Ischemic Stroke

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 Pathology 6 Genetics 7 Clinical-manifestations 8 Laboratory 9 Radiology 10 Complications 11 Management 12 More General Terms 13 Additional Terms 14 Internet Database 15 References

More Specific Terms

• lacunar infarct
• vertebrobasilar stroke

Introduction

• A stroke caused by an insufficient supply of blood & oxygen to a part of the brain, generally result of cerebrovascular disease.

Etiology

• thrombus related to atherosclerosis of large arteries (30%)

• internal carotids
• aortic arch {uncommon} [24]
• large intracranial arteries

• embolus from cardiac source (20%)

• secondary hemorrhage may occur
• patent foramen ovale [24,31],

• cryptogenic stroke, all ages, epecially < 55-60

• atrial septal aneurysm in 28-40% of ischemic strokes in patients < 55 years of age
• patent foramen ovale & atrial septal aneurysm frequently occur together
• multiple cardiac emboli are suggested by 2 or more areas of ischemic infarction
• myocardial infarction [11] resulting in LV systolic dysfunction
• atrial fibrillation [11]

• lacunar (small vessel) (20%)

• lipohyalinosis
• atherosclerosis
• vasculitis

• other (30%)

• pharmacologic:

• oral contraceptives

• controversial
• avoid in women with migraine or who smoke

• cocaine
• over the counter sympathomimetics

• hypercoagulable state

• antiphospholipid antibody, especially high titer IgG anticardiolipin
• protein S deficiency
• protein C deficiency
• antithrombin III deficiency
• polycythemia vera
• disseminated intravascular coagulaton ( DIC)
• thrombotic thrombocytopenic purpura
• hyperhomocysteinemia

• arteritis

• giant cell arteritis
• Takayasu arteritis

• fibromuscular dysplasia
• migraine
• Moya Moya disease

• idiopathic in 50% of patients < 55 years of age [41]
• also see risk factors associated with ischemic stroke

Epidemiology

• 3rd most common cause of death
• most common cause of adult disability
• most preventable of catastrophic conditions
• 75% of all strokes are ischemic

Pathology

• infarction of a vascular territory of the brain due to ischemia
• an ischemic zone surrounds an infarct & secondary phenomena increase the severity of the irreversible injury
• these secondary phenomena include excitotoxin-induced neuronal injury, cerebral edema & altered local blood flow
• morbidity & mortality associated with massive hemispheric ischemic strokes is due to brain tissue edema resulting in brainstem & diencephalic compression [23]

Genetics

• susceptibility to ischemic stroke associated with

• defects in protein kinase C-eta ( PRKCH)
• defects in P-selectin ( SELP)
• genetic variations in ALOX5AP
• defects in factor V
• defects in prothrombin

Clinical-manifestations

• sensory involvement of affected areas may result in sensory deficits
• motor involvement of affected areas may result

• paresis, paralysis, generally unilateral
• dysarthria, dysphagia

Laboratory

• telomere length in peripheral blood mononuclear cells allegedly predicts cognitive decline, dementia & death after stroke [27] - difficult to envision mechanism

Radiology

• carotid ultrasound
• echocardiogram

• transesophageal ultrasound can also detect aortic arch thrombi: thrombi > 3 mm are suspect
• identifies atrial septal defect in young adults with stroke

• angiography is the gold standard for delineating vascular anatomy
• magnetic resonance angiography is useful for evaluating exatracranial & large intracranial arteries
• transcranial doppler ultrasound showing increased flow velocity can confirm magnetic resonance angiographic findings

Complications

• cerebral edema or cerebellar edema resulting in increased intracranial pressure may occur after major ischemic stroke
• delirium occurs in 12% of patients admitted to stroke unit; associated with poor prognosis [40]
• seizures early after stroke

• less common with ischemic stroke than hemorrhagic stroke (4% vs 15%) [43]
• more common with cortical stroke than subcortical stroke (19% vs 10%)
• do not predict mortality or function at 6 months [43]

• poststroke dementia due to cerebrovascular disease [45]
• anxiety & depression common [46]
  
• disease interaction(s) of stroke with urinary incontinence
• disease interaction(s) of stroke with Alzheimer's disease

Management

• acute ischemic stroke (within 4 hours, 4.5 hours [37])

• see ACLS algorithm for suspected stroke
• see thrombolysis for ischemic stroke
• NCY-059, a free radical trapping agent, 72 hour infusion appears to improve outcomes in clinical trials [21]
• craniotomy for massive (malignant MCA) infarcts [23]
• coronary stenting may be of benefit [36]

• do not attempt to acutely lower blood pressure unless

• systolic blood pressure > 220 mm Hg, or
• diastolic blood pressure > 120 mm Hg, or
• mean arterial blood pressure > 140 mm Hg
• patient has acute coronary syndrome
• aortic dissection suspected
• thrombolytic therapy planned [4]

• maintain blood glucose < 140 mg/dL at least for 1st 24 hours [3]
• supportive therapy directed towards:

• reducing risk factors (attenuating pathologic processes)
• removing underlying cause
• minimizing secondary brain damage by maintaining adequate perfusion & limiting edema
• monitor for cerebral edema for 3-5 days post stroke [3]
• avoid postural hypotension, a frequent cause of neurologic deterioration after completion of ischemic stroke

• return to supine position
• administer fluids ( normal saline)
• monitor blood pressure
• reassess pharmacologic therapy

• avoid/treat hyperthermia or fever

• routine acetaminophen of no benefit [38]

• pharmacologic therapy

• aspirin 325 mg QD

• 650 mg BID for intracranial arterial stenosis

• minocycline 200 mg PO QD for 5 days (window 6-24 hours after onset of stroke) [29]
• clopidogrel ( Plavix) 75 mg PO QD superior to aspirin [32]
• statin ( HMG CoA reductase inhibitor if LDL > 100 mg/dL)

• simvastatin useful for primary, but not secondary stroke prevention [15]
• atorvastatin may be useful for secondary stroke prevention, in high-risk patients [26,42]
• continue statin without interruption in patients with ischemic stroke who took statin prior to stroke [28]
• in very high-risk patients, goal may be LDL < 70 mg/dL [3]
• aggressive statin therapy (i.e. high-dose atorvastatin) recommended for secondary stroke prevention [44]

• combination therapies

• Plavix 75 mg + aspirin 81 mg QD

• NOT superior to Plavix alone [16] (see MATCH study)

• Aggrenox ( dipyridamole + aspirin)

• superior to aspirin, same benefit as Plavix [32]
• number need to treat = 67 for 1 year to prevent 1 stroke ( Aggrenox vs aspirin)

• ACE inhibitor + diuretic may be of some value [4]
• heparin* followed by warfarin

• in general, do NOT use, except in embolic stroke
• prevention of cardiac emboli
• only after hemorrhage has been ruled out

• thrombolytic therapy (within 1st 3 hours)

• tissue plasminogen activator ( tPA)

• fluoxetine 20 mg PO QD for 90 days starting 5-10 days after stroke may diminish motor disability [39]

• blood pressure reduction predicts poor prognosis: [14]

• reduction in blood pressure (both systolic or diastolic) during the 1st 24 hours associated with negative outcomes
• antihypertensive therapy does not seem to affect either blood pressure or outcome during the 1st 24 hours [14]
• initial blood pressure < 150/70 mm Hg associated with increased mortality

• stroke units ( neurorehabilitation) improve outcomes [44] (see neurorehabilitation)
• telestroke systems of benefit for rural areas (see telehealth)
• secondary prevention

• consider carotid endarterectomy (70-99% stenosis)
• secondary prevention in patients with cardiovascular disease
  

• * unfractionated heparin & low-molecular-weight heparin not as effective as aspirin for acute ischemic stroke [12]
  
• Follow-up:

• workup for coronary artery disease

• lipid panel*
• rule out hyperhomocysteinemia
• ECG stress testing
  

• * no association with dietary fat [13]
  
• 'Get with the Guidelines - Stroke' an internet-based tool improved outcomes in hospitalized stroke patients [34]

More General Terms

• stroke; cerebrovascular accident (CVA)
• cerebral ischemia

Additional Terms

• ACLS algorithm for suspected stroke
• cardiac conditions associated with embolic stroke
• internal carotid artery disease (carotid stenosis)
• intracranial arterial stenosis
• ischemic stroke prevention trial
• neurorehabilitation
• risk factors associated with ischemic stroke
• secondary prevention in patients with cardiovascular disease
• thrombolysis for ischemic stroke
• transient ischemic attack (TIA)

Internet Database

OMIM: 601367

References

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ischemic stroke