumsy 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
Evaluation
  • Labs
    • should include coagulation studies
    • lumbar puncture to r/o encephalitis
  • Echo to check for mural thrombus, rule out endocarditis
  • Imaging
    • CT without contrast for acute presentation 
      • important to diagnose as ischemic or hemorrhagic 
    • MRI for subacute
    • vascular studies of intra and extracranial vessels
  • EEG to rule out seizure
Differential
  • Brain tumor, epi / subdural bleeds, brain abscess, endocarditis, multiple sclerosis, metabolic (hypoglycemia), neurosyphillis
Treatment
  • For occlusive disease 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
  • Thrombectomy 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. 
  • For embolic disease and hypercoagulable states give warfarin / aspirin once the hemorrhagic stroke has been ruled out
  • Endarterectomy 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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