Stroke

Definition
Stroke: sudden onset of neuro deficit from the death of
brain tissue
o Ischemic (85%): normal CT, focal nature, insidious
Thrombosis
Embolism
o Cardiogenic: Afib, Valve Dz, DVT via PFO
o Carotid Stenosis
o Hemorrhagic (15%): HA, Elevated BP, abrupt
TIA: <24h of stroke sxs that resolve completely w/o
change on imaging
o Usu last <1hr, indicate more strokes are likely coming
o Always embolic or thrombotic, never due to hemorrhage (dont resolve in 24h)
o Amaurosis fugax (transient monocular vision loss 2/2 opht. Artery occlusion)
Risk factors: SHODDY (same as for MI)
Clinical Presentation
MCA Stroke (>90%)
o Contralateral Weakness or Sensory Loss
o Homonymous Hemianopsia
L-sided MCA stroke = loss of R visual fields, eyes deviate to L
o the eyes look toward the lesion
o Aphasia
Only if stroke is on same side of speech center (Left side in 90%)
ACA Stroke
o Personality Change/Cog. Deficit/Confusion/Psych Disturbance
o Incontinence
o Leg weakness more significant than arm weakness
PCA Stroke
o Ipsilateral sensory loss of face, IX and X
o Contralateral sensory loss of limbs
o Limb ataxia
Diagnostic Testing
Best Initial Test: CT w/o contrast
o CT first to r/o hemorrhage! (more se to blood)
o CT needs 4-5d to reach >95% se (nml CT until this time!!)
Most Accurate Test: MRI
o MRI needs 24-48h to reach >95% se
o MRA most accurate for brainstem
Echocardiogram
o Vessel dmg, PFO, thrombi hep then warf to INR 2-3 for thrombus
EKG
o Afib or flutter (warfarin to INR 2-3 if arrhythmia persists)
o All stroke pts should be placed on telemetry to detect Afib/Aflutter
Holter (24-48h ambulatory monitoring)
o Greater se in detecting atrial arrhythmias
Carotid duplex u/s
o If pt is sx, with >70% block perform CEA
o If pt is sx with <50% block, do not perform surgery
o Angioplasty with stenting has no proven value (DO NOT SELECT THIS)
Blood work
o Pts <50: ESR, VDRL/RPR, ANA, dsDNA, Protein C/S, Factor V, AntiPhosopholipid Ab


Treatment
< 3h since onset of stroke: thrombolytics (eg. tPA)
o CI to thrombolytics
Hx of hemorrhagic stroke
Intracranial neoplasm/mass
Active bleed/surgery within 6 weeks
Bleeding disorder
Traumatic CPR within 3 weeks
Suspicion for Aortic dissection (which would be?)
Stroke in past year
Head trauma/surgery past 6 months
> 3H since onset: ASA
o ASA +/- dipyridamole OR clopidogrel
o No clear evidence of heparins benefit for stroke
o NEVER choose ticlopidine (no benefit + ADEs like TTP, neutropenia)
Hemorrhagic: lower BP
Patient already on ASA?
o add dipyridamole or switch to clopidogrel
Stroke Prevention
STOP SMOKING
HTN: <130/80 in a diabetic
Obesity: lose it
Diabetics: lower Hbg A1C to below 7%
Dyslipidemia: Reduce LDL to <100 if carotid stenosis
is source (carotid stenosis ~ CAD)
Stroke Presentation
ACA
o contralateral paresis and sensory loss
o loss of bladder control (hypertonic detrusor)
Internal carotid
o premonitory TIA or transient monocular blindness (amaurosis fugax),
asymptomatic or similar to MCA occlusion
PICA (Lateral Medullary or Wallenburg Syndrome)
o ipsilateral ataxia, Horners, facial sensory loss
o contralateral limb impairment of pain and temperature
o nystagmus, vertigo, N/V, dysphagia, dysarthria, hiccup
Lacunar Infarcts (basal ganglia, thalamus, posterior limb
internal capsule) -
o pure motor hemiparesis: contralateral arm, leg, and face
o pure sensory loss: hemisensory loss (usually thalamic)
o ataxic hemiparesis: ipsilateral ataxia and leg paresis
o dysarthria-clumsy hand syndrome: dysarthria, facial weakness, dysphagia, mild
hand weakness and clumsiness
Stroke Presentation
PCA
o contralateral homonymous hemianopsia (especially superiorly)
o midbrain findings (vertical gaze palsy, CN III palsy, INO)
o occipital findings (anomia, alexia without agraphia, visual agnosia)
o if bilateral: cortical blindness or prosopagnosia

Basilar artery
o proximal (usually thrombosis) occlusion: CN VI palsy, impaired horizontal
EOM impairment, vertical nystagmus, reactive myosis, hemi- or
quadriplegia, coma, locked-in syndrome
o distal (usually embolic) occlusion (aka Top of the Basilar Sydrome):
decreased LOC, CN III palsy, decerebrate or decorticate posturing

Stroke Presentation
MCA: proximal occlusion involves all of the below
o superior division
contralateral face and arm paresis and sensory loss
Brocas (expressive) aphasia (if in dominant hemisphere)
o inferior division
contralateral homonymous hemianopsia (esp. inferiorly)
contralateral agraphesthesia and astereognosis
anosognosia
contralateral neglect
Wernickes (receptive) aphasia (if in dominant hemisphere)
MCA stroke can cause CHANGes
Contralateral paresis and sensory loss in the face and arm
Homonymous hemianopia
Aphasia (dominant)
Neglect (nondominant)
Gaze preference toward the side of the lesion

Stroke Syndromes
ACA Stroke
Contralateral paresis and sensory loss
o Upper body = mild weakness
o Lower body = profound weakness
Incontinence 2/2 hypertonic detrussor
Personality Change/Psych Disturbance


Algorithm
Blood
o CBC, Glu, PT/PTT
o Pts <50: ESR, VDRL/RPR, ANA, dsDNA, Protein C/S, Factor V, Anti-
Phosopholipid Ab
(lower age = incr. chance its vasculitis or hypercoag state)
EKG
o Looking for Afib/Aflutter
If present, start on warfarin to INR 2-3
CT without contrast
o No bleeding, continue to find source
o If bleeding, neurosurg consult (unlikely to intervene)