 Stroke is the commonest cause of death in developed
countries.
 Hypertension is the most treatable risk factor.
 Thromboembolic infarction (80%), cerebral and
cerebellar haemorrhage (10%) and subarachnoid
haemorrhage (about 5%) are the major
cerebrovascular problems.
Ischemic stroke usually results when an artery to the 
brain is blocked, often by a blood clot or a fatty deposit
due to atherosclerosis
 Stroke is defined as the clinical syndrome of rapid onset of
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cerebral deficit (usually focal) lasting more than 24 hours
or leading to death, with no apparent cause other than a
vascular one.
Completed stroke means the deficit has become
maximal, usually within 6 hours.
Stroke-in-evolution describes progression during the
first 24 hours.
Minor stroke. Patients recover without significant deficit,
usually within a week.
Transient ischemic attack (TIA). This means a focal
deficit, such as a weak limb, aphasia or loss of vision lasting
from a few seconds to 24 hours. There is complete recovery.
The attack is usually sudden.
An ischemic stroke is death of an area of brain tissue 
(cerebral infarction) resulting from an inadequate
supply of blood and oxygen to the brain due to
blockage of an artery
Causes
By forming in and blocking an artery:An atheroma 
in the wall of an artery may continue to accumulate
fatty material and become large enough to block the
artery
By traveling from another artery to an artery in 
the brain: A piece of an atheroma or a blood clot in
the wall of an artery can break off and travel through
the bloodstream (becoming an embolus(
By traveling from the heart to the brain: Blood 
clots may form in the heart or on a heart valve,
particularly artificial valves and valves that have been
damaged by infection of the heart's lining
(endocarditis).
Several conditions besides rupture of an atheroma can 
trigger or promote the formation of blood clots,
increasing the risk of blockage by a blood clot. They
include the following
Blood disorders: Some disorders, such as an excess of 
red blood cells (polycythemia), antiphospholipid
syndrome, and a high homocysteine level in the blood
(hyperhomocysteinemia), make blood more likely to
clot. In children, sickle cell disease can cause ischemic
stroke
Oral contraceptives: Taking oral contraceptives, 
particularly those with a high estrogen dose, increases
clots the risk of blood
Lacunar infarction is another cause of ischemic 
stroke. In lacunar infarction, one of the small arteries
deep in the brain becomes blocked when part of its
wall deteriorates and is replaced by a mixture of fat
and connective tissue—a disorder called
lipohyalinosis.
Blood clots in a brain artery do not always cause a 
stroke. If the clot breaks up spontaneously within less
than 15 to 30 minutes, brain cells do not die and
people's symptoms resolve. Such cases are called a
transient ischemic attack
Risk factors:
The major risk factors for ischemic stroke 
Atherosclerosis (narrowing or blockage of arteries by 
patchy deposits of fatty material in the walls of
arteries)
High cholesterol levels 
High blood pressure 
Diabetes 
Smoking 
Other risk factors include 
Having relatives who have had a stroke 
Consuming too much alcohol 
Using cocaine or amphetamines 
Having an abnormal heart rhythm called atrial fibrillation 
Having another heart disorder, such as a heart attack or infective 
endocarditis (infection of the heart's lining)
Having inflamed blood vessels (vasculitis) 
Being overweight, particularly if the excess weight is around the 
abdomen
Getting too little physical activity 
Eating an unhealthy diet (such as one high in saturated fats, trans fats, 
and calories)
Having a clotting disorder 
Determining the Location
Large Vessel: •
Look for cortical signs –
Small Vessel: •
No cortical signs on exam –
Posterior Circulation: •
Crossed signs –
Cranial nerve findings –
Watershed: •
Look at watershed and borderzone areas –
Hypo-perfusion –
Stroke Symptoms
Sudden numbness or weakness of face, arm or leg, 
especially on one side of the body
Sudden confusion, trouble understanding or speaking 
Sudden trouble seeing in one or both eyes 
Sudden trouble walking, dizziness, loss of balance or 
coordination
Sudden severe headache with no known cause 
Other Symptoms
Sudden nausea, fever and vomiting, distinguished 
from a viral illness by rapid onset (minutes or hours vs.
days)
Brief loss of consciousness or period of decreased 
consciousness (fainting, confusion, convulsions or
coma)
Lacunar Stroke Syndromes
Well-defined syndromes 
Pure motor hemiparesis (with dysarthria) 
Pure sensory stroke (loss or paresthesias) 
Dysarthria-clumsy hand (with contralateral face and 
tongue weakness)
Ataxia-hemiparesis (contralateral face and leg 
weakness)
Isolated motor-sensory stroke 
Large Vessel Stroke Syndromes
MCA: •
Arm>leg weakness –
LMCA cognitive: Aphasia –
RMCA cognitive: Neglect,, topographical difficulty, apraxia, –
constructional impairment
ACA: •
Leg>arm weakness, grasp –
Cognitive: muteness, perseveration, abulia, disinhibition –
PCA: •
Hemianopia –
Cognitive: memory loss/confusion, alexia –
Cerebellum: •
Ipsilateral ataxia –
Brainstem Stroke Syndromes
Usually a combination of cranial nerve abnormalities, and •
crossed motor/sensory findings such as:
Double vision –
Facial numbness and/or weakness –
Slurred speech –
Difficulty swallowing –
Ataxia –
Vertigo –
Nausea and vomiting –
Hoarseness –
Watershed: •
Look for the watershed pattern –
Think about reasons of hypo-perfusion –
Hypotension •
Stenosed vessel, etc
•
Diagnosis
Doctors can usually diagnose an ischemic stroke based 
on the history of events and results of a physical
examination
Computed tomography (CT) is usually done first 
CT helps distinguish an ischemic stroke from a 
hemorrhagic stroke, a brain tumor, an abscess, and
other structural abnormalities
Imaging
CT scan 
Non- contrast CTH remains the gold standard as it is •
superior for showing IVH and ICH
CT with contrast may help identify aneurysms, AVMs, •
or tumors but is not required to determine whether or
not the patient is a tPa candidate
MRI 
Superior for showing underlying structural lesion 
If available, diffusion-weighted magnetic resonance 
imaging (MRI), which can detect ischemic strokes
within minutes of their start, may be done next
Electrocardiography (ECG) to look for abnormal heart 
rhythms
Imaging tests—color Doppler ultrasonography, 
magnetic resonance angiography, CT angiography, or
cerebral (standard) angiography—to determine
whether arteries, especially the internal carotid
arteries, are blocked or narrowed
Blood tests to check for anemia, polycythemia, blood 
clotting disorders, vasculitis, and some infections
(such as heart valve infections and syphilis) and for
risk factors such as high cholesterol levels or diabetes
Treatment
The first priority is to restore the person's breathing, 
heart rate, blood pressure (if low), and temperature to
normal.
An intravenous line is inserted to provide drugs and 
fluids when needed
doctors do not immediately treat high blood pressure 
unless it is very high (over 220/120 mm Hg) because
when arteries are narrowed, blood pressure must be
higher than normal to push enough blood through
them to the brain.
Management
Most likely related to decreased level of consciousness 
(LOC), dysarthria, dysphagia
GCS < 8 - INTUBATE 
Avoid Hyperventilation or Hypoventilation 
NPO until swallow assessment completed- high 
aspiration risk
Begin mobilization as soon as clinically safe 
very high blood pressure can injure the heart, kidneys, 
and eyes and must be lowered
If a stroke is very severe, drugs such as mannitol may 
be given to reduce swelling and the increased pressure
in the brain
Hyperthermia
Treat fevers! 
Evidence shows that fevers > 37.5 C that persists for > 24 
hrs correlates with ventricular extension and is found in
83% of patients with poor outcomes
BP Management
The goal is to maintain cerebral perfusion!! 
CPP = MAP – ICP (needs to be at least 70) 
Higher BP goals with Ischemic stroke 
Lower BP goals with Hemorrhagic stroke (avoid hemorrhagic 
expansion, especially in AVMs and aneurysms)
BP increase is due to arterial occlusion (i.e., an effort to 
perfuse penumbra)
Failure to recanalize (w/ or w/o thrombolytic therapy) 
results in high BP and poor neuro outcomes
Lowering BP starves penumbra, worsens outcomes 
Supportive Therapy
Glucose Management 
Infarction size and edema increase with acute and chronic 
hyperglycemia
Hyperglycemia is an independent risk factor for hemorrhage 
when stroke is treated with t-PA
Antiepileptic Drugs 
Seizures are common after hemorrhagic CVAs 
ICH related seizures are generally non-convulsive and are 
associated to with higher NIHSS scores, a midline shift, and
tend to predict poorer outcomes
Thrombolytic (fibrinolytic) drugs
In certain circumstances, a drug called tissue 
plasminogen activator (tPA) is given intravenously to
break up clots and help restore blood flow to the brain
Before tPA is given, CT is done to rule out bleeding in 
the brain
To be effective and safe, tPA, given intravenously, must 
be started within 3 hours of the beginning of an
ischemic stroke
Intravenous rTPA
IV thrombolytic therapy remains the cornerstone 
of evidence-based acute ischemic stroke therapy
(Class I; level A)
IV rt-PA is efficacious and cost-effective for 
patients with acute ischemic stroke treated within
3 hours of symptom onset
6.6% complication of symptomatic intracranial 
hemorrhage (sICH)
In patients with acute ischemic stroke in whom 
treatment can be initiated within 3 h of symptom
onset, we recommend IV recombinant tissue
plasminogen activator (r-tPA) over no IV
r-tPA (Grade 1A). 
In patients with acute ischemic stroke in whom 
treatment can be initiated within 4.5 h but not
within 3 h of symptom onset, we suggest IV r-tPA
over no IV r-tPA (Grade 2C).
Inclusion criteria 
Diagnosis of AIS causing measurable neurological 
deficit
Onset of symptoms < 3hours before beginning 
treatment
Age >18 or older 
Exclusion Criteria
Significant head trauma or prior stroke in the last 3 months 
Symptoms suggest SAH 
Arterial puncture in non compressible site <7 days 
History of previous ICH 
Intracranial neoplasm, AVM or aneurysm 
Recent intracranial or intraspinal surgery 
Elevated BP (SBP >185 or DBP> 110 mm Hg) 
Active internal bleeding 
Platelet count <100,000 
Heparin received <48 hours resulting in elevated PTT 
Current use of anticoagulant with INR >1.7 or PT >15 secs 
Current use of Direct Thrombin inhibitors 
or factor Xa inhibitors
Blood glucose concentration <50 mg/dl 
CT with multilobar infarction (> 1/3 of cerebral hemisphere) 
RELATIVE EXCLUSION CRITERIA
CONSIDER RISK TO BENEFIT OF IVrTPA 
ADMINSTRATION CAREFULLY IF ANY OF THESE
RELATIVE CONTRAINDICATIONS EXISTS:
MINOR OR RAPIDLY IMPROVING SYMPTOMS 
SEIZURE AT ONSET WITH POST ICTAL 
IMPAIRMENTS
MAJOR SURGERY OR SERIOUS TRAUMA <14 
DAYS
RECENT GI OR URINARY TRACT HEMORRHAGE 
<21 DAYS
RECENT ACUTE MI <3 MONTHS 
After 4.5 hours, most of the damage to the brain 
cannot be reversed, and the risk of bleeding outweighs
the possible benefit of using tPA
If people arrive at the hospital 3 to 6 hours 
(occasionally, up to 18 hours) after the stroke began,
they may be given tPA or another thrombolytic drug.
But the drug must be given through a catheter placed
directly in the blocked artery rather than intravenously
For this treatment (called thrombolysis-in-situ), 
doctors make an incision in the skin, usually in the
groin, and insert a catheter into an artery. The catheter
is then threaded through the aorta and other arteries,
to the clot
Antiplatelet drugs and
anticoagulants
If a thrombolytic drug cannot be used, most people are 
given aspirin(an antiplatelet drug) as soon as they get
to the hospital
If symptoms seem to be worsening, anticoagulants 
such as heparin are occasionally used, but their
effectiveness has not been proved
Regardless of the initial treatment, long-term 
treatment usually consists of aspirin or another
antiplatelet drug to reduce the risk of blood clots and
thus of subsequent strokes
People who have atrial fibrillation or a heart valve 
disorder are given anticoagulants (such as warfarin
instead of antiplatelet drugs, which do not seem to
prevent blood clots from forming in the heart.
Dabigatran, apixaban, and rivaroxaban are new
anticoagulants that are sometimes used instead of
warfarin
Occasionally, people at high risk of another stroke are 
given both aspirin and an anticoagulant
If people have been given a thrombolytic drug, doctors 
usually wait at least 24 hours before antiplatelet drugs
or anticoagulants are started because these drugs add
to the already increased risk of bleeding in the brain
Anticoagulants are not given to people who have 
uncontrolled high blood pressure or who have had a
hemorrhagic stroke
Surgery
Carotid endarterectomy can help if all of the following 
are present:
The stroke resulted from narrowing of a carotid artery 
by more than 70% (more than 60% in people who have
been having transient ischemic attacks).
Some brain tissue supplied by the affected artery still 
functions after the stroke.
The person's life expectancy is at least 5 •
years
In other narrowed arteries, such as the vertebral 
arteries, endarterectomy is typically not done because
it is riskier when it is done in arteries other than the
internal carotid arteries
Stents
If endarterectomy is too risky 
A wire mesh tube (stent) with an umbrella filter may 
be placed in the carotid artery
The procedure appears to be as safe as endarterectomy 
and as effective in preventing strokes and death
Statins
Statins are drugs that lower levels of cholesterol and 
other fats (lipids(
Such therapy can help prevent strokes from recurring. 
They are often given when strokes result from the 
buildup of fatty deposits in an artery
Prognosis
About 10% of people who have an ischemic stroke 
recover almost all normal function
about 25% recover most of it 
About 40% of people have moderate to severe 
impairments requiring special care
about 10% require care in a nursing home or other 
long-term care facility
About 20% of people who have a stroke die in the 
hospital
About 25% of people who recover from a stroke have 
another stroke within 5 years
Younger people and people who start improving 
quickly are likely to recover more fully