Ischemic Stroke

blood, oxygen, glucose, location, infarcts, hemorrhages

Stroke Overview

• Disease process that interrupts _____ flow to the brain

  • Injury related to loss of ______ and _______ required for cellular processes

• Clinical findings are determined by __________ of the lesion

• Divided into _________ (ischemia) and ___________ (bleeding)

vascular, location, ischemia, hemorrhage, neuronal

Overview of Stroke Pathophysiology

• Two major mechanisms d/t __________ supply; clinical findings related to _________ of lesion

• __________ (MC)

  • Thrombotic, embolic, lacunar, hypoperfusion related

• __________

  • intracerebral

  • Non-traumatic subarachnoid hemorrhage

• Final common pathway is altered _________ perfusion

occlusion, pale, softens, necrosis, disintegration, macrophages, glial, HTN

Ischemic Stroke → Pathophysiology and Risk Factors

• Area in the brain loses blood suply because of vascular _________ → area becomes _____ and _________

• Infarction is followed by ________, swelling and mushy ___________

• __________ phagocytose necrotic tissue → cavity surrounded by _______ scarring

• Risk Factors

  • ***___***, DM, hyperlipidemia, smoking, CV disease, HIV, trigeminal HZV, drugs, heavy alc consumption, Fam Hx

thrombus, large, small, atherosclerosis, inflammatory, fragments, outside, small

Ischemic Stroke Pathophysiology

• Thrombotic Strokes (Central Thrombosis)

  • Ischemia from arterial occlusions caused by ________ formation in ______ or ______ arteries supplying the brain or intracranial vessels

  • Most often d/t ___________ and ____________ diseases that damage arterial walls

• Embolic Stroke

  • Ischemia d/t _________ that break from a thrombus formed ________ the brain (usually heart (a fib), aorta, common carotid)

  • Usually involves ______ brain vessels

edema, arteriolar, small, basal ganglia, motor, sensory, hypoperfusion, cardiac, bilateral

Ischemic Stroke → Pathophysiology

• Lacunar Stroke

  • Ischemic lesions usually caused by perivascular ______, thickening and inflammation of the __________ wall in a deep artery that supplies ______ penetrating vessels

  • Predominantly in the ______ _______, internal capsules, and pons

  • D/t location, may have pure _______ and _________ deficits

• Hemodynamic Stroke (Brain _____________)

  • Caused by ________ failure, PE, hemorrhage

  • Sx usually __________ and diffuse

contralateral, ipsilateral, slurred, droop, AMS, visual

Ischemic Stroke Clinical Manifestations

• Varied Presentations (depends on what is obstructed)

• ________ symptoms → opposite side of the body

• _________ symptoms → same side of the body

• Numbness, weakness

• ______ speech

• Facial ______

• dizziness

• vomiting

• ____

• ________ changes

contralateral, lower, hands, mutism, motor, hemineglect

Anterior Cerebral Artery Ischemia

• Uncommon

• ___________ sensory and motor symptoms in the _______ extremity

  • Typically spares _______ and face

• Left sided lesions associated with akinetic _________ and _______ aphasia

• Right sided lesions associated with confusion and motor ___________

Middle Cerebral Artery (MCA)

Which artery is most commonly involved in stroke?

variable, contralateral, facial, homonymous, face, upper, dominant, inattention, constructional

Middle Cerebral Artery Ischemia

• Clinical findings can be _________

• ___________ hemiparesis, ______ plegia, ___________ hemianopia, and sensory loss that affect _____ and _______ extremity >>> lower extremity

• _________ hemisphere involved → (+) Aphasia

• Non-dominant hemisphere involved → (+) ___________, neglect, extinction, ___________ apraxia

frontal, fluent, word-finding, dysarthria, weakness, inferior, jargon, comprehend, contralateral

Middle Cerebral Artery Ischemia

• Broca’s Aphasia

  • Associated with lesions affecting the _______ lobe

  • Non-________ speech that is labored and interrupted by ____-________ pauses

  • Usually _________

  • Aphasia is accompanied by facial __________

  • ± arm weakness

• Wernicke’s Aphasia

  • Associated with _______ MCA involvement

  • _______ speech and inability to __________ written and spoken language

  • Often accompanied with __________________, homonymous superior quadrantanopia

weakness, blurry, dysarthria, loss, gait, ataxia, VII, sensory, contralateral, cortical

Posterior Cerebral Artery Ischemia

• Symptoms → Unilateral limb __________, dizziness, ______ vision, headache, and __________

• Signs → Visual field _____, unilateral limb weakness, _____ ataxia, unilateral limb ______, cranial nerve ___ signs, lethargy, ________ deficits

• Visual field loss

  • __________ homonymous hemianopia

  • Unilateral __________ blindness

weakness, unsteady, diplopia, dysphagia, Horner, locked-in, death, poor

Basilar Artery (Middle Posterior Circulation) Ischemia

• Unilateral limb ________, dizziness, _________ gait, dysarthria, _________, and headache

• ± __________, N/V, _______ syndrome

• Can also caused ______-__ syndrome

• High risk of _______ and ______ outcomes

lacunar infarct

contralateral pure motor hemiparesis or pure hemisensory deficit, ipsilateral ataxia with hemiparesis and dysarthria with clumsiness of the hand

anterior cerebral artery

weakness and cortical sensory loss in the contralateral leg and sometimes weakness of the arm (rare)

Middle cerebral artery

contralateral hemiplegia, hemisensory loss, facial plegia, homonymous hemianopia with eyes deviated to side of lesion

vertebral artery

vertigo, nystagmus, ipsilateral spinothalamic sensory loss involving the face, dysphagia, limb ataxia, Horner syndrome

Basilar artery

Partial occlusion → unilateral limb weakness, dizziness, dysarthria, diplopia, headache, Horner syndrome

Complete occlusion → coma with pinpoint pupils, flaccid quadriplegia and sensory loss, and variable cranial nerve abnormalities

20, 60, glucose, troponin, pregnancy, EKG, noncontrast CT, angiography

Ischemic Stroke Diagnosis

• Act quickly!

  • Door → start imaging <__ min

  • Door → IV thrombolytic <__min

• Labs

  • POC ______, O2 sat

  • CMP, CBC, _________, PT/INR, PTT, tox screen, BAC, _________ test

• ___ / cardiac monitoring

• Imaging

  • ____________ ___ scan head

  • CT ____________ of head and neck

stroke, 185/110, 60, 140, alteplase, 3, 24, aspirin, clopidogrel, speech

Ischemic Stroke Management

• ADMIT

  • ______ care unit

  • BP goal < ___/___ mm Hg

  • Manage glucose

    • > __ mg/dL to < ___ mg/dL

• Thrombolytic Therapy

  • ____________ IV → within _ hours

  • Tenecteplase IV

  • Pt MUST present within __ hours

• Post-Stroke Management

  • Dual Antiplatelet Therapy

    • ___________

      • In 24-48 hours, unless thrombolytic given within last 24 hours

    • _____________

  • Physical Therapy

  • Occupational Therapy

  • ______ therapy

intracranial, subarachnoid, internal, 3, surgery, trauma, neoplasm, diathesis, hypertension

Alteplase Contraindications

• Current _____________ hemorrhage

• ____________ hemorrhage

• Active __________ bleeding

• Recent (within _ months) intracranial or intraspinal _________ or severe head ________

• Presence of intracranial conditions that may increase the risk of bleeding (intracranial ___________, AV malformation, aneurysm)

• Known bleeding ___________

• Severe uncontrolled ____________

Anterior Cerebral Artery Ischemia

A 68-year-old man with a history of hypertension and atrial fibrillation presents to the emergency department with sudden-onset right-sided weakness and slurred speech that began 45 minutes ago. On examination, he is alert but has right leg weakness and expressive aphasia. Blood glucose is normal.

middle cerebral artery ischemia

A 72-year-old woman with a history of type 2 diabetes and hypertension presents with sudden-onset left-sided weakness and facial droop that began one hour ago. On examination, she has left hemiplegia, left facial droop, and gaze deviation to the right. Sensation is decreased on the left side, and she has expressive aphasia.

Broca’s Aphasia

What kind of APHASIA is this?

64-year-old right-handed man with a history of hypertension presents with sudden-onset difficulty speaking and weakness of the right arm and face. He follows commands and appears frustrated when trying to speak, producing short, effortful phrases with intact comprehension. Sensation is preserved, and strength in the right arm and face is decreased.

Wernicke’s Aphasia

What kind of APHASIA is this?

59-year-old woman with no significant past medical history presents with sudden-onset confusion and difficulty understanding speech. She speaks fluently with normal prosody but uses nonsensical words and phrases. She appears unaware of her language deficit. Neurologic exam shows no motor weakness or facial droop.

posterior cerebral artery ischemia

A 66-year-old man with a history of hyperlipidemia presents with sudden-onset vision loss. On examination, he is alert and oriented but has left homonymous hemianopia with preserved pupillary light reflexes. Motor and sensory functions are intact.

basilar artery ischemia

70-year-old woman with a history of hypertension and coronary artery disease presents with sudden-onset dizziness, double vision, and difficulty speaking. On examination, she has dysarthria, bilateral facial weakness, and quadriparesis. She is awake but can move only her eyes vertically.

lacunar infarct

A 64-year-old man with a history of long-standing hypertension and type 2 diabetes presents with sudden-onset weakness of the right face, arm, and leg. Sensation and language are intact. On examination, he has pure motor hemiparesis without cortical signs.