Stroke

Objectives (regarding the Blueprint):

1. Recognize the clinical presentation of acute ischemic

stroke and intracerebral hemorrhage
2. Recognize common imaging findings of ischemic
and hemorrhagic stroke
3. Manage patient presenting with hyperacute and
acute ischemic stroke
4. Address risk factors for ischemic and hemorrhagic
stroke

439 Team Leader:

Nourah Alklaib

439 Team Member:

Afnan Almohsen
Editing File

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● Slides / Reference Book ● Important
● Doctor notes ● Extra
● OnlineMeded / Amboss
 stroke
Types of stroke

Ischemic stroke Intracerebral Subarachnoid

hemorrhage hemorrhage

Morbidity and Mortality

Ischemic Stroke
• The leading cause of long-term physical disability.
• The increase in life expectancy will increase the incidence of stroke.
• A second to only heart disease in causing death world-wide.
• According to the WHO 15 million people worldwide suffer a stroke each year.
• 30-day mortality is 12%.

High Socio-Economic
For survivors aged > 65 years:
• 50% have hemiparesis
• 30% are unable to ambulate
• 19% are aphasic
• 35% are depressed
• 26% resides in nursing home.

Ischemia Mechanism:
TOAST classification:
1) Large-artery atherosclerosis
2) Cardio-embolism
3) Small-vessel occlusion
4) Stroke of other determined aetiology*
5) Stroke of undetermined aetiology.
* For example: Hypercoagulable state, dissection, hypoperfusion, etc.
History taking (symptoms )
Onset: Acute focal neurologic deficit
- Unilateral weakness(whole or in part) - Difficulty swallowing
- Unilateral sensory symptoms - Simultaneous bilateral weakness
- Slurred speech - Imbalance
- Vertigo
- Language difficulty
- Crossed motor or sensory loss
- Visual symptoms (monocular, - Difficult dressing, combing hair
homonymous hemianopsia,double vision) - Visuospatial neglect
- LOC
Past medical history:
- HTN - Ischemic/ Valvular Heart Disease
- Diabetes - Previous TIA/ Stroke
- Dyslipidemia - Any thrombo-embolism
- Smoking/ Illicit drugs
Physical examination in stroke patient

● Cranial nerves examination

Differential diagnosis :
- Migraine aura
- Seizure
- Multiple sclerosis
- Metabolic (hypoglycemia)
- Brain tumor
- Syncope Conversion/somatization

Investigations

1- CBC

2- coagulation profile
● PT
● PTT
● INR

3- chemistry
● fasting glucose
● HbA1c
● Lipids

4-imaging (immediate investigation )

● CT scan
○ CT scanning is the mainstay of emergency stroke imaging. It allows the rapid
identification of intracerebral bleeding and stroke ‘mimics’ (i.e. pathologies other
than stroke that have similar presentations), such as tumors. it is done to exclude
hemorrhage and early infarct
○ non-contrast CT is the only way to differentiate between ischemic and
hemorrhagic strokes
● MRI

5- vascular imaging (later investigation)

● carotid US
● CTA
● MRI
● Cerebral angio

6- cardiac workup
● ECG
● Echo (TTE or TEE)
● Holter

7- in specific cases
● Hb
● Electrophoresis
● Hypercoagulable workup Further Investigations:Look for
● CTD screen the source
● HIV and syphilis
Recognize the clinical presentation of acute ischemic
stroke and intracerebral hemorrhage
The Clinical presentation of ischemic stroke
(Depending on the site of occlusion) :
Clinically we can’t differentiate between ischemic and hemorrhagic strokes.

● Middle Cerebral Artery (MCA) occlusion

(Total anterior circulation syndrome (TACS)
Common cause:
● Embolism from heart or major vessels
Symptoms:
Combination of:
● Hemiparesis: Arm + face (UE) more than leg weakness (LE)
● Hemisensory loss
● Higher cerebral dysfunction:
○ Aphasia if affecting the dominant (left) hemisphere.
○ Neglect if affecting the non-dominant hemisphere.
● Contralateral homonymous hemianopia

Types of aphasia

● Damage in the left inferior frontal lobe causes reduced speech fluency with
1. Broca’s
relatively preserved comprehension.
(expressive,
● The patient makes great efforts to initiate language.
anterior)
● Patients who recover say they knew what they wanted to say, but could not
aphasia:
get the words out.

● Left temporo-parietal damage leaves fluency of language but words are

muddled.
2. Wernicke’s
● This varies from insertion of a few incorrect or non-existent words into
(receptive,
speech to a profuse outpouring of jargon (i.e. rubbish with wholly
posterior)
non-existent words).
aphasia:
● Severe jargon aphasia is bizarre and often mistaken for psychotic behaviour.
● Patients could neither stop speaking nor understand speech.

3. Nominal
(anomic,
● difficulty naming familiar objects (early feature in all types of aphasia)
amnestic)
aphasia:

● combination of the expressive problems of Broca’s aphasia and the loss of

4. Global comprehension of Wernicke’s with loss of both language production and
(central) understanding.
aphasia: ● Due to widespread damage to speech areas, the commonest aphasia after a
severe left hemisphere infarct. Writing and reading are also affected.
Recognize the clinical presentation of acute ischemic
stroke and intracerebral hemorrhage
The Clinical presentation of ischemic stroke
(Depending on the site of occlusion) :
● Anterior Cerebral Artery (ACA) occlusion
Symptoms:
● Weakness LE more than UE (Opposite to MCA)
● Emotional disturbance.
● Visual field is spared

● Branch of MCA or ACA occlusion

(Partial anterior circulation syndrome (PACS))
Common cause:
● Embolism from heart or major vessels Symptoms Could be:
● Isolated motor loss (e.g. leg only, arm only, face)
● Isolated higher cerebral dysfunction (e.g. aphasia, neglect)
● Mixture of higher cerebral dysfunction and motor loss
(e.g. aphasia with right hemiparesis)
● Internal Carotid occlusion
Symptoms
● Above and ophthalmic.
● Posterior Cerebral Artery (PCA) occlusion
Symptoms
● Vision - visual field (homonymous hemianopia sparing the center)
● memory
● Vertebrobasilar (posterior circulation stroke)
Common cause:
● Embolism from heart or thrombosis in situ leading to occlusion of vertebral, basilar,
or PCA
Symptoms
● Cranial nerve syndrome with crossed motor
● Crossing weakness or numbness (L arm and R leg for example)
● cerebellum (cerebellar syndrome): Ataxia, vertigo, vomiting
● altered LOC. (often misdiagnosed as seizures or intoxication)
● homonymous hemianopia
● Midbrain
Symptoms
● CN III: signs of complete CN III palsy:
○ dilated pupil (if the left midbrain is affected → dilated and abducted left eye)
○ Unilateral complete ptosis (levator weakness)
○ Eye deviated down and out (unopposed lateral rectus and superior oblique
● Weber’s syndrome: Ipsilateral IIIrd nerve palsy with contralateral hemiplegia is due to
a unilateral infarct in the midbrain. Paralysis of upward gaze is usually present.
Recognize the clinical presentation of acute ischemic
stroke and intracerebral hemorrhage
The Clinical presentation of ischemic stroke
(Depending on the site of occlusion) :

● Pons
Symptoms
● CN V → Sensory: facial numbness, anterior ⅔ of the tongue sensory loss. Motor:
weakness of jaw movements.
● CN VI → lateral rectus palsy (horizontal diplopia when looking into the distance,
maximal when looking to the side of the lesion.)
● CN VII → facial weakness.
● Medulla
Symptoms
● CN VIII → vertigo, hearing loss.
● CN IX, X → dysphagia.
● CN XII → tongue weakness.
● Small penetrating arteries (Lacunar syndrome)
Common cause:
● thrombosis in situ of small penetrating arteries.
Symptoms: unlike MCA and ACA ischemia, in lacunar syndrome legs, arms and face will be
affected to the same degree, could be:
○ pure motor stroke affecting two limbs
○ Pure sensory stroke
○ Sensory motor stroke
● Note: no higher cerebral dysfunction (no cortical involvement, that leads to
peripheral weakness when present) or hemianopia

Four Major Stroke Syndromes:

● for Rapid Recognition in the ED
● All Occur Suddenly in Stroke Patients

Left (Dominant) Right (non-dominant) brainstem Cerebellum

Cerebral Hemisphere Cerebral hemisphere

- Aphasia - Neglect (Lt - Neglect (Lt - Truncal = gait

- L gaze preference hemi-inattention) hemi-inattention) ataxia
- R visual field deficit - R gaze preference - R gaze preference - Limb ataxia
- R hemiparesis - L visual field deficit - L visual field deficit
- R hemisensory loss - L hemiparesis - L hemiparesis
- L hemi-sensory loss - L hemi-sensory loss

Note: The dominant cerebral hemisphere is the side that controls language function.
Recognize the clinical presentation of acute ischemic
stroke and intracerebral hemorrhage
The Clinical presentation of hemorrhagic stroke :
At the bedside, there is no entirely reliable way of distinguishing between haemorrhage and
thromboembolic infarction. Both produce stroke. Intracerebral haemorrhage tends to be
dramatic with severe headache. It is more likely to lead to coma than thromboembolism.
● Alteration in level of consciousness (approximately 50%).
● Nausea and vomiting due to increase ICP (approximately 40-50%).
● Headache (approximately 40%)
● Seizures (approximately 6-7%)

Focal neurological deficits:

➔ depending on the location:

Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate gaze paresis,

Putamen homonymous hemianopia, aphasia, neglect, or apraxia.

Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia,

Thalamus miosis, aphasia, confusion
Any focal sensory loss, think of the thalamus

Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous

Lobar hemianopia, abulia, aphasia (if affecting the left side), neglect (if affecting the right side), or
apraxia.

Caudate Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion.

nucleus

Ataxia on the same side

Cerebellum

Transient ischemic attack (TIA):

● Sudden transient focal neurological deficit
● Symptoms lasting less than 24 hours (less than one hour) —-> complete resolution
● Symptoms maximal at onset
● Normal CT/MRI of brain
Risk for subsequent Stroke:
Among TIA pts who go to ED:
- 5% have stroke in next 2 days
- 25% have recurrent event in next 3 months
Stroke risk decreased significantly with proper medical therapy
Recognize common imaging findings of ischemic and
hemorrhagic stroke
ischemic stroke:

➔ CT brain at ER
Normal

➔ CT brain of subacute stroke

Left hemisphere

➔ Acute wedge-shaped embolic

stroke
Wedge infarcts are typical of
cardioembolic strokes

➔ DWI (MRI) for acute

Rt PCA
Reach central line posteriorly = PCA
Recognize common imaging findings of ischemic and
hemorrhagic stroke
ischemic stroke:

➔ Frontal lobe ≠ ACA !!

● Left
● Incompe MCA

➔ MRI vs CT for same pt:

➔ CT Angio:
Left MCA occlusion

➔ Acute ischemic change in CT

Obscuration of lentiform nucleus
Recognize common imaging findings of ischemic and
hemorrhagic stroke

➔ Acute Ischemic changes in CT

● Loss of gray-white matter differentiation: You can’t
Identify the border between gray and white matter
● Sulcal effacement: The brain sulci are pushed into the
skull because of cerebral edema causing them to flatten

➔ Hyperdense MCA sign

● The affected MCA appears hyper
dense because of the thrombus

➔ Acute wedge-shaped
embolic stroke
● Wedge infarcts are typical of
cardioembolic strokes

➔ Acute ischemic changes in MRI

Recognize common imaging findings of ischemic and
hemorrhagic stroke
Hypertensive hemorrhage

➔ Putamen hemorrhage
● hemorrhage is hyperdense in CT scan.
● A typical location for hypertensive hemorrhage.
● Hemorrhage is compressing the ventricles (Mass effect)
● Symptoms will be weakness in the contralateral side

➔ Thalamic hemorrhage
● picture shows a left thalamic haemorrhage with
ventricular expansion
● Patient presents with numbness and decreased
sensation on the right side

➔ Pontine
● hemorrhage in the bilateral pontine area.
● very poor prognosis (brainstem hemorrhage)

➔ Cerebellar hemorrhage
● Easy surgery, good prognosis
● left cerebellar hemorrhage which is very close to the
brainstem so neurosurgeon must interfere and
evacuate→ good outcome. if we didn’t interfere it
will push the brainstem → herniation → death.
● patient will present with ataxia on the left side.
Recognize common imaging findings of ischemic and
hemorrhagic stroke
Hypertensive hemorrhage

➔ Lobar hemorrhage

It is the 5th most common cause of hypertinstive haemorrhage,

but it could also be caused by:
● Tumor with ICH:
○ lobar hemorrhage
○ Hemorrhage in a tumor:
○ Very hyperdense area (haemorrhage) next to little
hyper-dense area (tumor).
● AVM :
○ The artery will drain directly to the vein without
passing into venuoles and capillaries which
will cause dilatation and hemorrhage,
Treatment is by embolization of artery
○ MRI showing collection of
worms → typical appearance of AVM
Manage patient presenting with hyperacute and
acute ischemic stroke
Management of ischemic stroke
Stroke treatment:
● primary stroke prevention
● Acute stroke treatment Stroke penumbra:
● Secondary stroke prevention The target of acute stroke
● Stroke rehabilitation treatment

Acute ischemic Stroke Management

Modalities of Acute Stroke Treatment:

1. IV t-PA (standard)

Inclusion criteria Exclusion criteria

● Clinical Dx of stroke ● Intracranial Hge in imaging or clinical

● Stroke onset < 270 minutes presentation suggests SAH
● Age is > or = 18 ● Active/ recent internal bleeding or on warfarin
with INR > 1.7 or platelets < 100K
● Serum Glucose <50 or > 400
● Systolic BP > 185 or diastolic >110
● Recent MI (3/52)
● Recent (2/52) major surgery or trauma
● Recent arterial puncture at noncompressible site
● Others (see NINDS protocol)

● Stroke onset: timing of first neurological deficit OR last time pt was seen well
● TIA: has to end with complete neurological recovery
● IV t-PA (alteplase)
○ 0.9mg/kg to a maximum of 90mg
○ 10% bolus over 1 minute then infuse rest over 60 minutes
○ Hold infusion and re-evaluate the pt in case of HTN (S>185,D>110),
sudden headache, or sudden reduction in LOC
● outcome with IV t-PA :
Acute ischemic Stroke Management
Modalities of Acute Stroke Treatment:

2- Endoarterial Mechanical Disruption

● Merci Retriever
○ first FDA approved device
○ Increased recanalization rate and secondary clinical outcome
○ when used for large cerebral arteries
● Penumbra system:
○ FDA approved
○ It does: clot suctioning
○ Similar rates of recanalization and clinical outcomes to Merci
retriever
● 3rd Generation of devices:
○ Solitaire Device: Solitaire was superior to Merci in Swift trial
○ Trevo retriever: Trevo was superior to Merci in Trevo II trial

3- Endoarterial thrombolysis:
● Combined IA and Mechanical disruption
● General recommendation:
○ For M1 (MCA) clot
○ For Basilar artery clot
○ In certain cases where IV t-PA can not be given e.g. patient is on warfarin or
recent MI
● Limitations:
○ Time (should not delay IV t-PA initiation)
○ Expertise
○ Costs ?
Key time intervals
● Perform an initial patient evaluation within 10 minutes of arrival in the ER
● Notify the stroke team within 15 minutes of arrival
● Initiate a CT scan within 25 minutes of arrival
● Interpret the CT scan within 45 minutes of arrival
● Ensure a door-to-needle time for IV rt-PA within 60 minutes from arrival
Recommendation strategies
● Advance hospital notification by EMS
● Rapid triage and stroke team notification
● Single call activation system
● Rapid access to CT and rapid interpretation
● Rapid laboratory testing (point of care)
● Mix t-PA a head of time
● Team-based approach
Barriers for acute stroke therapy
● Late patient presentation to ER (In USA; only 30% present within t-PA window)
● Poor stroke recognition and delay ed triage at ER (mainly for unusual stroke
presentations)
● Lack of appropriate infrastructure
● Presence of a contraindication
● Difficulty in getting patient’s or family’s verbal consent
Workup for secondary stroke prevention:

● Vascular Imaging: carotids, vert’s, COW

○ (US – CT angio – Conventional Angiogram)
● 72 hour Holter Monitor (can be repeated or extended)
● Echocardiogram: TTE vs TEE
● Thrombophilia: Young pts with Rt – Lt shunt

● Compare work up for lacunar stroke vs. embolic stroke.

Address risk factors for ischemic and hemorrhagic stroke

1- Risk Factors for ischemic stroke

Modifiable Non Modifiable
- Hypertension. (Most important one) - Age, risk after 60 double with each
- Diabetes mellitus. decade.
- Hyperlipidemia. - Sex, generally men are more prone to
- Cardiac diseases (particularly Atrial stroke. However, young women are at
fibrillation, CHF, IE). higher risk than men due to
- Stroke, TIA, and carotid artery stenosis. pregnancy, hormonal changes.
- Smoking/Illicit drugs. - Ethnicity (African americans)
- Sedentary lifestyle. - Genetic determinants (e.g. sickle cell
- Stress, type A personality. disease)
- Air pollution - Previous vascular events (MI, stroke,
- Obstructive sleep apnea PVD)
- Polycythemia
- Any thrombo-embolism

2- Risk Factors for Hemorrhagic stroke

 Lecture Quiz
Cases by the doctor

➔ Case 1
A 60 y.o lady with acute stroke few hrs post IV
t-PA . She is known with HTN and controlled
DM-2.

Oro-lingual angioedema

➔ Case 2
21 y.o man a university student presented to ER
with Left sided throbbing headache and mild
expressive aphasia. Nothing else. NIHSS:2,
PMHx:Migraine

Acute Left MCA (upper division) ischemic stroke

with (N) CT brain

➔ Case 3
A 53 y/o male with sudden reduction in LOC,
jerking in 4 limbs, and difficulty in breathing
→Got intubated in ER then CT brain was done.
PMHx: smoker, HTN

Acute Basilar artery stroke

MedEd notes
MedEd notes
 1:D / 2:A / 3:A / 4:C

Lecture Quiz
Q1: A 73-year-old patient with a stroke experiences facial drooping on the right
side and right-sided arm and leg paralysis. When admitting the patient, which
clinical manifestation will the nurse expect to find?
A. Impulsive behavior
B. Right-sided neglect
C. Hyperactive left-sided tendon reflexes
D. Difficulty comprehending instructions

Q2: A 35-year-old previously healthy woman suddenly develops a severe

headache while lifting weights. A minute later she has transient loss of
consciousness. She awakes with vomiting and a continued headache. She
describes the headache as “the worst headache of my life.” She appears
uncomfortable and vomits during the physical examination. Blood pressure is
140/85, pulse rate is 100/min, respirations are 18/min, and temperature is 36.8°
C (98.2°F). There is neck stiffness. Physical examination, including careful
cranial nerve and deep tendon reflex testing, is otherwise normal. Which of
the following is the best next step in evaluation?
A. CT scan without contrast
B. CT scan with contrast
C. Cerebral angiogram
D. Holter monitor

Q3: A 79-year-old man is admitted with left hemiparesis. CT reveals a middle

cerebral artery infarct. What is his most significant risk factor for stroke?
A. Hypertension
B. Smoking
C. Family history
D. Diabetes
E. Cholesterol

Q4: A 71-year-old right-handed male is brought in by ambulance at 17:50 having

suffered a collapse. His wife came home to find him on the floor unable to move
his right arm or leg and unable to speak. Her call to the ambulance was logged at
17:30. He has a past medical history of well-controlled hypertension, ischaemic
heart disease and atrial fibrillation for which he is on warfarin. He had a hernia
repair three months ago and his brother had a ‘bleed in the brain’ at the age of
67. What is the absolute contraindication to thrombolysis in this male?
A. Family history of haemorrhagic stroke
B. History of recent surgery
C. Time of onset
D. Current haemorrhagic stroke
E. Warfarin treatment