Stroke

Syndromes
PGI CASTILLO J
PGI DE LARA
01
Stroke
STROKE
● any disease process that interrupts blood flow to the brain
○ Injury is related to the loss of oxygen and glucose substrates
● Two major mechanisms
○ Ischemia
■ Thrombotic
■ Embolic
■ Hypoperfusion
○ Hemorrhage
■ Intracerebral
■ Nontraumatic subarachnoid hemorrhage
CLINICAL FEATURES
● Diagnosis
○ focused, accurate history and physical
examination

● Timing of symptom onset, the presence of

associated symptoms, and the medical history
may point toward a particular mechanism of
stroke
● Accurately determine the time of symptom
onset
○ The time of onset is defined as the last
known time when the patient’s condition
was at their baseline (i.e., “last known
well” time).
Physical Examination
● Assessment of airway, breathing, and
circulation is the top priority

● Exclude stroke mimics, and identify

comorbidities

● Fever should prompt an investigation

for potential infection
The National Institutes of Health Stroke
Scale (NIHSS)
● validated stroke severity scale to assess the neurologic status
● an 11-category (15-item) neurologic evaluation (score range of 0 to 42) that is rapid (5 to 10
minutes), has a high interrater reliability
● provides a baseline score that is useful in predicting patient outcomes
● An important caveat is that the NIHSS is weighted toward the detection of anterior circulation
strokes
02
Ischemic
Stroke
Syndromes
ANTERIOR CEREBRAL ARTERY
INFARCTION
● uncommon (0.5% to 3% of all strokes)
● Unilateral occlusion
○ cause contralateral sensory and motor
symptoms in the lower extremity, with
sparing of the hands and face
○ Left sided lesions
■ akinetic mutism and transcortical
motor aphasia
○ Right sided lesions
■ confusion and motor hemineglect
MIDDLE CEREBRAL ARTERY INFARCTION
● Vessel most commonly involved in stroke
● Variable clinical findings, depends on:
○ location of lesion
○ Dominant brain hemisphere
■ Dominant affected: aphasia (receptive, expressive, or both)
■ Non dominant affected: inattention, neglect, dysarthria without aphasia
● Typically presents with hemiparesis, facial plegia, and sensory loss contralateral to the
affected cortex
● variably affect the face and upper extremity more than the lower extremity
POSTERIOR CEREBRAL ARTERY INFARCTION
(DISTAL POSTERIOR CIRCULATION)
● Classic symptoms:
○ ataxia, nystagmus, altered mental status, and vertigo.
● Common symptoms:
○ visual field loss, unilateral limb weakness, gait ataxia, unilateral limb ataxia, cranial
nerve VII signs lethargy, and sensory deficits
● Motor dysfunction, although common, is typically minimal, which can keep some patients
from realizing they have had a stroke
BASILAR ARTERY OCCLUSION VERTEBROBASILAR INFARCTION
(MIDDLE POSTERIOR (PROXIMAL POSTERIOR
CIRCULATION) CIRCULATION)

● most common presenting ● Common presenting signs

signs are unilateral limb include unilateral limb ataxia,
weakness, cranial nerve VII nystagmus, gait ataxia, cranial
signs, dysarthria, Babinski sign, nerve V signs, limb sensory
and oculomotor signs deficit, and Horner’s syndrome
CEREBELLAR INFARCTION
● Can present with Very Non specific symptoms
○ dizziness (with or without vertigo)
○ nausea and vomiting
● May also present with gait instability, headache, limb ataxia, dysarthria, dysmetria,
nystagmus, hearing loss, and intractable hiccups
● Mental status may vary from alert to comatose.
● 25% of noncontrasted head CTs can be normal in cerebellar infarction
LACUNAR INFARCTION
● infarction of small penetrating arteries

● pure motor or sensory deficit

● commonly associated with chronic hypertension and increasing age

● Variable presentation, based on location and size of the lesion

● Favorable prognosis
CAROTID AND VERTEBRAL ARTERY DISSECTION
● a major cause of stroke (up to 20%
CAROTID ARTERY DISSECTION
prevalence) in young adults and the
middle-aged
● Prominent risk factor is history of
neck trauma, usually minor
● typical first symptom:
○ unilateral headache (68%),
○ neck pain (39%), or
○ face pain (10%)
● Symptoms may be transient or
persistent
VERTEBRAL ARTERY DISSECTION
● most commonly in the frontotemporal region
○ may mimic subarachnoid hemorrhage
temporal arteritis, or preexisting migraine
● Partial Horner’s Syndrome, traditionally linked
● Can progress to cause cerebral ischemia or, rarely,
retinal infarction
● commonly presents with dizziness/vertigo (58%),
headache (51% to 65%), and neck pain (46% to 66%)
● headache is typically occipital
● Untreated vertebral artery dissection may result in
infarction in regions of the brain supplied by the
posterior circulation
03
Hemorrhagic
Stroke
Syndromes
Hemorrhagic Stroke
● Spontaneous intracerebral hemorrhage may be clinically indistinguishable from ischemic infarction
○ But are distinct clinical entities in terms of management.
■ perform CT to differentiate between the two
● Headache, nausea, and vomiting often precede the neurologic deficit, and the patient’s condition
may quickly deteriorate

● Cerebellar hemorrhage
○ may be clinically indistinguishable from cerebellar infarction
● Subarachnoid hemorrhage
○ Severe occipital or nuchal headache.
○ Careful history taking may reveal activities associated with a Valsalva maneuver
04
Stroke
Diagnosis
Brain Imaging
● Most ischemic strokes are not visualized in the early hours of a stroke in a non-contrast CT
scan.
● First brain CT scan can help in ruling out intracranial bleeding, abscess, tumor and other
mimics.
● Diffusion Weighted MRI is superior to non–contrast CT or other types of MRI.
● But with the wide availability and practicalness, non-contrast CT scan is the only imaging
necessary prior to administration of thrombolytics.
Vascular Imaging
● CT or MRI Angiography can help in detecting presence of large vessel stenosis or occlusion,
as to ascertain possible candidacy for endovascular therapy.
Perfusion Studies
● The size of the penumbra cannot be ascertained clinically.
● Perfusion CT and Diffusion Weighted MRI can help in measuring the size of the penumbra.
● Current AHA/ASA Guidelines do not recommend routine use of perfusion studies in all stroke patients.
05
Core ED
Interventions
06
Treatment
Modalities
Standard Treatment
● IV Fluids to prevent dehydration and increased blood viscosity
● O2 Support→ Maintain >94% O2 sat
● Control of Fever if present
● Admit all acute stroke patients
Blood Pressure Control
Hyperglycemia
● Blood Glucose should be maintained between 140-180 mg/dL
● Take note that hyperglycemia and hypoglycemia should be treated as they are both
mimics of stroke.
Antiplatelet Therapy
● Current AHA/ASA Guidelines recommend administration of oral or rectal aspirin within
24-48 hrs of stroke onset unless thrombolytics are given w/in 24 hrs.
● CHANCE trial found that mild stroke patients who received Clopidogrel had noted
fewer recurrence of stroke.
Thrombolysis
● Alteplase- currently the only FDA approved treatment for Acute Ischemic Stroke.
● AHA/ASA advised not to use this is the time of onset is not certain ( within 60 mins).
● Thrombolytics should be given within 3-4.5 hrs of acute stroke.
● Standard dose of alteplase: 0.9 mg/kg/IV with max dose of 90 mg, 10% of solution administered as bolus for
1 min, then the rest is infused over 60 mins.
● Monitoring: Blood pressure and Neurological Assessment must be done every 15 mins for 2 hrs upon
administration.
● Possible Complication: Orolingual Angioedema
Endovascular Therapy
Transient Ischemic Attack
● “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or
retinal ischemia, without acute infarction
● Published risk factors associated with increased risk for subsequent stroke include
hypertension, diabetes mellitus, symptom duration of ≥10 minutes, weakness, and
speech impairment, male sex, dyslipidemia
Transient Ischemic Attack Treatment
● CHANCE trial found that combination therapy of aspirin and clopidogrel are found to
decrease the risk of having stroke for the first 90 days, without risk for bleed.
● Anticoagulants are not recommended even with the presence of atrial fibrillation as it
may increase bleeding risk.
 Thanks
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