Updated: 6/18/2021

Stroke

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  • 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

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