Table of contents

Cerebrovascular Accident (CVA)

General

• Inadequate brain oxygenation leading to infarction of the brain parenchyma.

<aside> 💡 The 2 strongest risk factors

• Modifiable → Hypertension
• Nonmodifiable → Old Age
• UWT - Modifiable risk factors for TIA & ischemic stroke </aside>

Subtypes and Clinical Features

Types of ischemic stroke 💠 The concept of atherosclerosis vs lipohyalinosis is important

Diagnosis

• Best Initial Test [H.Y]
  • Noncontrast CT (rule-out hemorrhage, occasionally see signs of ischemia).
    • Needed quickly to help determine tPA candidacy
• Confirmatory Test
  • MRI (used later to help identify the extent of ischemia and stroke subtype).
• Source Localization
  • Duplex US or CTA/MRA
  • Cardiac monitoring
  • TTE.

CT Angiography

Management

1. Thrombolytic Therapy

   Apparently for Ischemic stroke

   • IV Alteplase for clear ischemia with measurable deficits.
     • Must be given within 3-4.5 hours of symptoms
       • <3 hours for elderly/DM.
   • Contraindications
     • Hemorrhage
     • Hx of intracranial lesion or stroke
     • Stroke/head trauma within 3 months
     • Recent intracranial surgery
     • BP > 185/110
     • Current active bleeding
     • PLT< 100k / INR > 1.7 / PTT > 40s / PT > 15s.
   • Relative Contraindications
     • Minor or improving neurologic deficits
     • Recent major surgery/trauma/MI/GI bleed

<aside> 🚨 Mechanical thrombectomy utilized for large artery obstruction

</aside>

A very important algorithm

1. BP Control
   • If tPA used → Target <185/110
   • If not used → <220/120 if not
     • This is called permissive hypertension (Moderate hypertension is tolerated within the first 48–72 hours with the goal of maintaining cerebral perfusion)
   • Medications
     • Labetalol
     • Nicardipine
     • Clevidipine
2. Antiplatelet/antithrombotic therapy
   • Aspirin
     • Within 48 hours of stroke but If tPA used, do not start ASA for at least 24 hours.
   • If patient already uses aspirin → add clopidogrel
   • Stroke With evidence of atrial fibrillation → Long-term anticoagulation (eg, warfarin, dabigatran, rivaroxaban
   • UWT - Antiplatelet/antithrombotic therapy for ischemic stroke
3. Statin
   • For all patients.

Secondary Prevention

• Lifestyle Modification
  • Control HTN, DM
  • initiate statin.
• Antiplatelet Therapy
  • Aspirin, Clopidogrel or
  • Aspirin-Dipyridamole.
• Stroke Management Extra algorithms

<aside> 💡

Malignant Hemispheric Infarction

• A life-threatening condition that may occur when an ischemic stroke causes massive cerebral edema and/or hemorrhagic transformation
• Typically are due to occlusion of a large vessel (eg, internal carotid, proximal middle cerebral artery)
• manifests with deteriorating mental status
• Deterioration in 48 H
  • Noncontrast CT scan of the head performed emergently to determine the extent of edema and/or hemorrhage
• Decompressive hemicraniectomy is often necessary

What is the best next step in a patient that presents with signs of increased intracranial pressure one day after a large ischemic stroke?

• Answer </aside>

Stroke Syndromes

Anatomy Introduction

• Overview