STROKE SYNDROME ETIOLOGY
AND CLINICAL FEATURES.
STROKE
• An 82 –Year old women with atrial fibrillation comes the emergency
department with 1 hour of difficulty moving her right arm and leg.
He medical history includes a transient ischemic attack(TIA),
hypertension, and diabetes mellitus. She had been taking warfarin but
discontinued it 3 months ago after a fall and now takes no medications.
On physical examination, she has weakness in and sensory neglect of
her right upper and lower extremities and a global aphasia with deficits
in comprehension and object naming. Complete blood count,platletes,
and coagulation panel findings are normal.
• Noncontrast computed tomography (CT) of the
brain shows no intracranial bleeding. Intravenous
recombinant tissue plasminogen activator is
administered
• What are the salient features of this patient’s problem?
How do you think through her problem.
SALIENT FEATURES
• Elderly patient; acute onset of aphasia, right-
sided hemiplegia and neglect; presentation
within 4.5 hours of symptom onset; risk factors
of atrial fibrillation, hypertension, diabetes
mellitus, and previous TIA; on no anticoagulant
medication; no intracranial bleeding.
How to think through:
• Stroke is the second leading cause of death in the
united states and is a major cause of morbidity.
• What are the likely mechanisms of this patient’s
stroke ?
(Aterial fibrillation leading to cardioembolic stroke or
Hypertension and diabetes leading to carotid
atherosclesis or intracrnial small vessel Disease and
thrombotic stroke.)
• What is her CHADS2 score?
(Using this decision aid, she receives 1 point each
for hypertension, age older than 75 years, and
diabetes plus 2 points for prior TIA for a total of 5
points; without anticoagulation, this confers a
6.9% risk of stroke per year.)
• Based on her examination, what vascular territory is
involved?
(Left middle cerebral artery.)
• How does one differentiate aphasia from
dysarthria?
(Repetition of simple words is intact in most cases of aphasia
and demonstrates intelligible speech production.)
• What factors must be assessed before
thrombolysis?
(Absence of hemorrhage on noncontrast CT scan; Stroke or
head trauma in prior 3 months)
(recent major surgery or major bleeding; duration of symptoms
>4.5 hours blood pressure >185/110 mm Hg)
(INR >1.7)
(platelets >100,000/mcL)
• If the patient is in atrial fibrillation the day
after her stroke, should cardiovascular be
considered?
(No!)
(Given her atrial fibrillation, recent stroke, and lack of
anticoagulation, cardioversion could precipitate and
embolic stroke.)
Essentials of Diagnosis
• Ischemic stroke is an occlusion of a major vessel
leading to cerebral infarction.
• Intracerebral hemorrhage is usually caused by
hypertension and occurs suddenly.
• With any stroke, the resulting deficit depends on the
particular vessel involved and the extent of any
collateral circulation.
General Consideration:
• Ischemic and Hemorrhagic strokes cannot be distinguished
solely by the clinical features.
• Brain imaging usually starting with and immediate
noncontrast head
CT Scan, is essential.
• In elderly adults, cerebral amyloid angiopathy is a frequent
cause of hemorrhage.
• The risk of both ischemic and hemorrhagic stroke increases
with age.
Symptoms and Signs
• Symptoms and signs depend on the structures involved.
• Ophthalmic artery occlusion: amaurosis fugax---Sudden and
brief monocular vision loss.
• Anterior cerebral artery occlusion: weakness and sensory loss
in contralateral leg,behaviour and memory disturbance,
rigidity, confusion, urinary incontinence.
• Middle cerebral artery occlusion: contralateral hemiplegia,
hemisensory loss, homonymous, hemianopia: language
disturbance if dominant hemisphere (usually left) involved.
• Posterior cerebral artery occlusion: ipsilateral facial,
ninth and tenth cranial nerve lesions, limb ataxia and
numbness, Horner syndrome.
• Occlusion of both vertebral arteries or the basilar
artery: coma, pinpoint pupils, quadriplegia.
• Partial basilar artery occlusion: diplopia, visual loss,
vertigo, dysathria, ataxia.
• Occlusion of any major cerebellar artery can cause
vertigo,nausea,vomiting,nystagmus,ipsilateral limb
ataxia: massive infarction can cause coma, herniation
and death.
• Cerebral hemorrhage: focal neurologic
signs , loss of consciousness
(50% of patients) , vomiting, headache,
hemiplegia or hemiparesis.
• Cerebellar hemorrhage: nausea, vomiting ,
disequilibrium, headache, loss of
consciousness
Differential Diagnosis
• Hypoglycemia
• Transient Ischemic attack
• Focal seizure (Todd paralysis)
• Migraine
• Peripheral cause of vertigo (Meniere Disease)
• Subarachnoid hemorrhage.
• Space –occupying lesion (e.g, Brain tumor)
• Subdural or epidural hemorrhage.
Laboratory Tests
• CBC,ESR,Blood glucose and serologic tests for
syphilis.
• Screening for hypercoagulable or bleeding disorders if
suspected clinically.
• Cerebrospinal fluid examination may be helpful for
cerebral vasculitis or an inflammatory or infectious
cause but only after imaging to exclude risk of
herniation.
Imaging Studies:
• CT scan of the head(without contrast) immediately in
all acute stroke to exclude hemorrhage.
• Subsequent MRI with diffusion-weighted sequences
should be performed to define area of possible
infarction.
• Imaging of the cervical vascular (e.g, MR
angiography) may be warranted in selected patients.
Diagnostic Procedures:
• ECG or continues cardiac monitoring and ECHO
if cardiac cause(arrythmia , clot, vegetation,
paradoxical embolus) is suspected.
Medications
• Aspirin is ischemic stroke after hemorrhage has been excluded and
if patient is not receiving thrombolysis .
• Intravenous thrombolytic therapy with recombinant tissue
plasminogen activator in ischemtic stroke will reduce neurologic
deficit without effect on mortality if given within 4.5 hours of
symptoms onset.
• Contraindications to thrombolytic therapy include recent
hemorrhage , risk of hemorrhage or blood pressure greater than
185/110mm Hg.
• Anticoagulant drugs(warfarin or dabigatran) for ischemic stroke in
the setting of atrial fibrillation
Surgery and Therapeutic Procedures :
• In cerebellar hemorrhage, prompt surgical evacuation of the
hematoma may be indicated
Therapeutic Procedures :
• Early management consists of general supportive measures.
• Permissive hypertension allowed in ischemic stroke to avoid
further ischemia.
• Physical and occupational therapy helps with functional
outcomes.
The end
