3What Is A Stroke ?A stroke occurs when blood flow to the brain is interrupted by a blocked or a ruptured blood vessel.A brain attack.
4StrokeAcute stroke is typically characterized by the sudden onset of a focal neurologic deficit, though some patients have a stepwise or gradual progression of symptoms.
5Stroke Common deficits include: Dysphasia (difficulty swallowing) Dysarthria (difficulty speaking)Hemianopia (difficulty with sight)Weakness
6Stroke Common Deficits AtaxiaSensory lossNeglectConsciousness is generally normal but maybe impaired
7Stroke Warning SignsSudden weakness or numbness of the face, arm or leg, especially on one side of the bodySudden confusion, trouble speaking or understandingSudden trouble seeing in one or both eyes
8Stroke Warning SignsSudden trouble walking, dizziness, loss of balance or coordinationSudden, severe headaches with no known cause (for hemorrhagic stroke)
9Stroke Warning Signs Acute loss of focal cerebral function Abrupt onsetSymptoms occur in all affected areas at the same timeSymptoms resolve graduallySymptoms are “negative”
10Nature of SymptomsPositive symptoms indicate active discharge from central nervous system neurons. Typical positive symptoms can be visual (e.g., bright lines, shapes, objects), auditory (e.g., tinnitus, noises, music), somatosensory (e.g., burning, pain, paresthesias), or motor (e.g., jerking or repetitive rhythmic movements).Negative symptoms indicate an absence or loss of function, such as loss of vision, hearing, feeling, or ability to move a part of the body.
11Annual Incidence of Ischemic Stroke In young adults (15–45 years) has been estimated at approximately 2–11 per 100,000 in Caucasians, 22.8 per 100,000 in African Americans10/100,000 in a Mayo Clinic study of women ages 15 to 29About 2–12% of cerebral infarcts occur in young adult patients, with a higher frequency between 31 and 45 years
12Annual Incidence of Ischemic Stroke Stroke ranks second after ischemic heart disease as a cause of lost disability-adjusted life-years in high-income countries
13Mortality of StrokesMortality in the first month after stroke has been reported to range from 2.5% in patients with lacunar infarcts to 78% in patients with space-occupying hemispheric infarction.Lacunar stroke or lacunar infarct (LACI) is a type of stroke that results from occlusion of one of the penetrating arteries that provides blood to the brain's deep structures.
14Stroke Stroke in young adults is surprisingly common. The differential diagnosis for potential etiologies is broader than that for older adults.
15Stroke In children and young adults; Congenital and acquired heart problems,Hematologic conditions,Vasculopathies,Metabolic disorders,Drug ingestionare more common.
16Causes of StrokeThe largest series studies of young adults with ischemic stroke cite undetermined as the most frequent etiology (up to 35% of patients)Ischemic stroke is much more common than hemorrhagic
17Causes of StrokeUp to 45% of strokes in young adults are due to spontaneous intracerebral hemorrhage.Vascular malformations, aneurysms, hypertension, and illicit drug use are the main causes.
18Causes of Ischemic Stroke in Young Adults Eur Neurol 2007;57:212–218
19Cardiovascular Risk Factors in 272 Young Patients % (n) Major cardiovascular risk factors 35 (96)Arterial hypertension 22 (59)Diabetes mellitus 8 (21)Hypercholesterolemia 17 (46)Atherosclerosis 5 (14)Causes of Ischemic Stroke in Young Adults Eur Neurol 2007;57:212–218
20Cardiovascular Risk Factors in 272 Young Patients % (n) Minor cardiovascular risk factors 63 (172)Cigarette smoking 49 (133)Oral contraceptives 18 (17)High alcohol intake 31 (84)Causes of Ischemic Stroke in Young Adults Eur Neurol 2007;57:212–218
21Prevention of Stroke Control high blood pressure Prevent heart disease Stop cigarette smokingRecognize signs of TIAReduce blood cholesterol levels
22Stroke Risk Factors That Can Be Treated Hypertension/High Blood PressureHeart DiseaseCigarette SmokingTransient Ischemic Attacks
23Stroke Risk Factors That Can Be Treated DiabetesElevated Blood Cholesterol/LipidsAsymptomatic Carotid Bruits
24Stroke Risk Factors That Cannot Be Treated AgeGenderRacePrior strokeFamily history
25Stroke Risk Factors Less Well-Documented Geographical LocationSocioeconomic FactorsExcessive Alcohol IntakeCertain Kinds of Drug Abuse
26What Are the Types of Stroke ? Ischemic Stroke (Blockage)• Caused by a blockage in blood vessels in brainHemorrhagic Stroke (Bleeding)• Caused by ruptured or leaking blood vessels in brain
27Stroke Background Inadequate blood flow Hemorrhage Ischemic stroke Focal – thrombotic or embolic occlusion of major arteryGlobal – inadequate cerebral perfusionHemorrhageParenchymal – into brain tissueSubarachnoid – surrounding subarachnoid space
29Causes of StrokeSome of the most common causes of ischemia in the youngCardioembolism (20–35%),Dissection of extracranial arteries (6–25%),Migraine with aura (1–20%)Drugs (10%)Hypercoagulable states (5–10%)Premature atherosclerosis (20-25%)
30Ischemic StrokeIn patients younger than 55 years, only about 10% of strokes are caused by large-vessel atherosclerotic disease.
31What Are the Causes of Ischemic Stroke? Large vessel diseasePremature atherosclerosisDissection (spontaneous or traumatic)Inherited metabolic diseases (homocystinuria, Fabry’s, pseudoxanthoma elasticum, MELAS syndrome)Fibromuscular dysplasiaInfection (bacterial, fungal, tuberculosis, syphilis, Lyme)Vasculitis (collagen vascular diseases — systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, polyarteritis nodosa; Takayasu’s disease, Wegener’s syndrome, cryoglobulinemia, sarcoidosis, inflammatory bowel disease, isolated central nervous system angiitis)Moyamoya disease: (Japanese, "puff of cigar smoke") is an inherited disease in which certain arteries in the brain are constrictedRadiationToxic (illicit drugs — cocaine, heroin, phencyclidine; therapeutic drugs — L-asparaginase, cytosine arabinoside, ephedra, phenylephrine)
32What Are the Causes of Ischemic Stroke? Cardiac disease (including congenital, rheumatic valve disease, mitral valve prolapse, patent foramen ovale, endocarditis, atrial myxoma, arrhythmias, cardiac surgery)
33What Are the Causes of Ischemic Stroke? Small vessel diseaseVasculopathy (infectious, noninfectious, microangiopathy)Independent predictors of arteriopathy are sickle cell disease and recent upper respiratory infection.
34What Are the Causes of Ischemic Stroke? Hematologic diseaseSickle-cell diseaseLeukemiaHypercoagulable states (antiphospholipid antibody syndrome, deficiency of antithrombin III or protein S or C, resistance to activated protein C, increased factor VIII)Disseminated intravascular coagulationThrombocytosisPolycythemia veraThrombotic thrombocytopenic purpuraVenous occlusion (dehydration, parameningeal infection, meningitis, neoplasm, polycythemia, leukemia, inflammatory bowel disease)
35Hematologic Disorders Many hematologic disorders are associated with ischemic stroke.The disorders most likely to cause ischemic stroke in patients younger than 45 years are:Antiphospholipid antibody syndromeSickle cell anemiaHeparin induced thrombocytopenia
36APSAntiphospholipid syndrome (APS or APLS) or antiphospholipid antibody syndrome is a disorder of coagulation that causes blood clots (thrombosis) in both arteries and veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, or severe preeclampsia. The syndrome occurs due to the autoimmune production of antibodies against phospholipid (aPL), a cell membrane substance. In particular, the disease is characterized by antibodies against cardiolipin (anti-cardiolipin antibodies) and β2 glycoprotein.
37Hematologic disorders Most of the common hereditary hypercoagulable disorders, such as factor V Leiden/activated protein C resistance, the prothrombin gene mutation (G20210A), antithrombin III deficiency, protein C deficiency, and protein S deficiency, typically cause venous thrombosis much more often than they cause arterial thrombosis.
38What Are the Causes of Ischemic Stroke? Migraine: especially with aura
39Embolism:Cardiogenic (atrial fibrillation, mural thrombus, myxoma, valvular vegetations)Artery-to-arteryFatAirParadoxical (emboli of venous origin passing through a patent foramen ovale)
40Cardiogenic Embolism Major risk factors: Anticoagulation Indicated Atrial fibrillationMitral stenosisProsthetic cardiac valveRecent MIThrombus in LV or LA appendageAtrial myxomaInfective endocarditis (No anticoagulation)Dilated cardiomyopathy
42Cardiogenic EmbolismOne-fifth to one-third of strokes in the young may be caused by cardioembolic phenomena.
43Cardiogenic EmbolismParadoxical embolization from the right heart to the left is believed to occur via a patent foramen ovale or atrial septal defect (which can be found on autopsy in up to one fourth of all people.Atherosclerosis of the aorta or carotid arteries can be a source of both atheroemboli and thromboemboli
44Cardiogenic EmbolismLeft atrial thrombi account for nearly half of cardiac thromboemboli. The most common cause is atrial fibrillation; other causes are dilated cardiomyoapthy, mitral valve stenosis, and some hypercoagulable states.
45LeftatriumLeft atriumRightatriumValsalvaFigure 1. Transesophageal Echocardiograms of a Patent Foramen Ovale.In Panel A, a transesophageal echocardiogram in the longitudinal plane shows a separation between the primum septum (arrowhead) and the secundum septum — a finding consistent with the presence of patent foramen ovale.Panel B shows a transesophageal echocardiogram, also in the longitudinal plane, obtained during the injection of agitated-saline contrast material through an antecubital vein with use of the Valsalva maneuver. There is complete opacification of the right atrium, and passage of a cloud of bubbles between the primum and secundum septa into the left atrium is visible.Right atrium
46RALAFigure 2. Transesophageal echocardiogram showing a thrombus (arrows) passing from right atrium (RA) to left atrium (LA) through a patent foramen ovale.
47LeftatriumLeftatriumRight atriumRightatriumLeftventricleRightventricleFigure 2. Transesophageal Echocardiograms of an Atrial Septal Aneurysm.In Panel A, a transesophageal echocardiogram (in the horizontal plane) shows an atrial septal aneurysm protruding into the right atrium (arrow). Atrial septal aneurysm is defined as either sustained bowing of a 15-mm segment of interatrial septal membrane in the fossa ovalis of at least 11 mm (or at least 15 mm by a more conservative definition) beyond the plane of the interatrial septum or as phasic excursion to either side totaling the same distance.Panel B shows a transesophageal echocardiogram showing the same atrial septal aneurysm (arrow) viewed in the longitudinal plane.
48PFO Figure 3. Percutaneous Closure of a Patent Foramen Ovale. With use of a femoral approach, a transvenous sheath is advanced across the foramen into the left atrium, where a folded disk is expanded and pulled back, apposing the primum and secundum septa closed. This step is followed by deployment of a right-sided disk, at which time the two-disk device is released. Clopidogrel and aspirin are recommended for a period of three months to prevent thrombus formation on the device, with aspirin therapy continued for an additional three months, when endothelialization is complete. Antibiotic prophylaxis for six months is recommended. Complete late closure of the foramen has been reported in 80 to 95 percent of patients.
51Cocaine AbuseAnother important cause of ischemic stroke is the use of sympathomimetic drugs such as cocaine amphetamines, ephedra, or phenylephrine. The strongest association is with cocaine, which has been seen in case series to cause cerebral vasoconstriction in a dose-dependent manner. Vasoconstriction is also related to a longer duration of cocaine use. Several case-control studies have found that the risk of stroke is 4.5 to 6.5 times higher in drug abusers than in controls, and that use of catecholamines or cocaine alone was associated with a significantly increased risk of stroke.
52What Are the Causes of Hemorrhagic Stroke? Occurs when a weakened blood vessel ruptures• Aneurysms: Ballooning of a weakened region of a blood vessel• Arteriovenous Malformations (AVMs): Cluster of abnormal blood vessels
53Arteriovenous Malformations Cerebral AVMs are most commonly discovered in young adults aged years.These lesions are usually detected in patients as the result of a seizure or hemorrhage.AVMs hemorrhage at a rate of 4% per year.Approximately half of these hemorrhages will carry significant morbidity or mortality.
55Moyamoya Moyamoya syndrome is characterized by progressive stenosis of the internal carotid arteries and formation of collateral vessels that give a "puff of smoke" appearance on angiography.Moyamoya disease occurs mainly in Japanese and other Asian populations and may have a genetic basis.Secondary moyamoya syndrome is seen in association with neurofibromatosis, Down syndrome, Williams syndrome, sickle cell disease, and as a sequela of cranial irradiation. Intracranial hemorrhage is common in young adults.Dissection — Arterial dissection is the most common vascular abnormality in some young adult series
56Intracerebral Hemorrhage Diffuse – subarachnoid hemorrhageFocal – intraparenchymalAccounts for 20% of all strokesAcute rise in intracranial pressure from arterial rupture frequently results in loss of consciousness at outsetSome patients die from herniation
58Causes of Spontaneous Intracerebral Hemorrhage (ICH) Cervical arterial dissection causes up to 20% of strokes in patients younger than 45 years.Dissections usually involve the extracranial portion of the vessel, and involve the internal carotid arteries at least three times as often as the vertebral arteries.
59Causes of Spontaneous Intracerebral Hemorrhage (ICH) In many cases the dissection is preceded by mild neck trauma, which may be as minor as a vigorous cough or turning of the head.Typical features of dissection include: Neck pain, headache, and Horner syndrome, followed minutes to hours later by symptoms of ocular or cerebral ischemia, usually a transient ischemic attack rather than a stroke.
60Causes of Spontaneous Intracerebral Hemorrhage (ICH) Inherited disorders that are associated with increased risk of cervical arterial dissection include:Ehlers-Danlos syndrome type IVMarfan syndromeAutosomal dominant polycystic kidney diseaseOsteogenesis imperfecta type IFibromuscular dysplasia
61Diagnosis, Management, and Prognosis of ICH CT diagnostic test of choiceHyperintense area with mass effect and later hypointense surrounding edemaMRI less sensitive in early stages
62Diagnosis, Management, and Prognosis of ICH Management depends on size and locationIn acute phase, mass effect far greater than in large cerebral infarction, so greater risk of herniation and deathIn chronic phase, prognosis for surviving patients much better than with ischemic stroke
63Subarachnoid Hemorrhage Aneurysms can rupture any time but more common during strenuous activityMost common manifestation is headache“worst headache of my life”Neck pain and rigidityLoss of consciousness and vomiting commonSeen on CT in 95% of cases – location may suggest site of ruptureNormal CT does not rule out so do lumbar puncture – xanthochromia (develops after 6 hours)
66Right (Non-dominant) Hemisphere Stroke: Common Pattern Neglect of left visual fieldExtinction of left-sided stimuliLeft hemiparesisLeft-sided sensory lossLeft visual field defectPoor left conjugate gazeDysarthriaSpatial disorientation
67Left (Dominant) Hemisphere Stroke: Common Pattern AphasiaRight hemiparesisRight-sided sensory lossRight visual field defectPoor right conjugate gazeDysarthriaDifficulty reading, writing, or calculating
68Brain Stem / Cerebellum / Posterior Hemisphere Stroke: Common Pattern Motor or sensory loss in all four limbsCrossed signsLimb or gait ataxiaDysarthriaDysconjugate gazeNystagmusAmnesiaBilateral visual field defects
69Small Subcortical Hemisphere or Brain Stem Stroke: Common Pattern Pure MotorWeakness of face and limbs on one side of the body without abnormalities of higher brain function, sensation, or vision Pure SensoryDecreased sensation of face and limbs on one side of the body without abnormalities of higher brain function, motor function, or vision
74Corneal arcusoptic atrophy in tuberous sclerosislens dislocation in marfan syndrome
75Diagnostic Testing for Patients With Stroke Basic stroke evaluationCranial computed tomography (CT)Carotid ultrasonography ± transcranial DopplerTransthoracic echocardiographyEKG monitoringRoutine blood studies (complete blood count with differential and platelet count, prothrombin time (international normalized ratio), activated partial thromboplastin time, glucose, chemistries, serology for syphilis, and an erythrocyte sedimentation rate)
76Diagnostic Testing for Patients With Stroke Comprehensive stroke evaluationCranial magnetic resonance imaging (MRI)Imaging of the intracranial arteries (MR, CT, or catheter angiographyof the brain)Imaging of the extracranial arteries (MR, CT, or catheter angiographyof the neck)Transesophageal echocardiography (TEE)Prolonged EKG monitoring with Holter or event loop recorderUrine toxicology screen (often productive)Urine pregnancy testBlood testing for a hypercoagulable state anticardiolipin antibodies, lupus anticoagulants, protein S, protein C, activated protein C resistance, antithrombin III) is requested in patients without a firmly identified cause of stroke or if the patient or family members have a history of thromboses. It is advantageous to send such a profile prior to initiating anticoagulation, as heparin can alter interpretation of some of those assays.In select cases, blood testing for rare genetic causes of stroke (CADASIL, Fabry disease, MELAS)
78Treatment of StrokesAntiplatelet therapy remains treatment of choice to prevent recurrent thromboembolism in majority of patientsAnticoagulation may be appropriateAtrial fibrillationRecent MISuspected propagation of thrombus or stroke in evolution
79Treatment of StrokesCT or MRI of the brain should be performed promptly; MRI is more sensitive for early ischemic changes, but either method can fully rule out hemorrhage.Treatment of TPA was associated with an increase of about 1.2 with minimal or no disability for every 10 patients treated.
80Limitations of Imaging CT will miss a minority of acute bleedsMRI with DWI (diffusion weighted imaging), quite sensitive for acute stroke, has an occasional false negative result (17 out of 782 patients in a recent study)MRA’s resolution is not yet on par with conventional angiography.
81Thrombolysis t-PA Guidelines for treatment: Present within 3 hours of onset of clearly defined stroke – frequency of symptomatic hemorrhage most likely increases after this timeCT scan shows no evidence of intracranial hemorrhageNo anticoagulants or antiplatelet agents given for 24 hoursAvoid BP values > 185/110
82Guidelines Not to Treat Previous stroke or serious head trauma in preceding 3 monthsHistory of intracranial hemorrhageRepeated systolic BP’s > 185 mm Hg or diastolic BP’s > 110 mm Hg
83Guidelines Not to Treat Requires aggressive treatment to reduce BP to specified limitsTaking anticoagulants or propensity to hemorrhageRecent invasive surgical procedureRapidly improving neurological deficit or minor symptoms
84How Are Strokes Treated Hemorrhagic StrokeSurgical InterventionEndovascular Procedures, e.g., “coils”
86What Is the Impact of Stroke? Stroke is the third leading cause of death in the United States• On average, someone suffers a stroke every 40 seconds• About 795,000 Americans suffer a stroke each year• About every 4 minutes, someone dies of a stroke
87What Is the Impact of Stroke? Stroke is a leading cause of serious, long term disabilityAbout 6.4 million Americans are stroke survivorsAmericans will pay about $73.7 billion in 2010 for stroke-related medical costs and lost productivity long-term
88RehabilitationAfter suffering a stroke, it’s important to begin a rehabilitation program as soon as possible.Types of rehabilitation programs:Hospital programsExtended care facilitiesOutpatient programsHome-based programs
90Family RelationshipsOverall, 13 studies reported consequences of stroke for family relationships and in those studies, 5% to 54% of the samples experienced family problems.Nine studies reported marital problems after stroke, including separation or divorce.Six of these reported that marital problems were a direct consequence of the stroke.One study reported that 5% of the sample had experienced deterioration in the spousal relationship, whereas another found that 38% of couples had experienced conflict since the stroke.
91Sexual RelationshipsTen studies investigated the impact of stroke on sexual relationships, reporting problems in participants’ sexual relationships or frequency of sexual activities.Prevalence of deterioration in sexual relationships reported in 8 studies ranged from 5% to 76%.
92Social ActivitiesNine studies reported consequences of stroke on social or leisure activities with 4 of these reporting deterioration or decrease in these activities.Five studies quantified reported decrease in leisure activities ranging from 15% to 79%.
104PrognosisThe outcome of stroke in young adults is better than that for older adults. In a recent study of 330 patients with first stroke or transient ischemic attack, followed for an average of 96 months, 8% died, 3% had another stroke, and 3% had a myocardial infarction. Approximately 16% were dependent, but 56% had returned to work. Unfortunately, only a minority of those who smoked at the time of their stroke subsequently stopped using tobacco. The overall annual recurrence rate is less than 1%.Prognosis is often closely associated with the underlying cause.A relatively good outcome may be found after many cases of arterial dissection.Risk of stroke recurrence is low (2% over 5 years) in women whose first stroke occurred in pregnancy.
107Stroke ChameleonsStrokes with atypical presentations that take on the appearance of other disease process may be termed stroke chameleons, for like the chameleon, these disguised strokes may change and evolve with time.The provider is left with the daunting problem of discovering the unusual manifestation of an uncommon clinical process.The presence of historical risk factors for cerebrovascular disease and the abrupt onset of symptoms may be the best clues available to the provider to detect these unusual stroke syndromes.
108Stroke ChameleonsIn the majority of cases of stroke, making the diagnosis is straightforward.Especially in patients with unusual features (e.g.,Gradual onset,Seizure at the onset of symptomsImpaired consciousnessThe differential diagnosis should include migraine, postictal paresis, hypoglycemia, conversion disorder, subdural hematoma, and brain tumors.
109Stroke ChameleonsAtherosclerosis (leading to thromboembolism or local occlusion) and cardioembolism are the leading causes of brain ischemia.Unusual causes should be considered, especially if patients are younger (e.g., below 50 years of age) and have no apparent cardiovascular risk factors.Some clinical clues that suggest alternative diagnoses are ptosis and miosis contralateral to the deficit (carotid-artery dissection), fever and a cardiac murmur (infective endocarditis), and headache and an elevated erythrocyte sedimentation rate.
110Differential Diagnosis Seizures and migraine auras characteristically (but not always) begin with positive symptoms, while TIAs invariably are characterized by negative symptoms.Seizures occasionally cause paralytic attacks but, on close observation, there are usually features of the history and physical examination that suggest the presence of a seizure disorder such as minor twitching of a finger or toe or a tingling sensation in the affected limb.
111Differential Diagnosis of Stroke Intracranial mass: Tumor, Subdural hematomaSeizure with persistent neurological signsMigraine with persistent neurological signsMetabolic
113Focal symptomsNonfocal symptomsCommon disordersSeizures++TIAs++++occasionallyMigraineSyncopeLess common disordersVestibulopathyMetabolic++++"Tumor attacks"Multiple sclerosisPsychiatricNerves and nerve rootTransient global amnesia
114Differential Diagnosis of Transient Neurological Diseases SeizureMigraine with auraSyncopeHypoglycemia
115HypoglycemiaThat transient hypoglycemia may produce a stroke like picture with hemiplegia and aphasia has been known for years.These patients may be drowsy but are often alert and do not show the more common response to hypoglycemia of confusion, diminished level of consciousness, or coma.Aphasia may make the history of diabetes more difficult to discover.Syndrome has also been reported in alcoholics with hypoglycemia.The pathogenesis of this focal CNS dysfunction is unclear.Hypoglycemia is generally defined as a blood glucose level of less than 45 mg/dl in these studies.The wide use of bedside rapid laboratory testing for glucose now makes this easily detectable and treatable.The hemiplegia may resolve immediately with the administration of intravenous glucose but resolution over a hours is also reported.
116Mass LesionsSubdural hematoma, cerebral abscess, primary CNS tumors, and metastatic tumors are among the clinical conditions simulating stroke in the studies cited above.The typical clinical presentation of a slowly increasing mass is a progressive syndrome; an abrupt onset of symptoms of these masses seems counter-intuitive.A review of patients with brain tumors presenting to an ED showed that 6% of patients had symptoms that were of less than one day’s duration; it was thought that these patients with brief symptom duration might reflect a sub-population who suffer acute deterioration from hemorrhage into the tumor or who develop obstructive hydrocephalus.Secondary effects of mass or edema on cerebral vasculature have been identified as possible causes of abrupt onset of seizures as well.Chronic subdural hematoma has been frequently reported as a cause of stroke and TIA-like symptoms.
117Functional Hemiparesis Little is written about a factitious or feigned stroke yet several studies discover rare patients initially thought to have cerebrovascular disease but later determined to have a functional cause of the hemiparesis or other stroke syndrome.Conversion disorder is the most commonly assigned psychiatric disorder.One study of emergency department presentations of conversion disorder noted that symptoms of paresis, paralysis, or movement disorders were common and were a presentation in almost 30% of patients.They noted significant comorbidity in this population, often other psychiatric disorders, and emphasized that conversion disorder is a diagnosis of exclusion.Patients often undergo multiple diagnostic tests before the diagnosis is assigned.
123Focal Seizure Partial (focal) seizure Positive sensory or motor symptomsSpread quickly (60 seconds)Negative symptoms afterward (Todd’s paresis)Multiple attacks
124What is a TIA Acute loss of focal cerebral function Symptoms last less than 24 hoursDue to inadequate blood supplyThrombosisEmbolism
125Transient Ischemic Attacks (TIAs) Warning strokes” that can happen before a major strokeOccur when blood flow through a brain artery is blocked or reduced for a short timeSymptoms are temporary (<24 hours) but similar to those of a full fledged strokeA person who has a TIA is 9.5 times more likely to have a stroke
126TIA Risk Factors/Epidemiology 300,000 TIAs per year in US5-year stroke risk after TIA 29%43.5% in 2 years with >70% carotid stenosis treated medicallyMany stroke patients have had a TIA25% - 50% in large artery atherothrombotic strokes11% - 30% in cardioembolic strokes11% to 14% in lacunar strokes
127Risk Factors for a TIA Risk factors are the same as stroke Increasing ageSexFamily history / RacePrior stroke / TIAHypertensionDiabetesHeart diseaseCarotid artery / Peripheral artery diseaseObesityHigh cholesterolPhysical inactivity
128TIA Symptoms Symptoms last less than 24 hours Most last less than one hourLess than 10 percent > 6 hoursAmaurosis fugax up to five minutes (Amaurosis fugax is loss of vision in one eye due to a temporary lack of blood flow to the retina. Symptoms include the sudden loss of vision in one eye.)
130TIA Presentation Acute loss of focal cerebral function Abrupt onset Symptoms occur in all affected areas at the same timeSymptoms resolve graduallySymptoms are “negative”
131TIA Presentation Acute loss of focal cerebral function Motor symptoms Weakness or clumsiness on one sideDifficulty swallowingSpeech disturbancesUnderstanding or expressing spoken languageReading or writingSlurred speechCalculations
132TIA Presentation Acute loss of focal cerebral function Sensory symptomsAltered feeling on one sideLoss of vision on one sideLoss of vision in left or right visual fieldBilateral blindnessDouble visionVertigo
133TIA Presentation Non-focal Symptoms (Not TIA) Generalized weakness or numbnessFaintness or syncopeIncontinenceIsolated symptoms (symptoms occurring alone)Vertigo or loss of balanceSlurred speech or difficulty swallowingDouble vision
134TIA Presentation Non-focal Symptoms (Not TIA) Confusion Disorientation Impaired attention/concentrationDiminution of all mental activityDistinguish fromIsolated language or visual-spatial perception problems (may be TIA)Isolated memory problems (transient global amnesia)
135TIASignificant risk factor for recurrent stroke, with average 5% risk per yearProphylactic antiplatelet therapy shown to prevent secondary effectsAspirinTiclopidine: thrombotic stroke reductionClopidogrel: reduce events associated with atherosclerosis that include strokes, MI, PVD
136TIATreat with warfarin if significant risk for cardiogenic thromboembolismHospital admission for new-onset and recurrent TIA’s unless confident in diagnosis of etiologyAngiography – treat medically or surgically
137TIA Usually minutes, mostly <1 hour Spells during days, weeks, months; not usually years
138TIA Associated Symptoms Headaches may occur during time period of a TIA
139Migraine Demography Younger age Women>men (4:1) 10-20% of the populationThe risk of migraine with aura and transient ischemic attacks (TIA’s) is greater than 2 fold.1/3 have migraine with aura
140Migraine with Aura Migraine with aura Positive symptomsSpread over minutesVisual disturbancesSomatosensory or motor disturbanceHeadache within 1 hourMigraine with aura is associated with a twofold risk of ischemic stroke. This risk is higher in women, age < 45, smokers, and women who used oral contraceptives.BMJ2009;339:b3914, Migraine and cardiovascular disease
141Migraine with Aura Aura without Headache 98% Visual symptoms 30% with other symptoms26% sensory16% aphasia6% dysarthria10% weaknessMean age 48.7 (vs. 62.1)Fewer cardiovascular risk factors
142Migraine CNS Timing Usually 20 to 30 minutes Sporadic attacks during years
144Migraine Associated Symptoms Headache after attack, nausea, vomiting, photophobia, phonophobia (usually GI or autonomic nervous system)
145MigraineAuras typically occur before the onset of migraine headache, and the headache usually begins simultaneously with or just after the end of the aura phase. However, headache onset can rarely occur an hour or more after the end of the aura phase. Although atypical, an aura can develop during or after the onset of headache, and many patients have migraine aura with only a minimal or no headache.
146MigraineMost migraine auras resolve in 20 to 30 minutes and seldom last more than one hour.Typical auras may involve any of the following manifestations:Visual disturbances ( the most common type of aura)Sensory symptomsMotor weaknessSpeech disturbances
147Migraine vs. TIA Positive visual symptoms Gradual onset / evolution Sequential progressionRepetitive attacks of identical natureFlurry of attacks mid-lifeDuration up to 60 minutesHeadache follows ~ 50%Visual lossAbruptSimultaneous occurrenceDuration <15 minutesHeadache uncommon accompaniment
148Syncope DemographyAny age, often youngerWomen>men
149Syncope TimingUsually a few secondsSporadic attacks during years
151Most Common Types of Syncope Neurocardiogenic (vasovagal) syncopeSituational syncope (during or immediately after urination, defecation, cough, or swallowing)Orthostatic syncope (associated with orthostatic hypotension)Syncope related to cardiac ischemia or cardiac arrhythmia
152Seizures TIAs Migraine Syncope Demography Any age, often younger Differential diagnosis of transient neurologic symptomsSeizuresTIAsMigraineSyncopeDemographyAny age, often youngerOlder patientsYounger ageStroke risk factors presentWomen>menMen>womenCentral nervous system symptomsPositive symptoms: limb jerking, head turning, loss of consciousnessNegative symptoms: numbness, visual loss, paralysis, ataxiaFirst positive symptoms, then negative in same modality: scintillating scotomas and parasthesias most common; second sensory modality is involved after first clearsLight-headed, dim vision, noises distant, decreased alertnessNegative symptoms may develop, remain postictally, and persistAll sensory modalities affected simultaneouslyTransient loss of consciousnessTiming20 to 80 secondsUsually minutes, mostly <1 hourUsually 20 to 30 minutesUsually a few secondsAbsence, atonic seizures and myoclonic jerks are shorterSpells during days, weeks, months; not usually yearsSporadic attacks during yearsPostictal depressionSpells occur during yearsAssociated symptomsTongue biting, incontinence, sore muscles, headache after attackHeadaches may occur during time period of TIAsHeadache after attack, nausea, vomiting, photophobia, phonophobiaSweating, pallor, nausea
153Transient Global Amnesia Sudden disorder of memoryAntegrade and often retrogradeRecurrence 3% per yearEtiology unclearMigraineEpilepsy (7% within 1 year)Unknown
154Transient Global Amnesia No difference in vascular risk factors compared with general populationFewer risk factors when compared with TIA patientsPrognosis significantly better than TIA
155Structural intracranial lesion TumorPartial seizuresVascular stealHemorrhageVessel compression by tumor
156Intracranial hemorrhage ICH rare to confuse with TIASubdural hematomaHeadacheFluctuation of symptomsMental status changes
157Multiple sclerosis Usually subacute but can be acute Optic neuritisLimb ataxiaAge and risk factorsSigns more pronounced than symptoms
158Labyrinthine Disorders Central vs. Peripheral vertigoMénière's diseaseBenign positional vertigoAcute vestibular neuronitis
159Others in the Differential Diagnosis Metabolic perturbations, such as hypoglycemia, can be associated with focal neurologic deficits.Multiple sclerosis occasionally can cause paroxysmal attacks, particularly of ataxia and dysarthria.Brain tumors can occasionally result in transient neurologic symptoms; the mechanism in these cases is thought to involve mechanical changes that result in pressure on structures adjacent to the tumor.
160Others in the Differential Diagnosis Subdural hematomas may cause attacks of transient neurologic dysfunction, again due to mechanical changes that result in pressure on structures adjacent to the hematoma.Cerebral amyloid angiopathy, better known as a cause of intracerebral hemorrhage, may also cause transient neurologic symptoms. Affected patients complain of recurrent, brief (minutes), often stereotyped spells of weakness, numbness, paresthesias, or other cortical symptoms that can spread smoothly over contiguous body parts.
161Others in the Differential Diagnosis Hepatic, renal, and pulmonary encephalopathies can produce temporary aberrations in alertness, behavior and movement.Compressive myelopathy may rarely cause sudden transient sensory changes and motor deficits.Pressure- or position-related peripheral nerve or nerve root compression can cause transient paresthesias and numbness.
162Others in the Differential Diagnosis Peripheral vestibulopathies can cause transient episodic dizziness.Hysteria and other psychiatric disorders may underlie attacks that include swoons, falls, and episodic blindness, deafness, and paralysis, which can be confused with organic loss of function.
163Case 1A 19 year old man had a history of a murmur since birth and intermittent episodes of hemiparesis that he ignored. He presented with collapse while playing handball.
164Case 1He fell and had tonic clonic movement of his extremities. He was in distress at presentationHis BP was 110/70, HR 76, RR 18. He had a persistently split S2 with a systolic ejection murmur in the upper left second intercostal area. His neurological exam was consistent with a right middle cerebral infarction with a left hemiplegia and left hemisensory defect.
166Case 2When 22-year-old Ms. KS began experiencing left arm weakness, she went to a clinic only to be told that nothing was seriously wrong. But when her symptoms persisted, so did she. She was finally referred to the Medical Center, where neurologists confirmed that her symptoms were the result of a stroke.
167Case 2Further testing in the Coagulation Laboratory revealed activated protein C resistance, the result of a heterozygous mutation in factor V Leiden, as well as a homozygous mutation in the methylene tetrahydrofolate reductase gene, responsible for elevated homocystine
168Case 2Although she had had only one clinical stroke, multiple other strokes were evident by imaging studies. Factors contributing to her hypercoagulable state included: 1. the methylene tetrahydrofolate reductase deficiency, which elevated her homocystine level, 2. the heterozygous state for factor V Leiden, causing activated protein C resistance, 3. oral contraceptives, 4. smoking, and 5. hypertension. She is doing well, without recurrence, on aspirin, and antihypertensive medicines, having stopped smoking and birth control pills.
169Case 3In another case, a 20-year-old female college student was sent to the Medical Center after a brain scan showed what her physicians thought to be a brain tumor. Neurosurgeons quickly realized there was no tumor, and that the young woman had suffered a stroke. After thrombosis of intracranial venous sinuses was diagnosed she was treated with heparin, and then Warfarin. Repeat imaging revealed recanalization of the previously thrombosed sinuses.
171Case 3Investigation in the Special Coagulation Laboratory revealed deficiency of antithrombin III, on two separate occasions, several weeks apart. This patient suffered a venous infarction secondary to a hypercoagulable state induced by inherited antithrombin III deficiency, probably exacerbated by use of oral contraceptives. With anticoagulation and careful monitoring, her prognosis is good.
172Case 4A 28-year-old man has sudden weakness of the left arm and leg and slurred speech.Except for untreated hypertension, his medical history is unremarkable.He is a current smoker.On arrival at the emergency department 1 hour 15 minutes after the onset of symptoms, he reports no headache or vomiting.His blood pressure is 180/100 mm Hg, and his pulse is 76 beats per minute and is regular.Neurologic examination shows dysarthria, a left homonymous hemianopia, severe left-sided weakness, and a failure to register light touch on the left side of the body when both sides are touched simultaneously (left tactile extinction).
173Case 4He had sudden left-sided hemiparesis, strongly suggestive of a right hemisphere stroke.
174SummaryThese are not isolated cases. Frequently young patients, even teenagers, who have suffered stroke are misdiagnosed. Though they may have presented with classic symptoms - dizziness, severe headache, weakness in a limb, or unilateral loss of sensation, for example - they often have been misdiagnosed by their provider, most likely because they do not fit the profile of the "typical" stroke patient.
175SummaryMisdiagnosis has included patients being told they had vertigo, migraine, alcohol intoxication or other conditions. They were discharged from clinic and later discovered to have suffered a stroke.
176SummaryThe second important point is that the causes of stroke in young people are much more diverse, and less likely to be the ones that commonly cause stroke in older people, such as atherosclerosis of brain-supplying vessels and emboli from cardiac disorders related to coronary artery disease. Without the right resources, providers may be at a loss to pinpoint the cause in order to treat it and prevent further damage.
177SummaryAbuse of amphetamine-like drugs ("speed" and cocaine, for example) can lead to stroke in teenagers and young adults. These drugs are popular in rural and urban areas alike.
178SummaryHowever, one of the increasingly recognized causes of stroke in a young person is a blood disorder that predisposes to blood clotting.This allows clots to form too readily, often in the veins, leading to stroke. Once such a disorder has been identified, treatment can help prevent future damage. Diagnosis of a hereditary disorder can also lead to identification of other family members who may be at high risk.
179SummaryThe long term outcome of cerebral infarction is better in young adults than in older patients, morbidity and mortality are still significant.Despite a good functional and motor outcome young adult patients usually encounter difficulties in social and work caused by cognitive impairment.
180SummaryThe bottom line: for young stroke patients, extensive testing and careful evaluation may be necessary to determine the underlying cause.