Strokes

 Stroke
Pathology
·       Hemorrhage vs. Ischemia
·       liquefactive necrosis
·       the most vulnerable to ischemic hypoxia is the hippocampus
·       after 5 minutes, irreversible neuronal damage occurs
⏰
Histology
1st day
·       Red neuron
·       cytoplasm is eosinophilic
·       nuclei are pyknotic
·       cell body shrinkage
·       loss of Nissl substance
2nd day
·       Tissue necrosis
·       Neutrophilic infiltration
5th day
·       Macrophage (microglial) infiltration
1 week
·       Reactive gliosis
·       Vascular proliferation
> 2 weeks
·       Glial scar
RF
·       MOST IMPORTANT RF: HTN + AGE
·       Rest are self-explanatory
S/S
·       Depends on area affected ⤵️
·       https://www.youtube.com/watch?v=4BftS-3EIRI
·       Also check table 👇🏻
Dx
Start w/ non contrast CT
Tx
·       IV tPA (pt has ISCHEMIC stroke within 3-4.5 h)
·       Aspirin
·       Surgery (thrombectomy) if large thrombus in proximal artery
within 3.5-4 hours of symptom onset & no contraindications
IV alteplase
no prior antiplatelet
Aspirin
Stroke on aspirin therapy
Aspirin + dipyridamole OR clopidogrel
Stroke on aspirin therapy & with intracranial large artery
Aspirin + clopidogrel
Stroke with evidence of atrial fibrillation
Long-term anticoagulation (eg, warfarin, dabigatran, rivaroxaban)
TIA Tx
TIAs are treated by modifying identifiable
risk factors to prevent recurrent TIA or stroke,
including discontinuing tobacco use,
initiating aspirin,
starting a statin for hyperlipidemia,
and reducing blood pressure.

 Criteria for thrombolytics in stroke
Inclusion
criteria
1.     Ischemic stroke with measurable neurodeficits
2.     Symptom onset <3-4 and half hours before treatment initiation
Strict
exclusion
criteria
1.     Hemorrhage or multilobar infarct involving >33% of
cerebral hemisphere on CT scan
2.     Stroke or head trauma in past 3 months
3.     History of intracranial hemorrhage, neoplasm, or
vascular malformation
4.     Recent intracranial or spinal surgery
5.     Active bleeding or arterial puncture in past 7 days at
noncompressible site
6.     Blood pressure >1 85/110 mm Hg
7.     Platelets < 100,OOO/mm3 or glucose mg/dL
8.     Anticoagulant use with INR >1.7, PT >15 sec, or t active PTT
Site affected
Sx
Anterior Circulation
ACA
Sensory & Motor loss in CONTRALATERAL Leg
MCA
·       contralateral weakness and sensory loss in face and upper limb
·       hemineglect if the non-dominant hemisphere is involved (right parietal)
·       Aphasia
·       Broca’s aphasia if the superior division of the MCA is involved in the dominant hemisphere
·       Wernicke’s aphasia if the inferior division of the MCA is involved in the dominant hemisphere
PCA
contralateral hemianopsia with macular sparing
Posterior Circulation
Rule of 4

Pons
Lateral pontine
Locked-in syndrome
·       AICA
·       facial paralysis (CN 7)
·       ↓ salivation, lacrimation, and taste from the anterior tongue (2/3rd)
·       vertigo
·       ↓ pain and temperature sensation (STT)
o   ipsilateral face
o   contralateral body
·       ipsilateral Horner’s
·       ataxia
·       Basilar a.
·       Quadriplegia
·       bulbar manifestations
·       able to perform vertical eye movements
·       preserved consciousness
Pons = Pinpoint pupil
Medulla
Medial
Lateral
·       Anterior spinal a.
·       ∆
·       ipsilateral hypoglossal loss
·       contralateral hemiparesis
·       contralateral proprioception loss
·       PICA
·       dysphagia (CN 9-10)
·       hoarseness (CN 9-10)
·       ↓ gag reflex (CN 9-10)
·       vertigo
·       ↓ pain and temperature sensation (STT)
·       ipsilateral face
·       contralateral body
·       Horner’s syndrome
·       ataxia
Cerebellum
·       Ataxia & nystagmus
·       Neck stiffness
Special places
Thalamus
·       Contralateral sensory loss
·       Eye deviation TOWARD hemiparesis
Basal Ganglia
·       Contralateral Sensory + Motor loss
·       Homonymous heminpsia
Posterior limb of internal capsule
·       ⓤ motor impairment
·       No sensory or cortical deficits
Lenticulostriate a.
·       CONTRALATERAL Motor & Sensory loss in face & body without cortical signs
Brain Lesions 
Clx
Posterior limb of
internal capsule
(lacunar Infarct)
1.  Unilateral motor impairment
2.     No sensory \cortical deficits
3.     No visual field abnormalities
Middle cerebral artery
occlusion
1.     Contralateral somatosensory & motor deficit in face, arm & leg.
2.     Conjugate eye deviation toward side of infarct
3.     Homonymous hemianopia
4.     Aphasia in dominant hemisphere
5.     Hemineglect (nondominant hemisphere)
Anterior cerebral artery
occlusion
1.     Contralateral somatosensory & motor deficit, predominantly in lower extremity
2.     Abulia (lack of will or initiative)
3.     Dyspraxia, emotional disturbances, urinary incontinence
Vertebrobasilar
system lesion
(supplying the brain stem)
1.     Alternate syndromes with contralateral hemiplegia & ipsilateral cranial nerve involvement
2.     Possible ataxia
Clx characteristics of stroke types
Ischemic (thrombotic)
1.     Atherosclerotic RFs such as (HTN/DM)
2.     ⊕ TIA
3.     Local arterial obstruction
4.     (Stuttering progression) the symptoms may show improvement in some periods
Ischemic (embolic)
1.     Hx related to cardiac dz (Afib,IE) or carotid atherosclerosis
2.     Sudden onset & maximal at the start
3.     Multiple infarcts in different vascular regions 
ICH
1.     Hx of uncontrolled HTN, coagulopathy, illicit drug use: amphitamines, cocaine
2.     Sx progress from minutes to hours
3.     FND lead to ⤴️ ICP Sx: vomiting, headache, bradycardia, reduced alertness
SAH 
1.     Bleeding from arterial saccular (“berry”) aneurysm or AV malformation
2.     Onset symptoms: severe headache
3.     Meningeal irritations like neck stiffness
4.     Focal deficits uncommon

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