Stroke (cerebrovascular accident, CVA)

This is a brief video on strokes, covering pathophysiology, presentation, as well as acute and chronic management/treatments.

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ADDITIONAL TAGS:
Stroke
cerebrovascular accident (CVA)
By Blausen Medical Communications, Inc. - see ticket for details, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=26986798
Overview & pathophys
Cause / risk factors
Presentation
Initial workup
Chronic therapy / prevention

Overview / pathophys
Stroke/cerebrovascular accident (CVA) is #3 cause of death in USA
#1 cause of neurologic disability
Ischemic
Thrombotic vs Embolic
Hemorrhagic
Subarachnoid hemorrhage (btwn arachnoid mater and pia mater)
vs
Intracranial hemorrhage (into
parenchymal or ventricular space)
By Manu5 - http://www.scientificanimations.com/wiki-images/, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=67489698
By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia
.org/w/index.php?curid=11414174
By Blausen Medical Communications, Inc. - see ticket for details, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=26986798
By ElinorHunt - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=69676318
Ischemic (85%)
Similar to heart attack but in the brain:
Embolic: clot forms (on damaged heart valves, during afib, carotid stenosis, (or DVT→PFO)), thrown to smaller vessel, gets lodged, occludes blood
Thrombotic: atherosclerosis. Risk factors include diabetes, hypertension, hyperlipidemia, obesity, smoking, age
Others: smaller arteries (lacunar), vasospasm/migraine, drug abuse, dissection, arteritis
Younger pts: hypercoag states, like OCPs; protein C/S deficiencies; cocaine, amphetamines; p vera, sickle cell
Cause / risk factors
Hemorrhagic (15%)
Subarachnoid hemorrhage
(btwn arachnoid mater
and pia mater)
vs
Intracranial hemorrhage (into
parenchymal or ventricular space)
Worst prognosis (50% 30-d mortality)
Cause: blood vessel or aneurysm rupture
Risks: hypertension, trauma, anticoagulant therapy
Overview & pathophys
SAH most common ruptures
Thunderclap → SAH
+/- neck stiff, vomiting
Xanthochromia:
ACA: paralysis of legs and feet, confusion, urinary incontinence
MCA: paralysis of face and arms, aphasia (speech), contralateral sensory, homonymous hemianopsia
PCA: vision, ipsilateral sensory of face, contralateral sensory of limps,
ACA
MCA
Locked in syndrome
Syncope
Cerebellar:
dysdiadokinesia, ataxia, discoordination
By William Laborde, MD, Brandon Mong, MD, and Joel Mosley, MD - William Laborde, MD, Brandon Mong, MD, and Joel Mosley, MD (2019-06-24). The Bloody CSF Tap – Pearls and Pitfalls. emDocs.net.- "emDocs is licensed under a Creative Commons Attribution 4.0 International License.", CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=89548872
By File:1421 Sensory Homunculus.jpg: OpenStax Collegederivative work: Popadius - This file was derived from: 1421 Sensory Homunculus.jpg:, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=88916983
By Rhcastilhos - Gray519.png, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1597012

Initial workup
First test: CT scan w/o contrast
If blood → hemorrhagic stroke (15%) → consult neurosurg to coil clip bleed, reduce BP 150, give FFP, prevent hydrocephalus with shunt or LPs or craniotomy, seizure prophylaxis with anticonvulsants, prevent vasospasm with CCB
Next consider tPA (tissue plasminogen activator) to break clot, save penumbra
If pt presents within 3 (4.5) hrs of definite symptom onset AND no head trauma AND no surgery within 21 days AND never had a brain bleed
Later workup:
BP → permissive hypertension with ischemic stroke.(unless tPA)
EKG → if afib, give anticoagulation (warfarin (without Hep bridge) or NOACs (apixaban, dabigatran, rivaroxaban, and edoxaban))
Echo → check cardiac valves and afib for source of embolism
Carotid duplex ultrasound
if 80% stenosis or 70%+symptoms → stent or carotid endarterectomy

Chronic therapy (for future stroke prevention)
BP → Chronic: maintain 140/80 with ACEi, diuretics, other agents
Hyperlipidemia → high intensity statin (atorvastatin 40, 80 OR resuva 20, 40)
Diabetes → maintain A1c 7% with metformin, other oral agents, insulin
Smoking cessation
Antiplatelet for life → aspirin (or clopidogrel) +/- dipyridamole
Anticoagulation for life → warfarin or NOAC; CHA2DS2-VASc score gets +2
Congestive heart failure
Hypertension
Age = 75
Diabetes type 2
Stroke or TIA or thromboembolism (2)
Vascular dz (PAD, MI)
Age 65-74
Sex category (female)

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