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Case 12 Stroke Rev'd Shorter
Case 12 Stroke Rev'd Shorter
Case 12 Stroke Rev'd Shorter
Vascular occlusion usually induces a territory of ischemia with the most severe deficits in blood flow at the core of this territory.
Surrounding this core is tissue with varying degrees of ischemia, depending on the availability of collateral perfusion. This
region, called the ischemic penumbra, may be salvageable if adequate perfusion is restored before cell death occurs.
TIA: mildest end of the spectrum in which no cell death results. This time-sensitive potential to rescue ischemic
penumbra from infarction drives all acute stroke therapies
Cerebral occlusion may result from local atherosclerosis, thrombosis, or embolism of a remote thrombus to the brain
deprive local brain tissue of O2 and nutrients required for normal metabolic function stroke can be viewed as the
final product of diverse factors that ultimately lead to vascular occlusion.
All ischemic stroke can be categorized into one of 5 underlying mechanisms of stroke:
I.
Embolism
a. causes ischemic stroke in one third or more of cases
b. typically cause large (>1 cm) infarcts involving the cortical surface, basal ganglia, or cerebellum
c. potential sources:
i. heart (atrial fibrillation, sick sinus syndrome, myocardial infarction with mural thrombus, dysfunctional or
artificial valves, dilated cardiomyopathy, and infective endocarditis); PFO is increasingly recognized as a
conduit for paradoxical embolism
ii. proximal internal carotid and vertebral arteries
iii. Ao arch d/t irregular surface of atherosclerotic lesions
iv. deep venous system
d. Hypercoagulable states: pregnancy, OCT, antiphospholipid syndrome may likelihood of embolization by promoting
thrombus formation
II.
III.
IV.
V.
other defined but unusual causes: dissection, arteritis, venous infarction, or infection.
6. List risk factors for stroke. ~CVD risks!!! (HTN, DM, smoking, dyslipidemia)
HTN
o
promotes the formation of atherosclerotic lesions, is the single most important treatable risk factor for
stroke!!!
o
risk of both stroke and CAD as BP > 110/75. Not causal, since BP could be a marker for other risk factors eg.
body weight, which is associated with dyslipidemia, glucose intolerance, metabolic syndrome.
o
Should be on hypertensive therapy and those who have had a stroke should consider hypertensive therapy for
the next 5yr
SMOKING Cigarette smoking is associated with an increased risk for all stroke subtypes and has a strong, dose-response
relationship for both ischemic stroke and subarachnoid hemorrhage. Observational studies have shown that the elevated risk of
stroke due to smoking declines after quitting and is eliminated by five-years later. Therefore, national guidelines recommend
smoking cessation for patients with stroke or transient ischemic attack (TIA) who have smoked in the year prior to the event and
suggest avoidance of environmental tobacco smoke.
DM Patients with diabetes mellitus have approximately twice the risk of ischemic stroke compared with those without diabetes.
Dyslipidemia, endothelial dysfunction, and platelet and coagulation abnormalities are among the risk factors that may promote the
development of carotid atherosclerosis in diabetics. Strict glycemic control reduces the risk of microvascular complications (eg,
retinopathy, nephropathy, and neuropathy) in patients with diabetes.
DYSLIPIDEMIA Hyperlipidemia is a major risk factor for coronary heart disease. However, the relationship between the serum
cholesterol concentration and stroke incidence appears to be more complex, in that cholesterol is an established risk factor for
atherosclerosis, but appears to be only a weak risk factor for ischemic stroke. Both low levels of high density lipoprotein (HDL)
cholesterol and a high total cholesterol to HDL ratio are risk factors for the development of carotid atherosclerosis. The relationship
however has found to be weak in many studies and may prove to be more important of a risk factor in those under 45. A main point
of conflict is that there has been limited relation to hyperlipidemia increasing risk of a stroke, however, statins have proved to reduce
risk of stroke.
Metabolic syndrome: presence of 3 components that include high fasting glucose, HTN, low HDL, abdominal obesity indicates a
pre-diabetic condition linked to insulin resistance. Unclear if an independent risk factor for ischemic stroke beyond the sum of its
individual components; available evidence is conflicting.
DiabetesMetformin - Decreases hepatic glucose production, decreasing intestinal absorption of glucose and improves insulin sensitivity
(increases peripheral glucose uptake and utilization)
Thiazolidinediones - PPAR-gamma agonist
HyperlipidemiaStatin therapy In patients with hyperlipidemia, treatment with HMG CoA reductase inhibitors (statins) decreases the risk of stroke,
while lipid lowering by other means (eg, fibrates, resins, diet) has no significant impact on stroke incidence.
Antiplatelet therapyASPIRIN the most commonly used antiplatelet agent, inhibits the enzyme cyclooxygenase, reducing production of thromboxane A2, a
stimulator of platelet aggregation. This interferes with the formation of thrombi, thereby reducing the risk of stroke.
CLOPIDOGREL is a thienopyridine that inhibits ADP-dependent platelet aggregation.
DIPYRIDAMOLE impairs platelet function by inhibiting the activity of adenosine deaminase and phosphodiesterase, which causes an
accumulation of adenosine, adenine nucleotides, and cyclic AMP. Dipyridamole may also cause vasodilation.