Ischemic Stroke

Outline
Clinical Presentation
Anterior Circulation Posterior Circulation

Stroke Mechanism
Heart Vessel Blood

Treatment T t t
Acute Management Long Term Prevention

Ischemic Stroke
Acute onset of neurologic deficits caused by impaired blood flow to the central y nervous system. 3rd leading cause of death leading cause of adult disability
30% impaired ADLs 20% impaired ambulation 16% require institutional care

Presentation of Ischemic Stroke

TIA
complete recovery of symptoms in 24hr

Stroke
persisting neurologic deficit after 24hrs f f infarct on CT or MRI

TIA
most TIAs last 5-20 minutes 5 if >1hr usually small infarction on MRI

TIA s TIAs predict future strokes

30% TIA will have a stroke in 5yrs, 20% in 1 month

High risk TIA: ABCD

Age>60, BP > 140/90, Clinical weakness or speech, Duration >10min diabetes >10min, if all 5 factors 40% risk stroke in 7 days urgent workup Lazarus effect, + emboli detection effect

TIA Syndromes
Amaurosis fugax
sudden onset painless vision l dd t i l i i loss, curtain over one eye, b i f 1-5 i t i brief 1-5min ophthalmic artery emboli

Subclavian steal
gives B/S ischemia, worse with arm exercise

Transient global amnesia

reversible antegrade + retrograde memory loss, repetitive questions

Crescendo TIAs
cerebral ischemia increasing in frequency, severity and duration Capsular warning syndrome: repeated weakness face arm leg face, arm,

DDx TIA
Migraine, Seizure, Syncope Tumor, Subdural, SAH Hypoglycemia Labyrinthine dz TIA rarely march across body
suggests Sz, migraine Sz involuntary movements more Sz fortification/scintillating light more migraine

Approach to TIA
Rule out other causes of transient events Imaging of Carotid arteries
Carotid U/S, MRA neck, CT angio neck Urgent for high risk patients Carotid endarterectomy early for stenosis >70%

Start ASA Control Vascular risk factors Follow up stroke prevention clinic if not admitted

Stroke Syndromes
Anterior Circulation
MCA ACA

Lacunar Posterior Circulation

PCA Basilar Vertebral

MCA Strokes
most common ischemic stroke arm + face > leg weakness and sensory loss can see aphasia neglect homonymous aphasia, neglect, hemianopia

MCA Strokes
Proximal MCA
contralateral hemiplegia, conjugate eye deviation, hemisanesthesia, homonymous hemianopsia, aphasia or neglect

Upper MCA
f face + arm affected more than leg, Brocas aphasia ff t d th l B h i

Lower MCA
leg> face + arm, Wernicke aphasia or behavioural disturbance (non dominant hemisphere), homonymous hemianopia hemisphere)

Angular gyrus
Gerstmanns syndrome: fi G t d finger agnosia, acalculia, R-L di i t ti i l li R- disorientation, agraphia

Right parietal
anosognosia, neglect apraxia impaired prosody confusion/delirium anosognosia neglect, apraxia, prosody,

ACA Strokes
less common 3% weakness LE >UE abulia, akinetic mutism, emotional di b li ki i i i l disturbance b transcortical motor aphasia head deviation toward lesion Paratonia Ant choroidal a. syndrome ant limb int capsule
hemiparesis, hemisensory loss, hemianopia

Lacunar Strokes
Infarct from small penetrating arteries p g 20 syndromes, 5 most common y ,
1. Pure motor weakness face, arm and leg 2. Pure sensory paresthesias & numbness, face, arm and leg 3. Sensory-Motor weakness and sensory loss Sensoryp 4. Ataxia hemiparesis -weakness LE, incoordination ipsilateral arm and leg 5. Dysarthria-Clumsy hand syndrome Dysarthria-dysarthria dysphagia dec fine motor hand dysarthria, dysphagia,

Posterior Circulation Strokes

Cerebellar Brainstem Parietal Occipital P i t l-O i it l ParietalThalamic Supplied by PCA, AICA, SCA PICA PCA AICA SCA, PICA, Basilar and Vertebral arteries

Cerebellar Strokes
Present with vertigo, nystagmus, gait ataxia, truncal g , y g ,g , ataxia, dysmetria, dysarthria Often associated with Brainstem Strokes
See cranial nerve involvement and Horners syndrome

If infarct large can cause decreased LOC, hydrocephalus, herniation and death need close observation should consult neurosurgery

Brainstem Strokes
Suspect based on involvement of cranial nerves, cerebellum, altered LOC, crossed motor and crossed , , sensory findings Midbrain
CN III ipsilateral paresis, dil t d pupil i il t l i dilated il

Pons
-CN V facial numbness weakness jaw movements numbness, -CN VI lateral rectus palsy -CN VII facial weakness

Medulla
CN VIII vertigo, hearing loss -CN IX, X dysphagia -CN XII tongue weakness

Brainstem Syndromes
Locked in Syndrome y
bilateral ventral pons lesion quadriplegia, aphonia, impairment horizontal eye movements can move eyes vertically, can blink normal wake/sleep cyles

Lateral Medullary Syndrome (Wallenbergs)

vertebral artery occlusion, less commonly PICA y y ipsilateral Horners, loss pain/temp face, weakness palate, pharynx, larynx, ataxia contralateral pain/temp body loss p p y

ParietalParietal-Occipital Strokes (PCA)

Visual Symptoms
homonoymous hemianopia (can be macular sparing), quandrantanopia visual hallucinations, visual or colour agnosia, prosopagnosia

Sensory Changes
paresthesias, altered position, pain, temperature sensation

Language
anomic or transcortical sensory aphasia alexia without agraphia difficulty naming colors, objects, photographs, but can name letters, letters, numbers can get amnesia agitated delirium amnesia,

ParietalParietal-Occipital Syndromes
Antons syndrome Anton s cortical blindness with denial of blindness Balints syndrome optic ataxia psychic paralysis of fixation (cant ataxia, (can t look to peripheral field), disturbance of visual atte t o , s u tago os a attention, simultagonosia

Thalamic Strokes
aphasia, akinetic mutism DejerineDejerine-Roussy syndrome (thalamic pain pain, sensory loss) visual field defects (quadrantanopia, secto a op a) sectoranopia)

Watershed Infarcts
Hypoperfusion of CNS
post CABG, cardiac arrest, respiratory hypoxia, bilateral carotid stenosis

Border zone infarcts

MCA-PCA bil t l parieto-occipital i f t MCA-PCA: bilateral parietoi t i it l infarcts
altitudinal filed defect, optic ataxia, cortical blindness dyslexia, dyscalculia, dysgraphia, impaired memory

ACA-MCA: ACAsensorimotor impairment (man-in-a-barrel) (man-inimpaired saccades (FEF)

PICA-AICA-SCA PICA-AICA-

Exam Tips
Cortical infarcts are suspect based on the presence of
visual field impairment language impairment neglect or anosognosia graphethesia or stereoagnosia

Pyramidal pattern weakness

UE extensor > flexor t fl
weakness shoulder abduction, elbow extension, wrist extension, finger extension

LE flexor > extensor

weakness hip flexion, knee flexion, ankle dorsiflexion

Tone decreased on side of weakness early on, later on increased Reflexes h R fl hypereflexic on side of weakness, with up-going t fl i id f k ith up- i toe look for a Horners syndrome: ptosis, miosis listen for heart murmur take pulse for atrial fibrillation

Mechanism Stroke
Vessel
Carotid U/S, MRA, CTA, Angio

Heart
EKG, Holter, EKG Holter Echo

Blood
INR, PTT, Platelets

Vessel
Atherosclerotic
Large vessel Lacunar

NonNon-atherosclerotic (5% of strokes)

Dissections Vasculitis Fibormuscular dysplasia Radiation Moyamoya CADASIL Fabry s Fabrys

Vessel: Atherosclerosis
Common in patients with vascular risk factors
Age, HTN, DM, S k H A HTN DM Smoker, Hyperlipidemia, CAD St k ABI <0.9 li id i CAD, Stroke, 09

ArteryArtery-artery embolism
-fatty streak fibrous plaque thrombosis plaque hmg / necrosis /calcification

Carotid disease cause 15% of strokes Carotid C tid U/S

-stenosis 70-99% benefit from early carotid endarterectomy 70-17% absolute risk reduction

-stenosis 50-69% may benefit from CEA if have vascular risk factors 50- % y
-male, smoker, diabetes, HTN, CAD, hemispheric stroke, ulcerative stenosis, contralateral carotid occlusion

balance risk of surgery vs risk of stroke g y

Vessel: Lacunar
microvascular disease caused by long standing HTN, DM, smoking involves putamen, pons, thalamus, post limb internal capsule caudate nucleus capsule, associated with cognitive impairment g p CT leukoariosis

Vessel: Non-Atheroslerotic NonDissections

subintimal hematoma of internal carotid artery or vertebral artery eye pain, headache, Horners, neck pain, stroke symptoms associations
trauma connective tissue: FMD Marfans syndrome Ehlers Danlos type IV FMD, Marfan s syndrome, atherosclerosis

Invx: Angio, MRA, CTA, U/S

see string sign, smooth tapered occlusion

Rx: Heparin / Warfarin 3-6mts 3 avoid anticoagulation in intracranial dissections risk SAH

Vessel: Non-Atheroslerotic NonI fl t V litid Inflammatory Vasculitides

fever, headache, seizure, cognitive deterioration mononeuritis multiplex, palpable purpura iti lti l l bl Invx: -Inc ESR / CRP, anemia, leukocytosis
-Angio, biopsy Angio

Rx: steroids Etiology Vasculitides

Infection syphilis, TB, fungal, VZV, HIV Drugs -cocaine, talwin, heroin, phencyclidine, ephedra Inflammatory / Systemic Vasculitides Lupus Behcets, Sarcoidosis, Post Strep Glomerulonephritis Takayasus arteritis Giant cell arteritis / Temporal arteritis Thromboangitis obliterans / Buergers disease

Vessel: Non-Atheroslerotic NonCADASIL

blood vessel disease from notch 3 gene mutation migraine with subcortical strokes, positive FmHx

Homocystinuria
inc homocysteine causes endothelial damage

Fabrys Disease Fabry s

X-linked deficiency of lysosomal a-galactosidase aaccumulation of ceramide trihexosidase in vessel walls

Cardioembolic Stroke
1515-20% of ischemic strokes suspect if infarct is l i f i large, multiple, bil l i l bilateral wedge shaped i f l d h d infarcts with hmg component Risk of Emboli High risk:
Muscle: AMI, Cardiomyopathy Valve: rheumatic mitral stenosis, mechanical valves, infective endocarditis Other: cardiac tumors (atrial myxoma, rhabdomyoma), A-fib Oth di t ( ti l h bd ) A-

Mod risk:
Muscle: remote MI, LV aneurysm, hypertrophic cardiomyopathy Valve: MVP, mitral or aortic valve calcification, valvular strands, Other: PFO, ASA, A-flutter, Chiari network A-

Low risk:
Congenital heart disease, Anemia

Cardioembolic Stroke
Atrial Fibrillation
5-6 fold higher stroke risk Risk of stroke based on CHAD2
CHF, HTN, Age >65, Diabetes 2 , previous stroke/TIA Presence of each factor increases risk of stroke in A-fib Ahigh risk group 5-7% strokes per year 5-

Warfarin INR 2-3 reduces stroke risk by 66% 2-

Cardioembolic Stroke
Patent Foramen Ovale
present in 25% of patients right to left shunt risk emboli high if larger or present with atrial septal aneurysm Invx: Bubble study or TEE Rx -no difference b/w ASA vs warfarin -transcather or surgical closure

Cardioembolic Stroke
AMIAMI -stroke occurs in 1% of AMI
85% of strokes occur in 1st wk, all by 3 months high risk: anterior wall MI, decreased ejection fraction

Cardiomyopathy C di th
dilated or congestive 2 HTN, inflammatory, infection, metabolic CHF uncommon to have embolism

Valvular
Mitral Stenosis -emboli in 9-14% 9SEM: inc t k i k Age>50 SEM i stroke risk if A 50 Infective Endocarditis vegetations by TTE Non-bacterial thrombotic endocarditis -emboli in 50% Non-

Blood Hypercoagulable
Primary y
Arterial:
Antiphospholipid Ab Syndrome Hyperhomocystenemia

Venous:
Activated Prot C resistance Factor V Leiden, Prothrombin G20210A mutation Leiden, Prothrombin Antithrombin III Deficiency Protein Protein C or S deficiency Abnormal Fibrinogen or Plasminogen

Rx: Warfarin or Heparin

Blood Hypercoagulable
Secondary y
Malignancy Hormonal
P Pregnancy BCP -avoid in females with HTN, age>35, smokers Ovarian Hyperstimulation Syndrome

Nephrotic Syndrome Polycythemia Vera Thrombocytopenia hrombocytopenia Sickle Cell Diabetes

Stroke Treatment
Acute Stroke Management
Reperfusion, Neuroprotection Supportive care: BP, Glucose, Feeding

Long Term Management

Risk Factor: HTN, DM, lipid, smoking, A-fib Antiplatelet or Anticoagulant Rehabilitation

Acute Stroke Treatment

1. 1 Reperfusion
IV TPA experimental procedures:
IA TPA, Catheter devices

2. Neuroprotection
no approved neuroprotective agent, 120 trials prevent hyperglycemia, hypoxia, hypoperfusion, hyperthermia

Reperfusion: Reperfusion: IV TPA

0.9 mg/kg IV TPA IV under 3 hrs of onset hrs Inclusion Criteria:
onset <3hrs, deficit on NIH stroke scale, no hmg on CT head

Exclusion criteria:
rapidly improving deficits, Sz at onset of event prior ICH Hx suggests of SAH, stroke past 3mts ICH, suggests SAH, GI or GU hmg in past 3wks, recent MI, major surgery 14d MI, arterial puncture noncompressible site past 7d Labs: glucose <2.7mM or >22.2mM, platelet <100 000, >22.2mM, 000, INR >1.7, PT >15 SBP >186 or DBP >110, Hg<100?

Reperfusion IV TPA
Risk of intracerebral hmg 6.4% g % Absolute benefit 11-13% 1130% chance mild neurologic deficit at 3 mts g mts Good response
treatment in 90min, normal CT, mild-mod stroke severity, mildno DM, normal glucose, normal BP glucose,

Poor response
large area hypo-attenuation with mass effect, advanced age, hypoDM, DM inc BP before/during/after treatment severe deficits treatment, deficits, protocol violations

Supportive Stroke Care

Stroke units CNS
seizures occur in <5% hyperthermia worsens stroke depression in >25%

CVS
MI in 3% BP: dont decrease by >10%

Resp
aspiration occurs in 25%, swallowing assement 25%, PE / DVT Heparin sc or pneumatic compression

GI
hyperglycemia worsens stroke

Risk Factor Reduction

Hypertension
most important modifiable RF 38% stroke reduction with a 10-12 t k d ti ith 10-12mmHg SBP reduction H d ti lowering blood pressure more important than drug used PROGRESS trial: perindopril, indapamide

Diabetes
no evidence that tighter glycemic control reduces stroke risk, but thi is recommende b t this i recommende d

Lipid
high LDL, low HDL associated with inc stroke risk statins reduce strokes 20-28% 20-

Smoking
inc RR stroke 2-3fold 2-

Antiplatelets
Primary Prevention -no role in low risk, middle y , age population Secondary prevention -start all patients with stroke or TIA on ASA -if have stroke on ASA, reasonable to change t A h to Aggrenox or Cl id Clopidogrel l -no benefit to ASA + Clopidogrel in longterm prevention, increase hemorrhage risk (MATCH) prevention ASA -irreversible inhibition of cyclo-oxygenase cyclo-reduced risk stroke, MI, vascular death by 25%