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Ischemic Stroke - Coggle Diagram
Ischemic Stroke
Pathophysiology
Ischemia
Failure of cerebral blood flow to part of the brain
Interruption to blood supply
Hypoxia
Stresses metabolic machinery of brain cells -> Malfunction
Damage can result from edema, depending on size, location of the stroke
Localization
Anterior Cerebral Artery -> Hemiparesis, hemianesthesia, Apraxia, Apathy
Middle Cerebral Artery -> Hemianesthesia, hemiparesis, conjugate deviation, visual ifeld defect, aphasia, apraxia, hemineglect
Anterior Choroid Artery
Hypokinesea, Hemiparesis, hemianopsia, hemianesthsia
Posterior Cerebral Artery
Hemianopsia
Basillar Braches
Mid-Brain: 3, 7, 12, Parkinson's, hemiparesis
Pons: 5,6,7 hypacussi, ataxia, nystagmus, Horner's syndrome, tetraplegia, pseudobulbar paralysis
Medulla Oblangata: 5,10, nystagmus, horner's syndrome, hemiataxia, hiccough, hemianesthsia, ageusiss, hypacusis, 12 hemiparesis, hemihypesthesia
Acute Ischemic Stroke
Artery to artery embolism, local arterial thrombosis, small vessel disease, Cardiac embolism, Hypoperfusion, Hypercoagulable states, Arterial Dissection
Small Vessel Disease
Changes in small vessels -> Tend to cause lacunar stroke
Proliferation of smooth muslce, degeneration of smooth muscle and collagen, Fribrinoid necrosis and occlusion
Dissection
Generally causes thrombotic events, treated similarly to ischemic strokes
LMWH can be considered in complicated, but antiplatelets are more typical in less complex scenarios
Can consider prophylactic antithrombotics in patients with dissection in highest risk time periods
Treatments
Paradigmn
Remove the initiating facotrs (antihypertensives, glycemic control, smoking cessation, statins)
Mitigate Inflammation and Stabilize Fibrous Cap (Statins)
Revascularize (endarterectomy/stent)
Antiplatelets
ASA- COX1 inhibitor
Clopidogrel - ADP antagonist
Dipyrimadole - PDE inhibitor
Ticagrelor - P2y12 Receptor antagonist
Dual antiplatelets for 3 weeks followed by single antiplatelet maximizes stroke prevention
generally treat dual antiplatelets for three months for Intracranial disease
Anticoagulants
Vitamin K Antagonist - Warfarin
Antithrombin-meidated inactivation - Heparin
Direct thrombin inhibition - Dabigatran
Factor Xa inhibition - Rivaroxaban, apixaban, edoxaban
Prevention
Smoking Cessation, Blood Pressure <140/90, Diabetes, dyslipidemia, Alcohol, exercise, diet
Risk Factors in Young
Low physical activity, Hypertension, Episodic Binge drinking, Cigarette smoking
Oral Contraceptives, Hormones and Pregnancy
1.7-6 fold increase in risk with estrogen-containing OCP
Pregnancy can also be. arisk factor for storke - especially in 3rd trimester + postpartum
Mimics and Chameleons
Mimic: Ishcemic stroke-like symptoms that are caused by another issue
Seizures
Cortical overactivity, commonly described as paresis
Pro: Stereotyped events followed by weakness
Caution: First onset seizures may be caused by stroke
Migraine
Pro: Typical spreading neurological symptoms may have prodrome associated with irritability
Caution: Migrane aura can be associated with risk of ishcemic stroke
Syncope/Sepsis
Associated with hypoperfusion but not necessarily
Pro: Altered level of consciousness without accompanying brainstem findings
Caution: May see systemic changes in context of stroke, medical conditions may predispose to prothrombotic states
Amyloid Spells
In context of cerebal amyloid angiopathy, and associated with microbleeds/subarachnoid hemorrhage
Pro: Recurrent spells despite appropriate therapy, absence of epileptic findings
Caution: Overlap risk with stroke population
Chameleon: Ischemic stroke caused by atypical symptoms, increasing risk of stroke being missed
Vertigo
Isolated vertigo may have higher risk of stroke in elderly
Decreased level of Consciousness
Abrubt onset of decreased LOC can be a feature of particular localizations (Tip of basilar, Bilateral Thalamic infarcts)
Consider especially if abrupt onset or if accompanied by other neurological findings (Quadriparesis, pupillary abnormatliesi)
Acute Confusional State
Abrupt onset of confusion, restlessness or agitation, reflect a localizing
Stroke Therapies
Thrombolysis
Tenetabplase given within 4.5 hrs of onset
Should be administered within 30 minutes of presentation to ED
Exclusion Criteria
Active hemorrhage, or condition that could increase major hemorrhage
Hemorrhage on brain imaging
Relative Exclusion
History of ICH, Stroke or serious trauma in past 3 months, Major surgery in past 14 days
Endovascular Thereapy
Removal of clot with catheter angiogram up to 24 hrs from onset
Best Medical Therapy
Antiplatelets, stroke unit, management of etiologies
Clinical Classification
Definition
Focal disturbance in cerebral function that due to vascular cause, acute ischemia or hemorrhage
Transient Ischemic Attack
Focal, Transient, due vascular cause, Supported by evidence of risk of acute ischemia
Ischemic vs Hemorrhagic
Ischemia: Loss of blood flow to certain areas of brain
Hemorrhagic: Bleed from blood vessel in brain
Autoregulation
Brain will auto regulate itself to maintain a certain blood flow at a certain MAP
Investigations
Blood Pressure, vascular risk factors, Vascular Imaging, cardiac monitoring, Other tests