What Is A Stroke ?
Stroke
Stroke
Ataxia
Sensory loss
Neglect
Consciousness is generally normal
but maybe impaired
Nature of Symptoms
Mortality of Strokes
Stroke
Stroke
Causes of Stroke
Causes of Stroke
Prevention of Stroke
Heart Disease
Cigarette Smoking
Diabetes
Age
Gender
Race
Prior stroke
Family history
Geographical Location
Socioeconomic Factors
Stroke Background
Inadequate blood flow
Ischemic stroke
Focal thrombotic or embolic occlusion of
major artery
Global inadequate cerebral perfusion
Hemorrhage
Parenchymal into brain tissue
Subarachnoid surrounding subarachnoid
space
Causes of Stroke
Ischemic Stroke
Premature atherosclerosis
Dissection (spontaneous or traumatic)
Inherited metabolic diseases (homocystinuria, Fabrys, pseudoxanthoma
elasticum, MELAS syndrome)
Fibromuscular dysplasia
Infection (bacterial, fungal, tuberculosis, syphilis, Lyme)
Vasculitis (collagen vascular diseases systemic lupus erythematosus,
rheumatoid arthritis, Sjgrens syndrome, polyarteritis nodosa; Takayasus
disease, Wegeners syndrome, cryoglobulinemia, sarcoidosis, inflammatory
bowel disease, isolated central nervous system angiitis)
Moyamoya disease: (Japanese, "puff of cigar smoke") is an inherited
disease in which certain arteries in the brain are constricted
Radiation
Toxic (illicit drugs cocaine, heroin, phencyclidine; therapeutic drugs Lasparaginase, cytosine arabinoside, ephedra, phenylephrine)
Hematologic disease
Sickle-cell disease
Leukemia
Hypercoagulable states (antiphospholipid antibody
syndrome, deficiency of antithrombin III or protein S or C,
resistance to activated protein C, increased factor VIII)
Disseminated intravascular coagulation
Thrombocytosis
Polycythemia vera
Thrombotic thrombocytopenic purpura
Venous occlusion (dehydration, parameningeal infection,
meningitis, neoplasm, polycythemia, leukemia,
inflammatory bowel disease)
Hematologic Disorders
APS
Hematologic disorders
Embolism:
Cardiogenic (atrial fibrillation,
mural thrombus, myxoma,
valvular vegetations)
Artery-to-artery
Fat
Air
Paradoxical (emboli of
venous origin passing through
a patent foramen ovale)
Cardiogenic Embolism
Anticoagulation
Indicated
Atrial fibrillation
Mitral stenosis
Prosthetic cardiac valve
Recent MI
Thrombus in LV or LA appendage
Atrial myxoma
Infective endocarditis (No anticoagulation)
Dilated cardiomyopathy
Cardiogenic Embolism
Cardiogenic Embolism
Cardiogenic Embolism
Paradoxical embolization
from the right heart to the left is
believed to occur via a patent
foramen ovale or atrial septal
defect (which can be found on
autopsy in up to one fourth of all
people.
Atherosclerosis of the
aorta or carotid arteries
can be a source of both
atheroemboli and
thromboemboli
Cardiogenic Embolism
Left
atrium
Right
atrium
Left atrium
Valsalva
RA
LA
Right
atrium
Left
atrium
Left
atrium
Left
ventricle
Right
atrium
Right
ventricle
PFO
Cocaine Abuse
Arteriovenous Malformations
HEMORRHAGIC
Arteriovenous malformation
Neoplasm (primary central nervous
system, metastatic, leukemia)
Hematologic (sickle-cell disease,
neoplasm, thrombocytopenia)
Moyamoya disease
Drug use (warfarin, amphetamines,
cocaine, phenypropanolamine)
Iatrogenic (peri-procedural)
Moyamoya
Intracerebral Hemorrhage
Causes of Spontaneous
Intracerebral Hemorrhage
(ICH)
Intraparenchymal hemorrhage
Trauma
Hypertension
Amyloid angiopathy
Arteriovenous malformation
Bleeding diathesis (anticoagulants,
thrombolytics)
Drugs (amphetamines, cocaine)
Causes of Spontaneous
Intracerebral Hemorrhage
Cervical arterial
(ICH)
dissection causes up
Causes of Spontaneous
Intracerebral Hemorrhage
In many cases the dissection is preceded
(ICH)
Causes of Spontaneous
Intracerebral Hemorrhage
Inherited disorders
that are
(ICH)
Diagnosis, Management,
and Prognosis of ICH
Diagnosis, Management,
and Prognosis of ICH
Subarachnoid Hemorrhage
Causes of Spontaneous
Intracerebral Hemorrhage
(ICH)
Subarachnoid hemorrhage
Congenital saccular aneurysm (85%)
Unknown (15%)
Right (Non-dominant)
Hemisphere Stroke:
Common Pattern
Left (Dominant)
Hemisphere Stroke:
Common Pattern
Aphasia
Right hemiparesis
Right-sided sensory loss
Right visual field defect
Poor right conjugate gaze
Dysarthria
Difficulty reading, writing, or
calculating
Crossed signs
Limb or gait ataxia
Dysarthria
Dysconjugate gaze
Nystagmus
Amnesia
Bilateral visual field defects
Small Subcortical
Hemisphere or Brain Stem
Stroke:
Common
Pattern
Pure Motor
Pure Sensory
Decreased sensation of face and limbs on one
side of the body without abnormalities of
higher brain function, motor function, or vision
Physical Exam
Neurologic Exam
Carotid Bruits
Cardiac Exam
Peripheral Pulses
Dermatologic
Ophthalmologic
Dermatologic
Xanthoma, eruptive
CAF AU LAIT spots
Neurofibromas
splinter hemorrhages
Opthalmlogic
Corneal arcus
optic atrophy in tuberous sclerosis
Treatment of Strokes
Antiplatelet therapy remains treatment
of choice to prevent recurrent
thromboembolism in majority of
patients
Anticoagulation may be appropriate
Atrial fibrillation
Recent MI
Suspected propagation of thrombus or
stroke in evolution
Treatment of Strokes
Limitations of Imaging
Thrombolysis t-PA
Guidelines for treatment:
Rehabilitation
Rehabilitation Specialists
Provider
Rehabilitation specialist
Physical therapist
Speech therapist
Occupational therapist
Physiatrist
Psychiatrist
Family Relationships
Sexual Relationships
Social Activities
Prognosis
Stroke Chameleons
Stroke Chameleons
Stroke Chameleons
Differential
Diagnosis
Hyperglycemia (nonketotic
hyperosmolar coma)
Hypoglycemia
Post-cardiac arrest ischemia
Drug/narcotic overdose
Focal
symptom
s
Nonfocal
symptoms
Seizures
++
++
TIAs
++++
occasionally
Migraine
++++
++++
Common
disorders
Syncope
Less common
disorders
Vestibulopathy
++
++
Metabolic
+++
"Tumor attacks"
+++
Multiple
sclerosis
++++
Psychiatric
++
Nerves and
nerve root
++++
Transient global
amnesia
++++
0
++
Differential
Diagnosis of Transient Neurological
Diseases
TIA
Seizure
Migraine with aura
Syncope
Hypoglycemia
Hypoglycemia
Mass Lesions
Functional Hemiparesis
Seizures Demographics
Seizures Timing
20 to 80 seconds
Absence, atonic seizures and
myoclonic jerks are shorter
Postictal depression
Spells occur over years
Focal Seizure
What is a TIA
Acute loss of focal cerebral function
Symptoms last less than 24 hours
Due to inadequate blood supply
Thrombosis
Embolism
Increasing age
Sex
Family history / Race
Prior stroke / TIA
Hypertension
Diabetes
Heart disease
Carotid artery / Peripheral artery disease
Obesity
High cholesterol
Physical inactivity
TIA Symptoms
TIA Demography
Older patients
Stroke risk factors present
Men>women
TIA Presentation
TIA Presentation
TIA Presentation
TIA Presentation
TIA Presentation
Disorientation
Impaired attention/concentration
Diminution of all mental activity
Distinguish from
Isolated language or visual-spatial perception
problems (may be TIA)
Isolated memory problems (transient global
amnesia)
TIA
Significant risk factor for recurrent
stroke, with average 5% risk per year
Prophylactic antiplatelet therapy shown
to prevent secondary effects
Aspirin
Ticlopidine: thrombotic stroke
reduction
Clopidogrel: reduce events associated
with atherosclerosis that include
strokes, MI, PVD
TIA
Treat with warfarin if significant risk for
cardiogenic thromboembolism
Hospital admission for new-onset and
recurrent TIAs unless confident in
diagnosis of etiology
Angiography treat medically or
surgically
TIA
Migraine Demography
Younger age
Women>men (4:1)
10-20% of the population
The risk of migraine with aura and
transient ischemic attacks (TIAs) is
greater than 2 fold.
1/3 have migraine with aura
Positive symptoms
Spread over minutes
Visual disturbances
Somatosensory or motor disturbance
Headache within 1 hour
Visual symptoms
with other symptoms
26% sensory
16% aphasia
6% dysarthria
10% weakness
Usually 20 to 30 minutes
Sporadic attacks during years
Migraine
Migraine
Visual loss
Abrupt
Simultaneous occurrence
Syncope Demography
Syncope Timing
Seizures
Demography
TIAs
Migraine
Syncope
Older patients
Younger age
Women>men
Women>men
First positive
symptoms, then
negative in same
modality: scintillating
scotomas and
parasthesias most
common; second
sensory modality is
involved after first
clears
Light-headed, dim
vision, noises
distant, decreased
alertness
Men>women
Central nervous
system symptoms
Timing
Positive symptoms:
limb jerking, head
turning, loss of
consciousness
Negative symptoms:
numbness, visual
loss, paralysis, ataxia
Negative symptoms
may develop, remain
postictally, and
persist
All sensory
modalities affected
simultaneously
20 to 80 seconds
Usually minutes,
mostly <1 hour
Usually 20 to 30
minutes
Usually a few
seconds
Absence, atonic
seizures and
myoclonic jerks are
shorter
Sporadic attacks
during years
Sporadic attacks
during years
Postictal depression
Spells occur during
years
Transient loss of
consciousness
Intracranial hemorrhage
ICH rare to confuse with TIA
Subdural hematoma
Headache
Fluctuation of symptoms
Mental status changes
Multiple sclerosis
Usually subacute but can be acute
Optic neuritis
Limb ataxia
Labyrinthine Disorders
Central vs. Peripheral vertigo
Mnire's disease
Benign positional vertigo
Acute vestibular neuronitis
Case 1
Case 1
Case 2
When 22-year-old Ms. KS began
experiencing left arm weakness, she
went to a clinic only to be told that
nothing was seriously wrong. But
when her symptoms persisted, so did
she. She was finally referred to the
Medical Center, where neurologists
confirmed that her symptoms were
the result of a stroke.
Case 2
Case 2
Case 3
Case 3
Case 4
Case 4
Summary
Summary
Summary
Summary
Summary
Summary
Summary