Ischemic Stroke

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Stroke is:

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sudden neurological dysfunction due to a vascular cause.

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Types of Ischemic Stroke:

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1) Cardioembolic stroke (about 25%)
*Strokes of cardiac origin
*Includes atrial fibrillation, valvular heart disease

2) Small vessel disease (about 25%)
*Strokes due to occlusion of vessels 0.05-0.5 mm
*Often due to HTN, diabetes

3) Large vessel disease (about 25%)
*Strokes due to occlusion of vessels 1-4 mm (carotid [3-4 mm], middle cerebral artery [1-2 mm])
*Often due to high cholesterol

4) Rare and unknown cause (about 25%)
*Includes stroke due to arterial dissection (tear), blood coagulation abnormality

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Superior branch of MCA?
Inferior?

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M2
M1

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Small vessel disease is most often attributed to:

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Hypertension

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Left middle cerebral artery (MCA) stroke:5

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-Aphasia
-Right hemiparesis (weakness); face and arm more than leg
-Right hemianesthesia (sensory loss)
-Right hemianopia (visual loss on the right out of each eye)
-Deviation of eyes to left

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Right middle cerebral artery (MCA) stroke

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-Neglect to left side.
-Left hemiparesis (weakness); face and arm more than leg.
-Left hemianesthesia (sensory loss)
-Left hemianopia (visual loss on the left out of each eye)
-Deviation of eyes to right

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Lacunar stroke:
*3 syndromes

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-Typically one side weakness W/O aphasia or neglect.

-Brainstem lacunes may have crossed findings e.g.
*Weber syndrome= 3 + contraletaral hemiparesis (midbrain)
*Benedikt syndrome= 3 + contraletaral dysmetria (midbrain)
*Millard-Gubler syndrome= 6 + 7 + contraleral hemiparesis (pons)

-IIIrd palsy
-INO (MLF compromise)

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Right MLF stroke=

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Right INO.

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Spinal cord infarction:

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-Affects anterior portion of spinal cord (ASA)

-Occurs typically in setting of AAA rupture or repair with hypoperfusion

-There may be associated renal failure

-Impaired motor and pinpoint/temp

-Preserved position/vibration

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A left middle cerebral artery (MCA) stroke is typically associated with all of the following except:
A. Aphasia
B. Gaze deviation to the right
C. Right side weakness
D. Right hemianopia

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B. Gaze deviation to the right

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A left lacunar stroke is typically associated with all of the following except:
A. Aphasia
B. Right hemiparesis
C. Right hemianesthesia
D. Right hemiataxia

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A. Aphasia

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Acute stroke treatment: proven treatments

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-tPA within 4.5 hours
the sooner the better! (NNT 3 within 90 minutes, 8 within 180 minutes, 23 within 270 minutes)

-Aspirin within 48 hours
*NNT 100
*Use if pt not eligible for tPA

-Stroke units
*NNT 20-30

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tPA basic facts:

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-B/t 0-4.5 hours

-Time last known well (25% of patients wake up with stroke. Timed to when they went to sleep).

-CT: must have no hemorrhage
-BP must be < 185/110
-Glucose must be b/t 50-400
-Platelets must be > 100
-INR should be < 1.7 (if not on warfarin, no need to wait)
-No “recent” procedures or events (1-3 months for surgery, MI, stroke)

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Acute stroke treatment: unproven

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-Heparin and heparinoids
*Not even in atrial fibrillation or large vessel atherosclerosis (such as carotid stenosis)

Oxygen

Intravenous fluids

Laying head of bed flat

Modifying blood pressure

Intra-arterial therapy

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ABCDE of stroke treatments:

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-Antiplatelets/anticoagulants

-BP control

-Carotid repair/Cholesterol lowering/cessation of smoking

-Diet

-Exercise

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antiplatelet meds:

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[aspirin, aspirin/dipyridamole (Aggrenox), cilostazol (Pletal)*, clopidogrel(Plavix)])

-Best choice for non-atrial fibrillation stroke

-Avoid combination of aspirin and clopidogrel for more than 12 months

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anticoagulant meds:

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[apixaban (Eliquis, dabigatran (Pradaxa), rivaroxaban (Xarelto), warfarin (Coumadin)]

Best choice for atrial fibrillation stroke

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BP control to prevent stroke:

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-Ideal target to be determined

-In general, less than 140/90 recommended

-Less than 130/80 may be helpful for lacunar strokes

-Use pharmacological (ACE inhibtors, ARBs, diuretics, calcium channel blockers, ß-blockers, alpha blockers) AND non-pharmacological (reduced salt diet, DASH diet) measures

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Carotid a repair to reduce stroke risk and recurrence:

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Stroke patients with more than 70% narrowing of the internal carotid artery on the same side of stroke have a significant reduction in stroke risk compared to medical therapy alone-- 9% risk versus 26% over 2 years

50-69% narrowing with symptoms
16% versus 22% over 5 years

>60% narrowing and no symptoms
5% versus 11% over 5 years

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Cholesterol lowering to prevent stroke:

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-LDL target is < 100
-HDL > 40 recommended for men ; > 50 for women
-Triglyceride target < 150

-Reduction can be achieved with diet, exercise and medications (including statins)

-Some statin effects appear to be independent of lipid lowering

No proven clinical benefit of niacin, gemfibrozil

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Cessation of smoking to prevent stroke:

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-Average number of quit attempts is 7

-Additional measures that can increase success include nicotine patch, buproprion (Zyban, Wellbutrin), and varenicline (Chantix*)

-*Depression and suicidal ideation are common after stroke and may be exacerbated by varenicline (Chantix)

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Diet to prevent stroke:

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-In general, low fat diet recommended

-Increased consumption of fruits, vegetables

-Examples include DASH diet, Mediterranean diet
DASH diet is associated with lower blood pressure and weight loss

-Mediterranean diet is associated with reduced recurrent MI and death

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Exercise to prevent stroke:

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-30 minutes on most days of the week recommended

-Poor exercise capacity is associated with an increased risk of stroke (as powerful a risk factor as hypertension)

-Tendency after stroke to reduce physical activity

-Patients should be encouraged to increase mobility and activity

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In a patient with atrial fibrillation and stroke, the treatment of choice for secondary stroke prevention is:
A. Aspirin
B. Clopidogrel (Plavix®)
C. Aspirin/Dipyridamole combination (Aggrenox®)
D. Warfarin (Coumadin®)

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D. Warfarin (Coumadin®)

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A patient with a left MCA stroke had 75% stenosis of the left internal carotid artery. Of the following, the best treatment to prevent a stroke over the next 2 years is:
A. Aspirin
B. Clopidogrel (Plavix®)
C. Carotid endarterectomy
D. Smoking cessation

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C. Carotid endarterectomy

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Which of the following is not recommended long-term after stroke?
A. Aspirin
B. Blood pressure lowering
C. Exercise
D. None of the above

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D. None of the above

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Lacunar artery:

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A single deep penetrating artery that arises directly from the constituents of the Circle of Willis, cerebellar arteries, and basilar artery.

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