SUMMARY: 

Cerebrovascular accident, or stroke, represents acute disruption of cerebral perfusion.  There are two categories of stroke, ischemic and hemorrhagic. Ischemic stroke (70% of all stroke) is when there is disruption of the vascular supply of the brain, be it by vascular occlusion or obliteration, with downstream ischemia. Hemorrhagic stroke (30% of all stroke) represents bleeding into the skull, which is further subdivided depending on the location of the bleeding. Below is a summary of guidelines that detail pre-hospital care, urgent and emergency evaluation, treatment with intravenous and intra-arterial therapies. Generally speaking, time is brain, and so emergent evaluation is highly recommended in the hyperacute/acute setting.In-hospital management is also covered, including secondary prevention measures that are appropriately instituted within the first 2 weeks.

Categorization of Stroke Types 

Ischemic Stroke

• Vascular disruption with subsequent prevention of cerebral perfusion
  • Thrombotic: The clot is formed at the site of vascular occlusion
  • Embolic: The thrombus travels to the brain (often from the heart)
  • Small vessel: obliteration of penetrating arteriole (arteriosclerosis)
  • Systemic Hypoperfusion (often in the setting of profound hypotension, or prolonged CPR)  

Hemorrhagic Stroke

• Blood vessel ruptures and impairs circulation
  • Intracerebral: Small arteries in the brain tissue
  • Subarachnoid: Usually due to outpouchings or aneurysms of the vessels that eventually rupture into the lining around the brain
  • Subdural: often seen because of trauma, where blood accumulates outside the brain, but below the dura 
  • Epidural: often seen in direct trauma to the side of the head, disruption of the middle meningeal artery 

Transient Ischemic Attack (TIA) 

• Clinical definition
  • Symptoms of stroke | Ischemic in nature | Present and resolve within 24 hours 
  • While many patients may symptomatically resolve, magnetic resonance imaging (MRI) may reveal imaging findings consistent with acute ischemia in a substantial fraction, thereby changing the diagnosis to acute stroke
• Evaluate Emergently for further risk stratification and implement secondary prevention measures implemented 
  • TIA is felt to be the precursor of stroke, with many who suffer from a TIA at high risk of having a stroke within the next two weeks 
  • Symptomatically there is no difference between ischemic stroke and TIA in the hyperacute setting

Symptoms

• Trouble speaking or difficultly with comprehension (expressive or receptive aphasia)
  • Speech may be incomprehensible or garbled
• Paralysis or numbness
  • Usually presents with hemiparesis
• Visual disturbances
  • May experience blurred or loss of all sight in one or both eyes
  • Usually in combination with the other symptoms, but sometimes can be found in isolation
• Headache due to increased intracranial pressure (more likely with hemorrhagic stroke)
  • Often the worst headache experienced in a patient’s life or “thunderclap” in nature
  • Associated with vomiting, dizziness, or altered level of consciousness
• Difficulty with walking or balance
  • Patients may develop dizziness and/or a loss of balance or coordination

Risk Factors

Modifiable Risk Factors

• Hypertension: Most common cause of stroke
• Tobacco abuse
• Diabetes mellitus
• Stimulant use
• Antithrombotics (for hemorrhagic stroke)
• Previous CVAs or TIAs
• Strenuous activity in patients who have family history or risk factor for aneurysms
• Sedentary lifestyle
• Excessive alcohol use
• Obesity
• High Cholesterol or triglycerides

Nonmodifiable Risk Factors

• Age: Risk increase with age, especially over the age of 60
• Male sex: More common in younger ages in men
• Race & ethnicity: African Americans & Hispanic Americans are at higher risk

Differential Diagnosis 

• Brain tumors
• Brain abscesses
• Seizure
• Complex migraine
• Multiple Sclerosis
• Acute Disseminated Encephalomyelitis (ADEM)

Treatment: Ischemic Stroke  

Medications

• Alteplase/Tenecteplase
  •  Thrombolytic mechanism of action increases the chances of cerebral perfusion, which often improves neurological deficits
  • Must be given within 3 hours of symptom onset
  • Certain patients are candidates for an extended 4.5 hour window
  • The major risk is hemorrhagic stroke (~3% risk for alteplase)  
• Dual Antiplatelet Therapy | Start within 24 hours of symptom onset
  • Ischemic stroke from intracranial atherosclerosis: Aspirin (160 to 325 mg loading dose, followed by 50 to 100 mg daily) plus clopidogrel (600 mg loading dose followed by 75 mg daily) for 21 to 90 days, followed by monotherapy indefinitely
  • TIA or minor stroke: Aspirin plus clopidogrel for 21 to 30 days with the same dosing as above

Note: Aspirin plus clopidogrel is more effective than aspirin but less effective than anticoagulation for preventing stroke from atrial fibrillation

• Anticoagulant prophylaxis for inpatient use
  • Lovenox | Heparin | Xarelto | Eliquis | Pradaxa
  • Ensure any medication is adjusted for abnormal renal function
  • Outpatient use of anticoagulants is only for treatment of atrial fibrillation

Blood Pressure Control

• Ischemic stroke treated with TPA: Treat BP if exceeds >185/>105
• Ischemic stroke without TPA: Allow for permissive hypertension and treat only if >220/>120 if no other comorbidities require normotension (weak evidence) | May be reasonable to lower by 15% in the first 24 hours

Surgery

• Mechanical thrombectomy can be offered at certain stroke centers within 24 hour time window, depending on patient deficits and the size of the occlusion

Treat Other Comorbidities

• Atrial fibrillation
• Hypertension
• Diabetes Mellitus
• High Cholesterol or Triglycerides

Treatment: Hemorrhagic Stroke

Medications

• Mainstay of treatment is blood pressure medications to maintain BP <140/<90

Surgery

• Ruptured aneurysm may require clips or stents to prevent further bleeding

Tests and Imaging

Diagnostic Neuroimaging

• Emergent non-contrast head computed tomography to identify hemorrhagic stroke
• Follow-up Multimodal CT or magnetic resonance imaging
  • Diffusion weighted MRI is more sensitive than CT for acute ischemic stroke

Additional Tests

• Complete blood count and electrolyte panel with glucose
• Electrocardiogram
• Lipid panel

Complications

• Cerebral edema
• Pneumonia
• Urinary tract infection (UTI) / Loss of bladder control
• Seizures
• Depression
• Bedsores
• Limb contractures
• Shoulder pain
• Deep venous thrombosis (DVT)

Learn More – Primary Sources:

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Use of Dual Antiplatelet Therapy Following Ischemic Stroke (Dong et al, Stroke 2020)

Optimal Blood Pressure After Intracerebral Hemorrhage: Still a Moving Target (Rabinstein, Stroke 2018)

Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA (Johnston et al, NEJM 2018)