ACUTE ISCHEMIC STROKE

OVERVIEW

• a condition in which there is an inadequate supply of blood

and oxygen to a portion of the myocardium
• It typically occurs when there is an imbalance between
myocardial oxygen supply and demand.
• The most common cause of myocardial ischemia is
atherosclerotic disease of an epicardial coronary artery (or
arteries) sufficient to cause a regional reduction in
myocardial blood flow and inadequate perfusion of the
myocardium supplied by the involved coronary artery.
ETIOLOGY
• Obesity, insulin resistance, and type 2 diabetes mellitus
are increasing and are powerful risk factors for IHD.
• These trends are occurring in the general context of
population growth and as a result of the increase in the
average age of the world’s population.
• With urbanization in countries with emerging
economies and a growing middle class, elements of
the energy-rich Western diet are being adopted.
PATHOPHYSIOLOGY
•Acute occlusion of an intracranial vessel causes
reduction in blood flow to the brain region it supplies.
•The magnitude of flow reduction is a function of
collateral blood flow, and this depends on individual
vascular anatomy (which may be altered by disease),
the site of occlusion, and systemic blood pressure.
PATHOPHYSIOLOGY

•A decrease in cerebral blood flow to values <20

mL/100 g tissue per minute cause ischemia without
infarction unless prolonged for several hours or days;
• values <16–18 mL/100 g tissue per minute cause
infarction within an hour;
•and values zero causes death of brain tissue within 4–
10 min
PATHOPHYSIOLOGY

•Focal cerebral infarction occurs via two distinct

pathways:
(1) a necrotic pathway in which cellular cytoskeletal
breakdown is rapid, due principally to energy failure of
the cell
(2) an apoptotic pathway in which cells become
programmed to die.
ARTERY-TO-ARTERY EMBOLIC STROKE

Thrombus formation on atherosclerotic plaques may embolize to

intracranial arteries producing an artery-to-artery embolic stroke. Less
commonly, a diseased vessel may acutely thrombose.
ARTERY-TO-ARTERY EMBOLIC STROKE

Carotid Atherosclerosis
Atherosclerosis within the carotid artery occurs most frequently within
the common carotid bifurcation and proximal internal carotid artery;
the carotid siphon (portion within the cavernous sinus) is also
vulnerable to atherosclerosis.
ARTERY-TO-ARTERY EMBOLIC STROKE

Intracranial atherosclerosis produces stroke either by an embolic

mechanism or by in situ thrombosis of a diseased vessel.
Dissection of the internal carotid or vertebral arteries or even vessels
beyond the circle of Willis is a common source of embolic stroke in
young (age <60 years) patients.
.
 SMALL VESSEL STROKE

• The term lacunar infarction refers to infarction

following atherothrombotic or lipohyalinotic occlusion
of a small artery in the brain.
• small-vessel stroke denotes occlusion of such a small
penetrating artery and is now the preferred term.
Small-vessel strokes account for ~20% of all strokes.
• Each of these small branches can occlude either by
atherothrombotic disease at its origin or by the
development of lipohyalinotic thickening.
 SMALL VESSEL STROKE

• Thrombosis of these vessels causes small infarcts that are

referred to as lacunes (Latin for “lake” of fluid noted at
autopsy).
• These infarcts range in size from 3 mm to 2 cm in diameter.
Hypertension and age are the principal risk factors.
MANAGEMENT

GOALS OF TREATMENT:
prevent or reverse brain injury.
Attend to the patient’s airway, breathing, and circulation
(ABCs), and treat hypoglycemia or hyperglycemia if
identified by finger stick testing.
Perform an emergency non- contrast head CT scan to
differentiate between ischemic stroke and hemorrhagic
stroke;
MANAGEMENT

6 categories of treatment:
(1) medical support
(2) IV thrombolysis
(3) endovascular revascularization
(4) antithrombotic treatment
(5) neuroprotection
(6) stroke centers and rehabilitation.
PROGNOSIS
Overall mortality rate at 30 days after stroke- 28%
Prognosis varies depending on the stroke severity and on the patient’s
premorbid condition, age, and poststroke complications.
Acute ischemic stroke has been associated with acute cardiac
dysfunction and arrhythmia.
References
Kasper, Dennis L., Hauser, Stephen L., Fauci, Anthony S. Et al..
Harrison’s Principles of Internal Medicine 20th ed. Chapter 420