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