Ischemic stroke - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Weakness of upper and lower limbs pattern of weakness depend on the place of the ischemia. When anterior cerebral artery is involved contralateral side weakness of the upper and lower limbs occur, but lower limbs weakness is more than upper limbs. When middle cerebral artery is involved weakness of the lower limbs and upper limbs occur, but upper limbs weakness is more than lower. ,,, Weakness of upper and lower limbs
pattern of weakness depend on the place of the ischemia. When anterior cerebral artery is involved contralateral side weakness of the upper and lower limbs occur, but lower limbs weakness is more than upper limbs. When middle cerebral artery is involved weakness of the lower limbs and upper limbs occur, but upper limbs weakness is more than lower. ,,,
speech Dysarthria occurs when infarct occurs in posterior inferior carebral artery. when middle cerebral artery is involved dysphasia(dominant hemisphere) or apraxia( non -dominant hemisphere) can occur.,,, speech
Dysarthria occurs when infarct occurs in posterior inferior carebral artery. when middle cerebral artery is involved dysphasia(dominant hemisphere) or apraxia( non -dominant hemisphere) can occur.,,,
behavior abnormalities when anterior circulation is involved higher function get altered.,,, behavior abnormalities
when anterior circulation is involved higher function get altered.,,,
memory impairment when anterior circulation is involved higher function get altered.,,, memory impairment
when anterior circulation is involved higher function get altered.,,,
Dysphagia occurs when infarct occurs in posterior inferior carebral artery.,,, Dysphagia
occurs when infarct occurs in posterior inferior carebral artery.,,,
seizures In 2-23% of patients, seizures occur after ischemic stroke within the first days.,,, seizures
In 2-23% of patients, seizures occur after ischemic stroke within the first days.,,,
Visual symptoms Patent may have visual disturbance according to the site of the ischemia. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery. ,,, Visual symptoms
Patent may have visual disturbance according to the site of the ischemia. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery. ,,,
onset of symptoms vascular pathologies have an acute onset of symptoms. ,,, onset of symptoms
vascular pathologies have an acute onset of symptoms. ,,,
alcohol intake heavy alcohol consumption of >5 units/day increase the risk by 1.6. ,,, alcohol intake
heavy alcohol consumption of >5 units/day increase the risk by 1.6. ,,,
Smoking habits smoking increase the risk by 1.6. Smoking reduces the amount of oxygen in the blood, causing the heart to work harder and allowing blood clots to form more easily. ,,, Smoking habits
smoking increase the risk by 1.6. Smoking reduces the amount of oxygen in the blood, causing the heart to work harder and allowing blood clots to form more easily. ,,,
history of cardiovascular diseases hypertension, dyslipidaemia, diabetes and myocardial infartion increase the risk of infarction.,,, history of cardiovascular diseases
hypertension, dyslipidaemia, diabetes and myocardial infartion increase the risk of infarction.,,,
History of bleeding disorders patient with bleeding disorders can get cerebral hemorrhage, which can cause acute stroke. ,,, History of bleeding disorders
patient with bleeding disorders can get cerebral hemorrhage, which can cause acute stroke. ,,,
History of recent trauma patient with a history of recent trauma can have undiagnosed cerebral hemorrhage , which can cause acute stroke. ,,, History of recent trauma
patient with a history of recent trauma can have undiagnosed cerebral hemorrhage , which can cause acute stroke. ,,,
Drug history oral contraceptive use is important as they can cause disorders coagulation. Drug history
oral contraceptive use is important as they can cause disorders coagulation.
use of cocaine Cocaine is a potent central nervous system stimulant, and acts by binding to specific receptors at pre‐synaptic sites preventing the reuptake of neurotransmitters. The exact mechanism of cocaine‐induced stroke remains unclear and there are likely to be a number of factors involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation. use of cocaine
Cocaine is a potent central nervous system stimulant, and acts by binding to specific receptors at pre‐synaptic sites preventing the reuptake of neurotransmitters. The exact mechanism of cocaine‐induced stroke remains unclear and there are likely to be a number of factors involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation.
Family history there are rare genetic causes for infarction. Mutations to F2 and F5 genes which are relatively common in general population has an increase risk of thrombosis. Mutations of the genes like nitric oxide synthase, ALOX5AP, and PRKCH also known to increase the risk. ,,, Family history
there are rare genetic causes for infarction. Mutations to F2 and F5 genes which are relatively common in general population has an increase risk of thrombosis. Mutations of the genes like nitric oxide synthase, ALOX5AP, and PRKCH also known to increase the risk. ,,,

Clinicals - Examination

Fact Explanation
ABC - Airway, breathing and circulation As this is an emergency patients' airway, breathing and circulation has to assessed first. If there is a impairment in any of them immediate resuscitation has to be carried out. ABC - Airway, breathing and circulation
As this is an emergency patients' airway, breathing and circulation has to assessed first. If there is a impairment in any of them immediate resuscitation has to be carried out.
Level of consciousness according to the National Institutes of Health Stroke Scale (NIHSS) level of consciousness is assessed using alertness, ability to answer questions regarding the month and his/her age and the ability in eye opening, gripping and releasing the non-paretic hand. Level of consciousness
according to the National Institutes of Health Stroke Scale (NIHSS) level of consciousness is assessed using alertness, ability to answer questions regarding the month and his/her age and the ability in eye opening, gripping and releasing the non-paretic hand.
Cranial Nerves This helps to localize the ischemia. Seen in Vertebrobasilar artery occlusions. Cranial Nerves
This helps to localize the ischemia. Seen in Vertebrobasilar artery occlusions.
Cerebellar Signs and Gait This helps to localize the ischemia. Seen in Vertebrobasilar artery occlusions. Gait apraxia can be seen in anterior cerebral artery occlusions Cerebellar Signs and Gait
This helps to localize the ischemia. Seen in Vertebrobasilar artery occlusions. Gait apraxia can be seen in anterior cerebral artery occlusions
Neurological examination of limbs - motor & reflexes when assessing the motor function of the upper and lower limbs weakness is shown according to the place of occlusion. This helps in localizing the occlusion. ,,, Neurological examination of limbs - motor & reflexes
when assessing the motor function of the upper and lower limbs weakness is shown according to the place of occlusion. This helps in localizing the occlusion. ,,,
Neurological examination of limbs - sensory when assessing the sensory function of the upper and lower limbs sensory loss is shown according to the place of occlusion. This helps in localizing the occlusion. When infarct occur in lacunar circulation pure sensory stroke can occur without any motor weakness,,, Neurological examination of limbs - sensory
when assessing the sensory function of the upper and lower limbs sensory loss is shown according to the place of occlusion. This helps in localizing the occlusion. When infarct occur in lacunar circulation pure sensory stroke can occur without any motor weakness,,,
eye examination visual disturbance also differ with the site of the occlusion. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery.,,, eye examination
visual disturbance also differ with the site of the occlusion. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery.,,,
Cardiovascular examination pulse examination is important in identifying arrhythmias. As strokes may occur concurrently with other acute cardiac conditions as acute myocardial infarction and acute heart failure, auscultation for murmurs and gallops is recommended. ,,, Cardiovascular examination
pulse examination is important in identifying arrhythmias. As strokes may occur concurrently with other acute cardiac conditions as acute myocardial infarction and acute heart failure, auscultation for murmurs and gallops is recommended. ,,,

Investigations - Diagnosis

Fact Explanation
Non contrast CT Done to exclude hemorrhagic stroke. Widely used because it is better tolerated and easier to perform than MRI. ,, Non contrast CT
Done to exclude hemorrhagic stroke. Widely used because it is better tolerated and easier to perform than MRI. ,,
MRI With its newest sequence DWI (diffusion - weighted imaging) has a great sensitivity than CT to differentiate hemorrhage from a infarct. Not widely used because it is slow and difficult to scan unstable, critically ill patient. ,, MRI
With its newest sequence DWI (diffusion - weighted imaging) has a great sensitivity than CT to differentiate hemorrhage from a infarct. Not widely used because it is slow and difficult to scan unstable, critically ill patient. ,,
ECG Done to evaluate conduction defect in heart as arrhythmia can cause emboli that can lead to cerebral infarction. ,, ECG
Done to evaluate conduction defect in heart as arrhythmia can cause emboli that can lead to cerebral infarction. ,,
Doppler studies of MCA Transcranial Doppler (TCD) can demonstrate arterial occlusion and subsequent recanalization in acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA). Doppler studies of MCA
Transcranial Doppler (TCD) can demonstrate arterial occlusion and subsequent recanalization in acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA).
CT Angiography This is a method for rapidly and reliably confirming intracranial vessel occlusion before thrombolytic treatment is desirable. , CT Angiography
This is a method for rapidly and reliably confirming intracranial vessel occlusion before thrombolytic treatment is desirable. ,

Investigations - Management

Fact Explanation
Lipid profile Done to evaluate the dyslipidemia. This is important to modify the management accordingly.,, Lipid profile
Done to evaluate the dyslipidemia. This is important to modify the management accordingly.,,
Glucose level Done to evaluate the diabetic control of the patient.,, Glucose level
Done to evaluate the diabetic control of the patient.,,
ECG done to evaluate the cardiac function.,, ECG
done to evaluate the cardiac function.,,
Coagulation profile When anticoagulants are prescribed routine coagulation profile is necessary to identify coagulation problems and adjust the dose. ,, Coagulation profile
When anticoagulants are prescribed routine coagulation profile is necessary to identify coagulation problems and adjust the dose. ,,
ECG Done to evaluate the cardiac function of the patient. infaction, conduction defects are identified. ,, ECG
Done to evaluate the cardiac function of the patient. infaction, conduction defects are identified. ,,
lipid profile Done to evaluate the dyslipidemia. As dyslipidemia is a risk factor for infarction it is important to identify undiagnosed dyslipidemia. ,, lipid profile
Done to evaluate the dyslipidemia. As dyslipidemia is a risk factor for infarction it is important to identify undiagnosed dyslipidemia. ,,
fasting glucose done to identify undiagnosed diabetes or evaluate the current diabetes status.,, fasting glucose
done to identify undiagnosed diabetes or evaluate the current diabetes status.,,
FBC This is done to identify any infections or anemia. this is important in planning management.,, FBC
This is done to identify any infections or anemia. this is important in planning management.,,
Renal function test Done to evaluate the renal function. Important in planing the management. ,, Renal function test
Done to evaluate the renal function. Important in planing the management. ,,
Toxicology Screen Urine toxicology studies done to identify cocaine,, Toxicology Screen
Urine toxicology studies done to identify cocaine,,
Coagulation Profile These are done to identify coagulopathy. They are useful prior to the use of fibrinolytics or anticoagulants. However rt-PA administration on who are not on anticoagulants or anti thrombotics where there isn't any suspicion of coagulation abnormality, shouldn't be delayed by this Coagulation Profile
These are done to identify coagulopathy. They are useful prior to the use of fibrinolytics or anticoagulants. However rt-PA administration on who are not on anticoagulants or anti thrombotics where there isn't any suspicion of coagulation abnormality, shouldn't be delayed by this
Cardiac biomarkers Done to evaluate the cardiac function of the patient and to possibility of myocardial infarction. ,, Cardiac biomarkers
Done to evaluate the cardiac function of the patient and to possibility of myocardial infarction. ,,
NIH Stroke Score This is a systematic clinical assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Consist of a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. A score >10 suggests 80% likelihood of occlusions of the proximal vessels . NIH Stroke Score
This is a systematic clinical assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Consist of a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. A score >10 suggests 80% likelihood of occlusions of the proximal vessels .

Management - Supportive

Fact Explanation
stop smoking Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but effective treatments and helpful resources exist. stop smoking
Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but effective treatments and helpful resources exist.
physical activities Activity limitations are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training. physical activities
Activity limitations are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training.
diet Healthy diet should be taken with low fats, sugar and salt; and rich in fruits and vegetables. if patient is having difficulty in chewing or swallowing diet has to be changed accordingly. diet
Healthy diet should be taken with low fats, sugar and salt; and rich in fruits and vegetables. if patient is having difficulty in chewing or swallowing diet has to be changed accordingly.
Rehabilitation The rehabilitation process involves six major areas of focus; preventing, recognizing, and managing comorbid illness and medical complications; training for maximum independence; facilitating maximum psychosocial coping and adaptation by patient and family; preventing secondary disability by promoting community reintegration, including resumption of home, family, recreational, and vocational activities; enhancing quality of life in view of residual disability; and preventing recurrent stroke and other vascular conditions such as myocardial infarction that occur with increased frequency in patients with stroke. To attain these goals, rehabilitation interventions should assist the patient in achieving and preserving maximum feasible functional independence. Rehabilitation
The rehabilitation process involves six major areas of focus; preventing, recognizing, and managing comorbid illness and medical complications; training for maximum independence; facilitating maximum psychosocial coping and adaptation by patient and family; preventing secondary disability by promoting community reintegration, including resumption of home, family, recreational, and vocational activities; enhancing quality of life in view of residual disability; and preventing recurrent stroke and other vascular conditions such as myocardial infarction that occur with increased frequency in patients with stroke. To attain these goals, rehabilitation interventions should assist the patient in achieving and preserving maximum feasible functional independence.
Patient education As the patient may have long term disabilities, patient and family have to be educated regarding that and about the risk factors of stroke in order to prevent it among relatives. Patient education
As the patient may have long term disabilities, patient and family have to be educated regarding that and about the risk factors of stroke in order to prevent it among relatives.
Palliative Care Primary palliative care should begin at the diagnosis. This includes patients for whom some reversibility is a realistic goal but for whom the stroke itself or its treatments pose significant burdens and may result in reduced quality of life. Palliative care should also be available to those stroke patients with significant functional impairments who have progressive chronic comorbidities, who are unlikely to recover, and for whom intensive palliative care is the predominant focus and goal for the remainder of their lives. Palliative Care
Primary palliative care should begin at the diagnosis. This includes patients for whom some reversibility is a realistic goal but for whom the stroke itself or its treatments pose significant burdens and may result in reduced quality of life. Palliative care should also be available to those stroke patients with significant functional impairments who have progressive chronic comorbidities, who are unlikely to recover, and for whom intensive palliative care is the predominant focus and goal for the remainder of their lives.

Management - Specific

Fact Explanation
acute management Assess the patient's air way, breathing, circulation and resuscitation has to be done first. Once the diagnosis of ischemic stroke has been made 300mg of asprin is given. Thrombolytic therapy(ateplase) is most beneficial if given with in first 90 minutes. acute management
Assess the patient's air way, breathing, circulation and resuscitation has to be done first. Once the diagnosis of ischemic stroke has been made 300mg of asprin is given. Thrombolytic therapy(ateplase) is most beneficial if given with in first 90 minutes.
Hypertention management Antihypertensive therapy is effective in reducing the risk of recurrent stroke. Careful identification of hypertensive patients with stroke and TIA, with initiation of single or combination therapy, is essential for secondary stroke prevention. Hypertention management
Antihypertensive therapy is effective in reducing the risk of recurrent stroke. Careful identification of hypertensive patients with stroke and TIA, with initiation of single or combination therapy, is essential for secondary stroke prevention.
antiplatelet drugs Antiplatelet therapy plays an important role in the long-term prevention of ischemic stroke and vascular events in patients who have experienced acute ischemic stroke or TIA. The most commonly used antiplatelet therapies are aspirin, ER-dipyridamole + low-dose aspirin, and the ADP receptor antagonist clopidogrel. antiplatelet drugs
Antiplatelet therapy plays an important role in the long-term prevention of ischemic stroke and vascular events in patients who have experienced acute ischemic stroke or TIA. The most commonly used antiplatelet therapies are aspirin, ER-dipyridamole + low-dose aspirin, and the ADP receptor antagonist clopidogrel.
Anticoagulation Warfarin is effective in the primary prevention of thromboembolic stroke in patients with atrial fibrillation. Warfarin is used by consensus only in patients with atrial fibrillation or a similar, definite cardiac source of embolus. Anticoagulation
Warfarin is effective in the primary prevention of thromboembolic stroke in patients with atrial fibrillation. Warfarin is used by consensus only in patients with atrial fibrillation or a similar, definite cardiac source of embolus.
Lipid lowering drugs the vast majority of patients with previous ischemic stroke or TIA are likely to benefit from statin use. Lipid lowering drugs
the vast majority of patients with previous ischemic stroke or TIA are likely to benefit from statin use.
Intra arterial reperfusion With higher local fibrinolytic agent concentrations at lower total doses, risks of a systemic bleed are lower, thus allowing a longer therapeutic window. However, longer time in initiating intra-arterial administration might remove some of these advantage , Intra arterial reperfusion
With higher local fibrinolytic agent concentrations at lower total doses, risks of a systemic bleed are lower, thus allowing a longer therapeutic window. However, longer time in initiating intra-arterial administration might remove some of these advantage ,
Mechanical Thrombectomy An alternative for those whom where fibrinolysis is ineffective or contraindicated, which includes the use of catheters to directly deliver a clot disruption or retrieval device during angiography to the thromboembolus which is occluding the cerebral artery., Mechanical Thrombectomy
An alternative for those whom where fibrinolysis is ineffective or contraindicated, which includes the use of catheters to directly deliver a clot disruption or retrieval device during angiography to the thromboembolus which is occluding the cerebral artery.,
Fever Control Hyperthermia accelerates the ischemic neuronal injury. Thus antipyretics are indicated in febrile stroke, , Fever Control
Hyperthermia accelerates the ischemic neuronal injury. Thus antipyretics are indicated in febrile stroke, ,
Cerebral Oedema Control In emergency situations, mannitol and other therapies may be used to reduce intracranial pressure (ICP) . However, prompt neurosurgical assistance should be sought when indicated.
Patient position, hyperosmolar therapy, hyperventilation, and, barbiturate coma may be used rarely, similar with increased ICP resulting from to closed head injury.
In Large hemispheric infarctions with life-threatening edema, hemicraniotomy is proven benificial,
Cerebral Oedema Control
In emergency situations, mannitol and other therapies may be used to reduce intracranial pressure (ICP) . However, prompt neurosurgical assistance should be sought when indicated.
Patient position, hyperosmolar therapy, hyperventilation, and, barbiturate coma may be used rarely, similar with increased ICP resulting from to closed head injury.
In Large hemispheric infarctions with life-threatening edema, hemicraniotomy is proven benificial,
Seizure control Secondary prevention of seizures in means of standard antiepileptic drugs is recommended where primary prophylaxis in poststroke seizures is not. , Seizure control
Secondary prevention of seizures in means of standard antiepileptic drugs is recommended where primary prophylaxis in poststroke seizures is not. ,
Neuro Protective Measures The rationale for the use of these is that reduction of the excitatory neurotransmitter release by neurons in ischemic penumbra may enhance the survival of them. However, randomized, placebo-controlled human studies are yet to support neuro-protective agents in ischemic stroke ., Neuro Protective Measures
The rationale for the use of these is that reduction of the excitatory neurotransmitter release by neurons in ischemic penumbra may enhance the survival of them. However, randomized, placebo-controlled human studies are yet to support neuro-protective agents in ischemic stroke .,
Fibrinolytic therapy rt-PA is the only fibrinolytic agent which has shown to be beneficial with acute ischemic stroke in selected patients which has to be given within 3 - 4 hours of onset of the stroke where CT scanning had ruled out the possibility of hemorrhage.
The inclusion criterias have to be fulfilled before this therapy; diagnosis of an ischemic stroke causing measurable neurologic deficit, neurologic signs neither minor nor isolated and does not clearing spontaneously to baseline, symptoms not suggesting towards subarachnoid hemorrhage, presence of neither head trauma nor prior stroke in the past 3 months, nor any myocardial infarction (MI) for same duration, Absence of gastrointestinal/genitourinary hemorrhage in prior 21 days, no arterial puncture made in a noncompressible site over the past 7 days, a major surgery not done within past 14 days, no prior history of intracranial bleeding, systolic and diastolic blood pressure under 185 mm Hg &110 mm Hg respectively, no evidence of bleeding or acute trauma, not on oral anticoagulants, or with an international normalized ratio (INR) <1.7 under anticoagulant, a normal activated prothrombin time (aPT) if on heparin within last 48 hours, more than 100,000/μL of platelets and more than 50 mg/dL (2.7 mmol) of blood glucose, Absence of seizure with residual postictal impairments, No CT evidence of multilobar infarction (over one third hemisphere hypodensity) or intracerebral hemorrhage, Awareness of the the potential risks and benefits by patient and/or family prior to therapy. ,
Fibrinolytic therapy
rt-PA is the only fibrinolytic agent which has shown to be beneficial with acute ischemic stroke in selected patients which has to be given within 3 - 4 hours of onset of the stroke where CT scanning had ruled out the possibility of hemorrhage.
The inclusion criterias have to be fulfilled before this therapy; diagnosis of an ischemic stroke causing measurable neurologic deficit, neurologic signs neither minor nor isolated and does not clearing spontaneously to baseline, symptoms not suggesting towards subarachnoid hemorrhage, presence of neither head trauma nor prior stroke in the past 3 months, nor any myocardial infarction (MI) for same duration, Absence of gastrointestinal/genitourinary hemorrhage in prior 21 days, no arterial puncture made in a noncompressible site over the past 7 days, a major surgery not done within past 14 days, no prior history of intracranial bleeding, systolic and diastolic blood pressure under 185 mm Hg &110 mm Hg respectively, no evidence of bleeding or acute trauma, not on oral anticoagulants, or with an international normalized ratio (INR) <1.7 under anticoagulant, a normal activated prothrombin time (aPT) if on heparin within last 48 hours, more than 100,000/μL of platelets and more than 50 mg/dL (2.7 mmol) of blood glucose, Absence of seizure with residual postictal impairments, No CT evidence of multilobar infarction (over one third hemisphere hypodensity) or intracerebral hemorrhage, Awareness of the the potential risks and benefits by patient and/or family prior to therapy. ,

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