Overview of Stroke
Cerebral Infarction
A Case: Chief Complaint
• 34 year old female presented to a
community hospital with abnormal
language. Her husband reported that she
had been normal 2 hours earlier at which
time the patient is said to have
demonstrated shaking of the arms and
legs for several seconds of duration.
Immediately thereafter the patient was
unable to speak and there was paucity of
movement on the right side of the body.
There was no report of urinary or bowel
incontinence and no report of tongue
biting.
The Previous Medical History
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Migraine Headaches
Frequent Urinary Tract Infections
Multiple episodes of epistaxis
Depression
Miscarriage
Current Medications
• Venlafaxine, An antidepressive
medication. Works by inhibiting the
re-uptake of serotonin, noradrenalin,
and dopamine.
Social History
• Married
• Four living children. G5P5014
• Does not smoke. No history of
tobacco use.
• No history of recreational or illicit
drug use.
• No history of alcohol abuse.
• No recent travel abroad.
Stroke Epidemiology
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First…………..180,000
Recurrent…….600,000
Incidence…….780,000/yr =1stk/40s
Prevalence…..6,500,000
Males…………2,600,000
Female……….3,900,000
Stroke Mortality
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3rd Leading Cause of Death in USA
150,000 Deaths Yearly
One of Every 17 Deaths in 2005
56,586 Males
86,993 Females
Death Rate Declined in 2005 i.e.
29.7% to 13.5%
Stroke Morbidity
• Leading cause of long term disability
• 30% of survivors require assistance
with ADL ( activities of daily living)
• 20% require assistance to ambulate
• 16% must be institutionalized.
• Health care and lost income cost
approach $41 billion
Stroke by Definition:
• An acute on set of neurologic
dysfunction caused by impairment of
blood flow the region of brain
mapping to the impaired function.
• Manifest on Brain imaging.
• Dysfunction last 24 hours.
• If < 24 hours and no signature on
brain image: TIA (transient
ischemic attack
• 0
Classification of Strokes
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Hemorrhagic
15-25 %
ICH
SDH
EDH
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Ischemic
71- 83 %
Embolic
Cardiac Source
Non-cardiac
Source
• Large Vessel
Disease
• Small Vessel
Disease
Ischemic Stroke Subtypes
• Large Vessel
• Small Vessel
• Embolic (usually Cardioembolic)
• Thrombotic (usually from Atherosclerotic
Cerebrovascular Disease)
• Microangiopathic Brain Disease
• Cortical
• Subcortical
The Cerebral Circulation
Cardiac Related Stroke
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Atrial Fibrillation
Cardiac Valve disease
MI (wall motion abnormality)
Septal Aneurysms
Patent Foramen Ovale
Atrial Septal Defect
Dilated Cardiomyopathy
Risk Factors
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Hypertension
Heart Disease
Atrial fibrillation
Diabetes
Tobacco
Lipids
Abnormal
hematology
• OSA
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Age
Race/ethnicity
Gender
Family history
genotype
CONGENITAL HYPERCOAGULABLE
CONDITIONS
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Factor 5 Leiden mutation
G2021A mutation
Antithrombin 3
Protein C deficiency
Protein S deficiency
Inherited Disorders
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Homocystinuria
Fabry’s Disease
Marfan’s Syndrome
Rendu-Osler-Weber Syndrome
34 year old female :Physical Examination
• VS: 98.6, 116/71, 23/min, 106/min
• Oxygen Saturation 97%, room air
• Mute, + commands, neck supple, no
bruits, fast RR (-)MRG, clear lungs,
abd: benign, extremities: no CCE.
• ® Arm>>® Leg Weakness, ® face
weakness, (left side normal), Deep
Tendon Reflexes absent on the ®,
Plantar Response: Up on the ® and
Down on the left. Sensation: Normal.
Case laboratory studies
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Serum glucose….106
Sodium…………..142
Creatinine………...0.7
WBC………………11,900/cu mm
Platelet count……..258000/cu mm
Hemacrit……….....42%
PT………………….12.9 sec
PTT…………………34.5 sec
Computed Tomography of the Head
• Arrival to ER, Airway, Breathing,
Circulation, then…
• Head CT is crucial in the management of
the stroke patient.
• The study distinguishes hemorrhagic
strokes from ischemic strokes.
• The HCT may or may not provide
additional diagnostic information
• Diffusion weighted MRI: better stroke
detection in the first 12 hours.
• Dense MCA Sign
34 yo female
Head CT
Performed
3.5 hours
past the
onset of
stroke
symptoms
Easter JS et al. N J Med 2010;362:2114-2120.
CT: Thrombosis in the Left
Middle Cerebral Artery
• Sources of emboli to the brain
Carotid Atherosclerosis
Carotid Dissection
Intracranial Vasculopathy
Atrial Fibrillation
Cardiac Valve Disease
Right-to-Left Cardiac Shunt
Hypercoagulable States
Acute Therapy
• Intravenous TPA within 4.5 hrs. of
onset
• Intra-arterial Thrombolysis within 6
hrs. of onset
• Mechanical Embolectomy
Case Patient Acute
Therapy
• Intravenous Heparin was started.
• Patient transferred to tertiary care
hospital.
• Neurological examination worsened.
• Required intubation (protect airway.)
• CT angiogram performed.
CT Angiogram of the Brain
Filling defect noted in left middle
cerebral artery
Case Acute Care
Continues
• Intra-arterial TPA was administered.
• Endovascular mechanical retrieval of
clot was performed.
• Flow through left MCA was restored.
• Right hemiparesis persisted.
• Chest x-ray read as right middle lobe
pneumonia.
• Antibiotic started: patient to ICU.
Chest X-Ray
Endotracheal Tube is in place. Right middle
lobe infiltrate. Aspiration pneumonia? Or
something else?
Additional Studies
• Echocardiogram: Suggested Atrial
septal defect.
• Hypercoagulopathy screen was
negative.
• Lower extremity venous ultrasound
was negative.
• Neck CT angiogram negative for
dissection.
Putting It All Together
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Young female with stroke.
Likely an embolic stroke.
History of nose bleed.
History of miscarriage
Family History of AVM.
Abnormal chest x-ray.
Could be consistent with hereditary
hemorrhagic telangiectasia.
• Chest CT: Hunt for pulmonary AVM
Contrast CT of the Chest
CT Scan of the Torso Obtained 1 Week after
Admission. The coronal-plane–formatted CT scan shows
an arteriovenous malformation in the lung (arrow).
Cause of this Stroke
• Most probably paradoxical through
the intrapulmonary shunt created by
the pulmonary arteriovenous
malformation.
• Pulmonary AVM is part and parcel of
Rendu-Osler-Weber Syndrome i.e.
HHT.
Rendu-Osler-Weber
Syndrome
• Autosomal Dominant
• Telangiectasia of skin mucous
membrane, various organs.
• Two different Gene Loci identified
(a) 9q33-34 and (b) 12q13
• Arises from spontaneous mutations
in 30% of cases.
Neurologic
Manifestations of HHT
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Headache
Dizziness
Seizure
Paradoxical Embolism Stroke
Transient Ischemic Attacks
ICH, SAH
Meningitis
Cerebral abscess
Treatment of HHT
• Manage the complications. Notably,
our patient walked out of the hospital
with improved speech and language.
• Early resection of lung AVM or
embolization of the fistula.
• Periodic Transfusion and Iron
Therapy
• ASA has been used for platelet
sequestration.