INTRO TO STROKE

FOR NEUROLOGY CLERKS

Igor Rybinnik, M.D

Department of Neurology,
Rutgers Robert Wood Johnson Medical School
DISCLOSURES
NO RELEVANT CONFLICTS TO DISCLOSE
OBJECTIVES

• Vascular anatomy, syndromes

• Diagnosis, management of acute ischemic stroke

• Mechanisms of ischemic stroke for prevention.

• Diagnosis, management of acute hemorrhagic stroke

• Mechanisms of hemorrhagic stroke for prevention.

 CLINICAL FEATURES
VASCULAR ANATOMY AND SYNDROMES

“Fasten your seatbelts, it’s going

to be a curvy ride.”
 CEREBRAL
VASCULATURE
Adapted from Kandel
ER, et al. Principles of
Neural Science 5th
Edition. McGraw Hill,
2012.
CIRCLE OF
WILLIS
Adapted from Kandel
ER, et al. Principles of
Neural Science 5th
Edition. McGraw Hill,
2012.
 VASCULAR
SUPPLY
Anterior cerebral
artery (ACA)

Middle cerebral
artery (ACA)

Lenticulostriate
ACA TERRITORY INFARCTION branches (MCA)

Abulia Posterior cerebral

artery (PCA)
Amnesia
Anterior choroidal
Contralateral leg artery

weakness Superior cerebellar

Artery (SCA)

Basilar
artery (BA)

Anterior inferior
cerebellar artery (AICA)

Posterior inferior
cerebellar artery (PICA)

Anterior spinal artery

(branch of vertebral a.)

Posterior spinal artery

(branch of vertebral a.)
 VASCULAR
SUPPLY
Anterior cerebral
artery (ACA)

Middle cerebral
artery (ACA)

Lenticulostriate
MCA TERRITORY INFARCTION branches (MCA)

Contralateral: Posterior cerebral

artery (PCA)
Hemiparesis
Anterior choroidal
Facial paresis artery
Gaze paresis
Superior cerebellar
Hemisensory deficits Artery (SCA)
Field cut
Basilar
Neglect artery (BA)
NON-DOMINANT
Aphasia Anterior inferior
DOMINANT cerebellar artery (AICA)

Posterior inferior
cerebellar artery (PICA)

Anterior spinal artery

(branch of vertebral a.)

Posterior spinal artery

(branch of vertebral a.)
 VASCULAR
SUPPLY
Anterior cerebral
artery (ACA)
PCA TERRITORY INFARCTION
Middle cerebral
Contralateral: artery (ACA)
Hemisensory deficits Lenticulostriate
Hemianopia branches (MCA)
Occasionally neglect Posterior cerebral
NON-DOMINANT artery (PCA)
Transcortical aphasia
DOMINANT Anterior choroidal
artery
Behavioral abnormalities,
confusion Superior cerebellar
Artery (SCA)
THALAMIC DAMAGE
Basilar
If midbrain involved: artery (BA)
Contralateral hemiparesis
Anterior inferior
Ipsilateral CN3 palsy cerebellar artery (AICA)
Contralateral ataxia
RED NUCLEUS DAMAGE Posterior inferior
cerebellar artery (PICA)

Anterior spinal artery

(branch of vertebral a.)

Posterior spinal artery

(branch of vertebral a.)
 VASCULAR
SUPPLY
BASILAR TERRITORY INFARCTION
Contralateral:
Hemiparesis with or without
UMN facial weakness
Hemisensory
Intranuclear ophthalmoplegia
MLF DAMAGE
Ipsilateral:
Horizontal gaze paralysis
PPRF DAMAGE
Ataxia
LMN facial weakness
CN7 NUCLEUS DAMAGE
Facial sensory loss
CN5 NUCLEUS DAMAGE
Nystagmus
Anterior cerebral
artery (ACA)
Middle cerebral
artery (ACA)
Lenticulostriate
branches (MCA)
Posterior cerebral
artery (PCA)
Anterior choroidal
artery
Superior cerebellar
Artery (SCA)
Basilar
artery (BA)
Anterior inferior
cerebellar artery (AICA)
Posterior inferior
cerebellar artery (PICA)
Anterior spinal artery
(branch of vertebral a.)
Posterior spinal artery
(branch of vertebral a.)
 VASCULAR
SUPPLY
Anterior cerebral
artery (ACA)

Middle cerebral
artery (ACA)

Lenticulostriate
SCA TERRITORY INFARCTION branches (MCA)

Ipsilateral Posterior cerebral

artery (PCA)
appendicular ataxia
Anterior choroidal
artery

Superior cerebellar
Artery (SCA)

Basilar
artery (BA)

Anterior inferior
cerebellar artery (AICA)

Posterior inferior
cerebellar artery (PICA)

Anterior spinal artery

(branch of vertebral a.)

Posterior spinal artery

(branch of vertebral a.)
 VASCULAR
SUPPLY
Anterior cerebral
artery (ACA)

Middle cerebral
artery (ACA)

Lenticulostriate
AICA TERRITORY INFARCTION branches (MCA)

Ipsilateral ataxia Posterior cerebral

artery (PCA)
Ipsilateral hearing loss
LABYRINTHINE A. BRANCH Anterior choroidal
artery
Vertigo
Superior cerebellar
Artery (SCA)

Basilar
artery (BA)

Anterior inferior
cerebellar artery (AICA)

Posterior inferior
cerebellar artery (PICA)

Anterior spinal artery

(branch of vertebral a.)

Posterior spinal artery

(branch of vertebral a.)
 VASCULAR
SUPPLY
PICA TERRITORY INFARCTION
Contralateral:
Hemisensory
Ipsilateral:
Tongue deviation
Facial sensory loss
Horner’s syndrome
SYMPATHETIC DAMAGE
Ataxia
Dysarthria, dysphagia,
nystagmus, hoarseness
Anterior cerebral
artery (ACA)
Middle cerebral
artery (ACA)
Lenticulostriate
branches (MCA)
Posterior cerebral
artery (PCA)
Anterior choroidal
artery
Superior cerebellar
Artery (SCA)
Basilar
artery (BA)
Anterior inferior
cerebellar artery (AICA)
Posterior inferior
cerebellar artery (PICA)
Anterior spinal artery
(branch of vertebral a.)
Posterior spinal artery
(branch of vertebral a.)
VASCULAR
SUPPLY
Anterior cerebral
artery (ACA)

Middle cerebral
artery (ACA)

Lenticulostriate
branches (MCA)

Posterior cerebral
artery (PCA)

Anterior choroidal
artery

Superior cerebellar
Artery (SCA)

Basilar
artery (BA)

Anterior inferior
cerebellar artery (AICA)

Posterior inferior
cerebellar artery (PICA)

Anterior spinal artery

(branch of vertebral a.)

Posterior spinal artery

(branch of vertebral a.)
ACUTE ISCHEMIC STROKE
DIAGNOSIS AND MANAGEMENT

“A brain is a terrible thing to

waste.”
CASE OF A CONFUSED MAN

74 yo man with hypertension, dyslipidemia, coronary artery

disease develops acute confusion, left facial droop, left sided
weakness while driving his car. He pulls over to the side of the
road, and bystanders witnessing the event call EMS. He arrived
to the emergency room one hour after symptom onset. He has
no headache and is protecting his airway.

Neurological exam:
• AAOx3, no aphasia, but dysarthria and profound neglect
(does not recognize deficits)
• Right gaze deviation (does not cross midline), left
homonymous hemianopia
• Left facial droop, and flaccid left hemiparesis
What is the differential
diagnosis of acute focal
neurological deficit?
• Cerebrovascular disorder
(ischemia or hemorrhage)
• Seizures with post-ictal
paralysis
• Hypoglycemia
• Brain neoplasm
• Demyelinating disorders
(multiple sclerosis)
• Infections (brain abscess,
encephalitis, meningitis)
• Complicated migraine
What is the next best step
in the management?
Adapted from JAMA
2015;313(4):1452
 55
60 5
Suspected
stroke arrives
at hospital.

50 10
Stroke Code
activated. Labs
drawn. Stroke
team eval.

45 15

40 20
35 25
30
 Adapted from Scrubs.
ABC 2001. Television.
Get a head
Patient’s CT STAT!
history?

Free
muffins?

What’s the
time last
known
normal? Any contra-
indications to
thrombolysis?
STROKE CODE
NIH STROKE SCALE
1a: Level of consciousness (0-3) 5a/b, 6a/b: Motor strength of
Requires mild stimulation; requires strong extremities (0-4)
stimulation; comatose Drift; some antigravity effort; no antigravity;
no movement
1b: Orientation (0-2)
Answers one or no questions correctly 7. Limb Ataxia (0-2)
Present in one or two limbs
1c: Commands (0-2)
Follows one or no commands 8. Sensory (0-2)
Partial loss; dense loss
2. Best gaze (0-2)
Partial gaze; forced deviation 9. Best language (0-3)
Mild-moderate (able to express); severe
3. Visual fields (0-3) (some speech, but unable to express); mute
Partial field cut; complete; bilateral (blind)
10. Dysarthria (0-2)
4. Facial palsy (0-3) Mild-moderate (still intelligible); severe
Minor; partial (lower face); complete (unintelligible or mute)
paralysis
11. Extinction/Inattention (0-2)
Some inattention; profound hemi-
inattention
BACK TO THE CASE…

Neurological deficits:

• Dysarthria
• Profound neglect, anosognosia
• Right gaze deviation (does not cross midline)
• Left homonymous hemianopia
• Left facial droop, flaccid left hemiparesis
OUR CASE

1a: Level of consciousness (0) 5a/b: Motor strength of arms:

Alert No drift in R arm (0), L arm no effort
against gravity (3)
1b: Orientation (0)
Answers both questions correctly 6a/b: Motor strength of legs:
No drift in R leg (0), L leg no effort
1c: Commands (0) against gravity (3)
TOTAL SCORE
Follows both commands

15
7. Limb Ataxia (0)
2. Best gaze (2) Absent
Forced gaze deviation, unable to cross
midline 8. Sensory (2)
Dense loss on left side
3. Visual fields (1) POINTS9. Best language (0)
Partial field cut No aphasia
4. Facial palsy (1) 10. Dysarthria (1)
Partial (lower face) Mild-moderate (still intelligible)

11. Extinction/Inattention (2)

Profound hemi-inattention
 FROM STROKE CODE
TO TREATMENT

55
60 5
Suspected
stroke arrives
at hospital.

50 10
Stroke Code
activated. Labs
drawn. Stroke
team eval.

45 NCCT,
CTA±CTP
completed.
15

40 20
35 25
30
 ACUTE IMAGING

• BEST INITIAL TEST

• SENSITIVE AND SPECIFIC
FOR HEMORRHAGE
Right Left
• MAY BE NORMAL IN ACUTE
ISCHEMIC STROKE DENSE VESSEL
(MCA) SIGN

NON-CONTRAST HEAD CT
Normal study
ACUTE IMAGING

Right Right

CTA HEAD, NECK

WITH CONTRAST
Coronal cut
demonstrating
right MCA stem
occlusion.

CTA HEAD WITH CONTRAST

Axial cut. Interruption of right MCA
flow is indicative of occlusion.
What is the primary goal of
acute ischemic stroke
treatment?
REM
O VE
BSTRUCTION

PRIMARY GOAL OF
AIS TREATMENT
 FROM STROKE CODE
TO TREATMENT

55
60 5
Suspected
stroke arrives
at hospital.

50 10
Stroke Code
activated. Labs
drawn. Stroke
team eval.

45 NCCT,
CTA±CTP
completed.
15

40 20
IV TPA
started.

35 25
30
 TPA CONTRAINDICATIONS

• ACTIVE BLEEDING
ESTABLISH TIME OF
ONSET OR LAST KNOWN • RECENT INTRACANIAL OR
AT BASELINE SPINAL SURGERY OR
SERIOUS HEAD TRAUMA
• BLEEDING DIATHESIS
ABCs (BP <185/105)
GLUCOSE
EXAM (NIHSS)

HEAD CT

BASIC LABS, COAGS

DON’T HAVE TO WAIT FOR RESULTS
BEFORE TPA UNLESS ANTICOAGULANT
ONBOARD

IV TPA
BACK TO THE CASE…

• TPA was started

• Neurological examination
remains unchanged

Have we accomplished our

primary goal?
 FROM STROKE CODE
TO TREATMENT

55
60 5
Suspected
stroke arrives
Groin punctured at hospital.
(endovasc. procedure
50 starts) 10
Stroke Code
activated. Labs
drawn. Stroke
team eval.

45
Patient prepared
NCCT,
CTA±CTP
completed.
15
for intervention.

40
Lab, imaging
results
available.
Determine
20
IV TPA
eligibility for started.
endovascular.

35 25
30
 32,000
NEURONS LOST
IN ONE SECOND
55
60 5
Suspected
stroke arrives
Groin punctured at hospital.
(endovasc. procedure
50 starts) 10
Stroke Code
activated. Labs
drawn. Stroke
team eval.

45
Patient prepared
NCCT,
CTA±CTP
completed.
15
for intervention.

40
Lab, imaging
results
available.
Determine
20
IV TPA
eligibility for started.
endovascular.

35 25
30

Adapted from Stroke 2006;37:263

 32,000
NEURONS LOST
IN ONE SECOND
55
60 5
Suspected
stroke arrives
Groin punctured at hospital.
(endovasc. procedure
50 starts) 10
Stroke Code
activated. Labs
drawn. Stroke
team eval.

45
Patient prepared
NCCT,
CTA±CTP
completed.
15
for intervention.

40
Lab, imaging
results
available.
Determine
20
IV TPA
eligibility for started.
endovascular.

35 25
30
1.9MIL
NEURONS LOST
IN ONE MINUTE
Adapted from Stroke 2006;37:263
120MIL
NEURONS LOST
32,000
NEURONS LOST
IN ONE HOUR IN ONE SECOND
60
3.6
YEARS AGED
55

Groin punctured
(endovasc. procedure
Suspected
stroke arrives
at hospital.
5

IN ONE HOUR 50 starts) 10

Stroke Code
activated. Labs
drawn. Stroke
team eval.

45
Patient prepared
NCCT,
CTA±CTP
completed.
15
for intervention.

40
Lab, imaging
results
available.
Determine
20
IV TPA
eligibility for started.
endovascular.

35 25
30
1.9MIL
NEURONS LOST
IN ONE MINUTE
Adapted from Stroke 2006;37:263
120MIL
NEURONS LOST
32,000
NEURONS LOST
IN ONE HOUR IN ONE SECOND
60
3.6
YEARS AGED
55

Groin punctured
(endovasc. procedure
Suspected
stroke arrives
at hospital.
5

IN ONE HOUR 50 starts) 10

Stroke Code
activated. Labs
drawn. Stroke
team eval.

45
Patient prepared
NCCT,
CTA±CTP
completed.
15
for intervention.

40
Lab, imaging
results
available.
Determine
20
IV TPA
eligibility for started.
endovascular.

35 25
30
1.9MIL
NEURONS LOST
IN ONE MINUTE
Adapted from Stroke 2006;37:263
 BENEFITS OF
THROMBECTOMY
5.0 DECREASE WITH
TIME
Odds Ratio For Less Disability at 3 mo

FAVORS ENDOVASCULAR THROMBECTOMY

1.0
FAVORS MEDICAL THERAPY ALONE

0.5
120 180 270 360 480
Time From Symptom Onset To Thrombectomy, min

Adapted from HERMES collaboration.

JAMA 2016; 316(12):1279-88
 RIGHT
MCA STEM
OCCLUSION

CEREBRAL
ANGIOGRAM
AFTER
THROMBECTOMY
BACK TO THE CASE…

• Endovascular therapy successful

• Neurological improvement noted post
procedure
• Patient was admitted to ICU

Now that flow has been

restored, what are the new
goals of treatment?
REPERFUSION
PERMISSIVE HYPERTENSION PREVENT
BP <180/105 POST TPA SECONDARY
OR <140-160 IF VESSEL OPENED
TO AVOID REPERFUSION INJURY INJURY

CLOSE OBSERVATION
IN ICU SETTING TREAT CEREBRAL
EDEMA
PEAKS AT DAY 3-5

FREQUENT NEURO
CHECKS, GROIN CHECKS
MAINTAIN HOMEOSTASIS

ANTITHROMBOTICS
(DELAYED FOR 24 HOURS IF TPA
PREVENT ADMINISTERED)
RECURRENCE STROKE WORKUP
ISCHEMIC STROKE PREVENTION
MECHANISMS, WORK-UP, AND TREATMENT

“My Mama always said, ‘Stroke was

like a box of chocolates; you have to
do an MRI, transesophageal echo,
and mobile cardiac telemetry to
know what you’re gonna to get.’”
Why do we need to do a
“stroke workup”?
FIND THE AMONG THE
WOLF SHEEP
ABNORMAL INCREASED
STASIS OF CLOTTING
BLOOD POTENTIAL
CLOT

VESSEL
WALL
INJURY
 ISCHEMIC STROKE
78%

THROMBOTIC THROMBOTIC RARE CRYPTOGENIC

CARDIOEMBOLIC
LARGE VESSEL SMALL VESSEL CAUSES EMBOLIC STROKE OF
(LACUNAR) UNDETERMINED
SOURCE (ESUS)
THROMBOTIC THROMBOTIC
LARGE VESSEL SMALL VESSEL (LACUNAR) SMALL
VESSEL
INFARCT

CLINICAL FEATURES: CLINICAL FEATURES:

AGE >40, VASCULAR AGE >40, VASCULAR
RISK FACTORS RISK FACTORS
PRECEEDING TIAs MILDER SYMPTOMS
ABSENCE OF
CORTICAL DEFICITS
RADIOGRAPHIC FEATURES: (I.E. APHASIA,
EVIDENCE OF LARGE NEGLECT, FIELD CUT)
VESSEL STENOSIS
RADIOGRAPHIC FEATURES: CAROTID ARTERY PLAQUE
<1.5CM DIAMETER (LARGE VESSEL DISEASE)
MECHANISM:
LESION ON MRI
ATHEROSCLEROSIS
(INTRACRANIAL OR SUBCORTICAL LESIONS
EXTRACRANIAL
VESSELS) MECHANISMS:
LIPOHYALINOSIS,
MICROATHEROMAS,
MICROEMBOLISM

Adapted from Gijsen et al.

Stroke 2015;46:2124-28
 CERVICAL ICA
STENOSIS (LARGE
VESSEL)
MRA Neck with
Gadolinium

CHRONIC SMALL VESSEL INFARCTS ACUTE WATERSHED INFARCTS

Non-contrast head CT MRI (DWI sequence)
 CARDIOEMBOLIC

CLINICAL FEATURES:
EMBOLIC SOURCES: MAXIMAL DEFICIT
ATRIAL FIBRILLATION AT ONSET
SEVERE DEFICIT
LAA THROMBUS, LV
THROMBUS
RADIOGRAPHIC
VALVULAR DISEASE FEATURES:

STRUCTURAL HEART LARGE ZONE OF

DISEASE (DILATED INFARCT
CARDIOMYOPATHY) INFARCTS IN
PARADOXICAL MULTIPLE
EMBOLUS THROUGH VASCULAR
Left ventricle
PFO TERRITORIES

AORTIC ARCH PLAQUE

CARDIAC TUMORS
 LEFT VENTRICULAR
THROMBUS
TTE, four chamber view

ACUTE CARDIOEMBOLIC
INFARCTS IN VARIOUS
ARTERIAL DISTRIBUTIONS
MRI, DWI sequence
RARE CAUSES Intramural
hematoma

ARTERIAL
DISSECTION

SICKLE CELL

HYPERCOAGULABLE
STATES
Internal
carotid
VASCULITIS artery

VASOSPASM
(COCAINE/SSRI
INDUCED)

VENOUS SINUS
THROMBOSIS

GENETICS
(CADASIL)
Common
COMPLICATED carotid
artery CERVICAL ICA
MIGRAINE DISSECTION
Adapted from Schievink WI.
NEJM 2001;344(12):898 MRA Neck with Gadolinium
ISCHEMIC STROKE RISK
BY MECHANISM

small vessel large vessel cardioembolism

 STROKE BRAIN MRI
WORKUP without Contrast

CEREBRAL CHECK FOR WORKUP FOR

VESSEL IMAGING WORKUP FOR RARE CAUSES
CARDIOEMBOLIC MODIFIABLE RISK
CTA Head and FACTORS
SOURCE Hypercoag.
Neck with Hypertension panel
Contrast Transthoracic
echocardiogram Dyslipidemia (LDL) Genetic testing
MRA Head
without, Neck Transesophageal Cerebral
echocardiogram Diabetes
with angiogram
(more sensitive) (hemoglobin A1c) (gold standard
Gadolinium
Extended cardiac Smoking of vascular
Carotid imaging)
Ultrasound + monitoring, and
Trascranial implantable loop Brain biopsy
Doppler recorder (for PAF)
MRI
• BEST TEST FOR DIAGNOSIS OF ACUTE
ISCHEMIC STROKE
• TYPICALLY DONE AFTER ACUTE TREATMENT
TO AVOID DELAY

MRI: DWI SEQUENCE (LEFT), ADC SEQUENCE (RIGHT)

Acute right MCA infarction
 VASCULAR
IMAGING
ACAs ACAs

MCA

SCA
ICA
ICA
BA
BA

VA
PICA

VA

MRA HEAD WITHOUT GADOLINIUM CTA HEAD WITH CONTRAST

Normal study Normal study
 VASCULAR
IMAGING

ICA

VA

ICA
VA

CCA
CCA
MRA NECK WITH CTA NECK WITH
GADOLINIUM CONTRAST
Normal study Normal study

Brachio-
cephalic Aortic Aortic
Arch Arch
BACK TO THE CASE…

• No carotid stenosis on initial CTA

• TTE showed EF 55%, dilated left atrium
• Telemetry monitoring revealed paroxysmal
atrial fibrillation.

What is the appropriate stroke

prevention regimen?
 HYPERTENSION ANTIHYPERTENSIVES
~4X INCREASED RISK FOR ISCHEMIC, AND BP GOAL <130/80
~9X FOR HEMORRHAGIC

STATIN THERAPY
CHOLESTEROL PLAQUE STABILIZATION

ANTITHROMBOTIC
CARDIAC DISEASE ANTICOAGULANT (APIXABAN)

SMOKING SMOKING CESSATION

ABDOMINAL OBESITY
DIABETES
PHYSICAL INACTIVITY
ALCOHOL USE
How would management change if
deficits resolved within 30
minutes, before TPA?

1. No thrombolysis
2. Clock is reset
3. Rapid, complete stroke workup still
necessary
 DISORIENTATION
AFTER OPIODS

TRANSIENT
TINGLING
EPISODE OF
SLURRED
SPEECH DURING
DIALYSIS
60 SECONDS
OF WORD
FINDING
DIFFICULTY

TRANSIENT
SLEEPINESS TRANSIENT
WASTEBASKET FACIAL
OF MEDICINE
DROOP
 What is a true TIA?
FEATURES OF A TYPICAL TIA
(ABCD2 SCORE)

• Age ≥ 60 years
• BP > 140/90
• Unilateral weakness or
TIA speech disturbance
=
BRAIN • Duration of 10-60 minutes
PAIN
• History of diabetes
ACUTE CEREBRAL HEMORRHAGE
DIAGNOSIS, AND MANAGEMENT

“My brain is trying to kill me.”

CASE OF A MAN WITH A HEADACHE

59 year old man with uncontrolled hypertension and frequent binge

drinking was found by his wife on kitchen floor with left sided
weakness, headache and lethargy after she heard him fall. There were
no previous such episodes. Family history is unremarkable. The
patient arrived to the hospital 1 hour after last seen at baseline. In the
emergency department, he vomited twice.

Neurological exam:
• BP 179/65, HR 80, RR 18, T 98.6, protecting his airway
• Lethargic, responds to voice, disoriented when awake
• No aphasia, no neglect, moderate dysarthria, left facial droop
• Flaccid left sided hemiparesis and hemisensory deficits
What is the next best step
in the management?
 Adapted from Scrubs.
ABC 2001. Television.
Get a head
Patient’s CT STAT!
history?

Free
muffins?

What’s the
time last
known
normal? Any contra-
indications to
thrombolysis?
STROKE CODE
NON-CONTRAST HEAD CT
Acute right thalamic
hemorrhage, with surrounding
edema, mass effect, and
intraventricular extension.
 What are the primary
goals in the management
of acute intracerebral
hemorrhage?
ICH DIAGNOSED

AGGRESSIVE BP CONTROL PREVENT EXPANSION,

KEEP SBP 120-140
CORRECT COAGULOPATHY
SECONDARY INJURY

MANAGE INTRACRANIAL SURGICAL CLOT

PRESSURE EVACUATION
NOT AN ISSUE IN THIS MISTIE PROCEDURE
CASE.

MAINTAIN
HOMEOSTASIS
NORMOTHERMIA,
NORMOGLYCEMIA

HEMORRHAGIC
PREVENT STROKE WORKUP
RECURRENCE
INITIAL NON-CONTRAST HEAD CT HEAD CT, 52 HOURS POST
Acute intraparenchymal hemorrhage in MISTIE
the right basal ganglia, with surrounding Dramatic reduction of the
edema and mass effect. hematoma and mass effect.

SURGICAL CLOT
EVACUATION:
MISTIE
HEMORRHAGIC STROKE PREVENTION
WORK-UP, MECHANISMS, AND TREATMENTS

“Your brain is experiencing technical

difficulties. Dispatching a medical
student. Please stand by…”
 HEMORRHAGIC STROKE
22%

INTRACEREBRAL SUBARACHNOID
(ICH) (SAH)

SMALL VESSEL DISEASE LOBAR HEMORRHAGIC

(HYPERTENSIVE) TRANSFORMATION OF
ISCHEMIC INFARCTION
 ICH

SMALL VESSEL DISEASE LOBAR

(HYPERTENSIVE)

RUPTURE OF SMALL VASCULAR

PENETRATING MALFORMATIONS
ARTERIOLES TUMORS
(BASAL GANGLIA, (METASTATIC DISEASE,
THALAMUS, OR PRIMARY)
PONS, CEREBELLUM)
COAGULOPATHY
VASCULOPATHY
(CEREBRAL AMYLOID
ANGIOPATHY, VASCULITIS)

ENDOCARDITIS
(SEPTIC EMBOLI)

DRUGS
(COCAINE)
 ICH WORKUP BRAIN MRI
without and with Contrast

CHECK FOR WORKUP FOR

CEREBRAL WORKUP FOR MODIFIABLE
VESSEL IMAGING CARDIOEMBOLIC RARE CAUSES
RISK FACTORS
SOURCE Genetic testing
CTA Head with
Contrast Transesophageal Hypertension
Cerebral
echocardiogram Smoking angiogram
MRA Head and blood culture
without (gold standard
when endocarditis Anticoagulant of vascular
Gadolinium is suspected. use imaging)
Brain biopsy
ARTERIOVENOUS
MALFORMATION (AVM)

Derdeyn CP, et al.

Stroke 2017;48:e200-24

Artery
Vein

www.stepwards.com
 CEREBRAL
AMYLOID
ANGIOPATHY
(CAA)
Age > 60
Multiple lobar
microhemorrhages
Amyloid deposits in
leptomeningeal and
cortical arterioles
Associated with
dementia

MRI, GRE SEQUENCE

MULTIPLE CORTICAL AND SUBCORTICAL
MICROHEMORRHAGES
What is the mechanism of
our patient’s acute
intracerebral hemorrhage?
BACK TO THE CASE…

• MRI Brain + Gad showed no evidence of neoplasm

• GRE sequence showed no microhemorrhages

suggestive of CAA.

• CTA Head was negative for vascular malformation.

• Final diagnosis: Hypertensive right basal ganglia

hemorrhage.

• Patient was discharged to rehab with BP 125/70

HEMORRHAGIC STROKE
RISK BY MECHANISM

small vessel disease lobar

SUBARACHNOID
(22%)
SAH
(SAH)

CLINICAL FEATURES:
SEVERE HEADACHE (97%)
MENINGEAL SIGNS
LETHARGY, NAUSEA,
VOMITING

CAUSES:

TRAUMA
SACCULAR (BERRY) ANEURYSMS
AT BRANCH POINTS IN CIRCLE OF
WILLIS
VASCULAR MALFORMATIONS

COMPLICATIONS:

REBLEEDING (24-48 HRS)

HYDROCEPHALUS (>24 HRS)
VASOSPASM (7-10 DAYS)
NON-CONTRAST HEAD CT
DIFFUSE SAH IN ALL BASAL CISTERNS, BILATERAL SYLVIAN
FISSURES AND INTER-HEMISPHERIC FISSURE Radiopaedia.org
ANEURYSMAL SAH DIAGNOSED

SECURE THE
PREVENT
AGGRESSIVE BP CONTROL
KEEP SBP 120-140
ANERYSM RE-BLEEDING,
CORRECT COAGULOPATHY
COILING OR
CLIPPING SECONDARY
INJURY
EXTERNAL
HYDROCEPHALUS WATCH VENTRICULAR DRAIN
MANAGE INTRACRANIAL TO DIVERT CSF FLOW,
PRESSURE AS NEEDED TREAT OBSTRUCTIVE
HYDROCEPHALUS

MAINTAIN HOMEOSTASIS
MONITOR FOR VASOSPASM
TREAT WITH NIMODIPINE FOR
PREVENTION

SMOKING CESSATION
ASPIRIN
PREVENT SURVEILLANCE AND REPAIR OF
OTHER ANEURYSMS
RECURRENCE
HOW TO BECOME A STROKE NEUROLOGIST

• Anterior versus posterior circulation: Deficits correspond to

vascular territories.

• Acute ischemic stroke is a neurological emergency

• Time is brain: Rapid diagnosis and treatment with intravenous

thrombolysis and endovascular thrombectomy.

• Ischemic stroke workup is necessary to find the wolf among the

sheep, and decide on proper stroke prevention therapy.

• Cardioembolic source has the highest risk of stroke recurrence.

• Mel Brooks is an awesome writer, and you should see all of his
movies.
HOW TO BECOME A STROKE NEUROLOGIST

• Acute hemorrhagic stroke is a neurological emergency

• Treat aggressively with reduction of blood pressure and reversal

of coagulopathy.

• MISTIE is a promising surgical procedure for evacuating

intraparenchymal hematomas to prevent secondary injury.

• Aneurysms should be secured early. Patients should be

monitored for vasospasm and obstructive hydrocephalus.

• Hemorrhagic stroke workup is necessary for effective prevention

of secondary bleeds.

• Lobar hemorrhages typically have the higher risk of bleed

recurrence.
THANK YOU