2 broad categories of stroke:

Ischemia Inadequate blood supply (oxygen & nutrients) to an area of the brain Hemorrhage Leakage of blood into the closed cranial cavity Direct damage to tissue by compression/edema

Incidence
~700K per year (~200K are recurrent)

80-90% are ischemic Male:Female ratio 1.25:1

Ratio reverses after age 80

Higher rates in Blacks, Hispanics, & Native Americans

Heart disease
AFib, Valvular Dz, MI, endocarditis

Hypertension Smoking Diabetes/Metabolic Syndrome Dyslipidemia Pregnancy Drug Abuse/Meds Bleeding Disorders/Anticoagulant Use

Thrombosis
In situ arterial obstruction Arteriosclerosis, dissection, FMD Superimposed thrombosis

Embolism
Arterial obstruction from debris from another

source

Systemic Hypoperfusion
Circulatory collapse Multiorgan involvement

Large Vessel Disease

Common & Internal

Carotids Circle of Willis & proximal branches

Small Vessel Disease

Penetrating arteries Lacunar Stroke

Stuttering course

Cardiac
Atrial fibrillation Heart valves, atrial thrombus, recent MI, dilated

CM, endocarditis, recent CABG

Aortic Arterial (e.g. carotids) Other/Unknown

DVT- Paradoxical embolus

Abrupt onset, rapid improvement

Shock
Cardiogenic, septic, hypovolemic

Sx are more diffuse/nonfocal Border-zone regions

Cortical blindness Stupor

Proximal Weakness

Intracerebral Hemorrhage (ICH)

Bleeding within the brain

tissue Forms a hematoma Growth stopped by tamponade or leaking into the ventricles or CSF Headache, vomiting, delirium Progressive sx

HTN Trauma Bleeding Disorder

Inherited Acquired, i.e. meds

Drug use
Cocaine Amphetamines

Amyloid

AVMs Bleeding into tumor Vasculitis

Subarachnoid Hemorrhage (SAH)

Bleeding into CSF on outer

aspect of brain Quick rise in ICP Sudden onset headache in 97% Aneurysm & AVMs are most common cause

Seizure with Todds Paralysis Syncope Migraine Head Trauma Brain tumor

Metabolic Causes
Hypoglycemia Hyponatremia Intoxication Uremia/ARF Hepatic Encephalopathy

Conversion Disorder

Vital signs
Temperature, Pulse, Blood Pressure

Pulses Carotid Bruit Cardiac Exam Funduscopic exam Skin exam Signs of trauma

Neurologic Exam
Level of consciousness/GCS Language/Speech

Cranial nerves
Vertigo, diplopia, ataxia Visual deficits Weakness/Paralysis Reflexes/ Babinski

Patients are awarded points based on eye opening, best verbal response, and best motor response. The patient's GCS score can range from 3/15 to 15/15 Eye opening score: 4, eyes open; 3, eyes open to speech; 2, eyes open in response to pain; 1, no eye opening Best verbal response score: 5, alert and oriented; 4, confused; 3, responds with inappropriate words; 2, makes incomprehensible sounds; 1, no verbal response Best motor response score: 6, obeys commands; 5, localizes pain; 4, responds to pain with normal flexion/withdrawal; 3, responds to pain with abnormal flexion; 2, extends in response to pain; 1, no response to pain

CBC with platelets Electrolytes, Bun, Cr Glucose LFTs PT/PTT O2 Sat ECG Chest XRay

ESR Blood Cultures ANA Tox screen Alcohol level Blood type & cross Urine/Serum HCG Hypercoaguability Profile

CT Scan
R/O

Bleed Sensitivity much better after 24 hrs for ischemic stroke Early signs (<6 hrs)
May indicate worse prognosis

MRI
T1/T2 images, DWI Provides immediate

evaluation of ischemia Not available for emergency use in many settings

Carotid U/S for stenosis If ASVD, but no stenosis

Risk Factor Modification

If stenosis, consider
Carotid Endarterectomy ?Carotid Stenting

Vertigo & Syncope are not considered symptomatic

100% occlusion
No treatment

70-99% occlusion
If good 5-yr survival & risks <6%, early CEA (within 2 weeks)

50-69%
If above criteria & male, early CEA If female, medical mgt

<50%
Medical management

Sudden onset of neurologic dysfunction that lasts less than 24 hrs, brought on by presumed transient ischemia to a portion of the brain May be better to describe as sx <1 hr with no evidence of infarction May have infarct even with sx lasting a few hours (~50% of TIA patients have MRI evidence of ischemia)

Transient Sx Associated with Infarction No established diagnostic criteria In one case series, 15% of TSI pts had a recurrent stroke in-hospital vs. 0% in TIA group.

Could consider home if able to expedite urgent outpatient work-up AHA does not make a recommendation re: hospitalization One study suggested cost-effective if 24-hr stroke risk is >5%

NASCET trial suggested 90-day stroke risk of 20% with nonretinal TIAs (higher than for true stroke) 2000 JAMA study
5% risk w/in 2 days

11% risk w/in 90 days

Higher risk with age >60, DM, sx >10 min, weakness, speech

impairment

2004 Neurology study: 21% risk of stroke/MI/death within 1 year of TIA

Age >60 = 1 pt Blood Pressure >140/90 = 1 Clinical Features

Unilateral weakness = 2

Isolated speech deficit = 1

Other = 0

Duration
>60 minutes = 2

Risk of early stroke Score 3: 0% 4: 1-9% 5: 12% 6: 24-31%

10-59 minutes = 1
<10 minutes = 0

Risk factor modification Antithrombotic therapy Anticoagulant therapy

Hypertension
Goal <130/80 Dropped SBP from 155 to 143 36% reduction in stroke over 4 years Pts >80 may not benefit as much & aggressive BP

lowering may increase mortality Diuretic +/- ACEI as 1st line

Smoking
Stop it

Diabetes
Goal A1c <7, i.e. normoglycemic

Metabolic syndrome

Dyslipidemia
Evidence not as strong as may think, but still a

good idea, especially given other vascular disease SPARCL Study

Atorvastatin 80 mg/day in pts 1-6 months from CVA/TIA Mean LDL reduction 56 Endpoint was stroke: 16% RRR, but only 2.2% ARR (NNT ~50)

Dyslipidemia, continued
For average-risk patient, goal LDL <100 For high-risk, goal <70 Diabetes Prior CAD Multiple RFs with continued smoking

Lifestyle Modification
Weight loss Exercise

Dietary changes

Reduce alcohol intake, especially heavy drinkers ?Homocysteine

Consider B12, B6, Folate (MVI doses OK)

Aspirin
20-25% reduction in stroke (& MI or other vascular

death) Standard doses of 81-325 mg as good as higher doses 81 mg dose just as good and less risk of bleeding ASA-non-responders?

Clopidogrel (Plavix)
8% RRR vs. ASA for stroke/MI/Vasc death 5.3% vs. 5.8%: NNT ~200 All for only $100+/month ?2nd-line therapy or ASA-allergic patients No increased bleeding vs. ASA, but combo should

be avoided No neutropenia (like ticlopidine)

Dipyridamole
Alone 50-100 mg TID Aggrenox (200mg ER-DP & 25mg ASA) BID

2 studies have shown ~3% ARR (NNT 33) over ASA

alone for stroke prevention Some guidelines are suggesting this a 1st line therapy over ASA alone for stroke prevention Cost >$100/month

Warfarin has only been proven effective in primary prevention of stroke in the setting of atrial fibrillation AF is responsible for 1/6th of all strokes in patients older than 60 Risk reduction
Warfarin about 3 times as effective as ASA Absolute annual risk reduction of ~3%

Low Risk patients may consider ASA rx

Highest Risk: Prior Stroke or TIA High Risk: Any of the following
Prior thromboembolism

Female >75 yo
SBP >160 Heart failure

Moderate Risk: None of above, but HTN Low Risk: None of the above, no HTN

Thrombolysis Blood Pressure Management Antithrombotic Therapy Management of Medical Complications

Time-sensitive
Studies show that thrombolytics must be given

within 3 hours of symptom onset

Effective
NINDS- Complete or near-complete recovery at 3

months post-event (38% vs. 21%, NNT=6) No difference in mortality

Harmful
At least 6% risk of ICH

Alteplase (tPA) 0.9 mg/kg dose up to 90 mg

10% as IV bolus, then 60 min infusion

Multiple exclusion criteria Obtain informed consent (if possible)

"There is a treatment for your stroke called alteplase that must be given within three hours after the stroke started. It is a 'clot-buster' drug that can lead to a complete or near-complete reversal of a stroke in about one of every three patients treated. However, it has a major risk, since it can cause severe bleeding in the brain in about one of every 15 patients. If bleeding occurs in the brain, it can be fatal. When used to treat large numbers of stroke patients, on average the potential benefits of this treatment outweigh the risks; however, in any individual patient it is a very personal decision."

Stroke/head trauma <3 mos Surgery <14 days GI Bleed <21 days Any prior ICH Acute MI or MI < 3 months LP < 7 days Arterial puncture @ noncompressible site <7d Rapidly improving or minor sx Seizure with postictal sx

Sx of SAH, even if CT (-) BP >185/110 Pregnancy Active bleeding or trauma Platelets <100K Glucose <50, >400 INR >1.7 or elev PTT Hemorrhage on CT Major infarct on CT

Guidelines for In-Hospital Evaluation

Physician Evaluation: 10 minutes Stroke Team Contact: 15 minutes Imaging: 25 minutes Interpretation: 45 minutes Thrombolysis Started: 60 minutes

?Coagulopathy- Dont wait for labs unless on

Coumadin, Heparin, or Dialysis

Early Treatment Less severe symptoms Younger Age Lack of systolic HTN Normoglycemia

Blood flow in dilated, post-obstructive blood vessels is BP-dependent Aggressive BP lowering can increase mortality In one study, a fall in SBP >20 in first 24 hrs was the most likely factor associated with neurologic deterioration This does NOT apply to hemorrhagic stroke

Do not treat BP unless >220/120, unless

Given thrombolytics (goal <180/105) Acute coronary syndrome Acute heart failure/pulmonary edema Aortic Dissection

Meds
Labetalol Nitroprusside Avoid SA nifedipine

ASA
IST- ASA 300 mg within 48 hrs Reduced 14 day recurrent stroke (NNT=100) Reduced nonfatal stroke & death (NNT=100) CAST- ASA 160 mg within 48 hrs Reduced mortality at 4 weeks (NNT=166)

Slight increased risk of hemorrhagic stroke

Heparin (LMWH)
No clear benefit over ASA alone Reduced recurrent ischemic strokes by 9/1000 patients, but increased hemorrhagic strokes by same number

?Effective in some subsets Stroke-in-evolution or Progressive Stroke Many patients show neurologic deterioration in 1st 24 hrs No studies effectively define this population or prove a benefit

Acute Coronary Syndromes/Heart Failure Infections

Venous thromboembolism
Consider DVT prophylaxis for all patients SCDs for pts with bleeds Heparin or Lovenox SQ for others
Aspiration pneumonia UTI

Malnutrition/Dehydration (consider Adv Directives) Decubitus ulcers Contractures

CONSIDER EARLY MOBILIZATION IN ALL PATIENTS!

Accounts for ~8% of all strokes Presenting sx

Headache (~50%)

Seizures (7-9%)
Delirium/Altered LOC Focal neuro sx (depends on area of brain)

Mortality 35-50%
Half of deaths in 1st 24 hours

Prognosis
Size & location of hemorrhage
Age Glasgow Coma Score Comorbid conditions Prior antiplatelet/anticoagulant therapy

Neurosurgery Constant monitoring Bedrest Pain control Reverse coagulopathies

Vitamin K, Fresh Frozen Plasma, Platelets

ICP control
Mannitol, Induced Coma, Hyperventilation

Blood pressure management Surgery

Indicated for cerebellar bleeds >3 cm

Supratentorial bleeds more controversial Depends on size, location, LOC, comorbidities

Recombinant activated factor VII (rFVIIa) therapy

Small studies show promise, but concern for pro-

thrombotic effects

High mortality rate, ~50%

10% pre-hospital 25% within 24 hrs

45% within 30 days

Prognostic Factors
Level of consciousness Age Amount of blood on CT

Diagnosis
Head CT (+) in 92% of cases w/in 24 hrs Most sensitive in first 12 hrs Lumbar Puncture Not necessary for diagnosis but consider if clinical suspicion & negative head CT Elevated pressure & RBCs Xanthochromia: pink/yellow tint due to RBC breakdown

Neurosurgical ICU Constant monitoring Bedrest Pain control Reverse coagulopathies DVT Prophylaxis (SCDs) Blood Pressure Management Management of Aneurysms/AVMs