summary Stroke is an acute onset of focal neurologic deficits resulting from diminished blood flow or hemorrhage in the brain. Diagnosis is made clinically with specific and thorough neurological examination. Treatment is emergent medical management and possible surgical management depending on underlying cause. Epidemiology incidence risk factors include diabetes smoking atrial fibrillation cocaine Etiology Two forms diminished blood flow (ischemic stroke) hemorrhage (hemorrhagic stroke) Pathophysiology etiology include 35% - atherosclerosis of the extracranial vessels (carotid atheroma) 30% -cardiac and fat emboli, endocarditis 15% - lacunar occur in areas supplied by small perforating vessels and result from atherosclerosis hypertension diabetes 10% - parenchymal hemorrhage 10% - subarachnoid hemorrhage 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 Symptoms of various strokes 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 (clusy 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 Imaging CT without contrast indicated for acute presentation important to diagnose as ischemic or hemorrhagic MRI indicated for subacute vascular studies of intra and extracranial vessels Studies Labs should include coagulation studies lumbar puncture to r/o encephalitis Echo to check for mural thrombus, rule out endocarditis EEG to rule out seizure Differential Brain tumor, epi / subdural bleeds, brain abscess, endocarditis, multiple sclerosis, metabolic (hypoglycemia), neurosyphillis Treatment Nonoperative thrombolytics indications for occlusive disease modalities 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 warfarin/aspirin therapy indications for embolic disease and hypercoagulable states give warfarin / aspirin once the hemorrhagic stroke has been ruled out anti-hypertensive medications do not overtreat hypertension. Allow BP to rise to 200/100 to maintain perfusion Operative thrombectomy indications 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. endarterectomy indications 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