Etiology of stroke Sanjeeva Onteddu

60 yo smoking, htn, hlpd, DM presents with right sided weakness. Patient 1 Patient 2

This matters for secondary stroke prevention All our work up is figure out etiology only

TOAST Classification 1 large vessel athero 2 lacunar 3 cardio embolic 4 strokes of other known causes 5 strokes of unknown or 2 or more etiologies

Other types of classifications Thrombosis Embolism SSS-TOAST CCS Classification etc

40 Year old with no hx with left sided weakness

Lacunar Strokes Pure motor hemiparesis. Pure sensory hemi anesthesia. Ataxic hemiparesis. Dysarthria–clumsy hand syndrome. Absence of cortical deficits plus one of the following

Cortical vs subcortical. Cortical signs.   Aphasia (if the dominant hemisphere is affected) and Sensory neglect (if the non dominant hemisphere is affected), apraxia, asomatognosia, anosognosia. Gaze deviation. Cortical blindness. Contralateral hemiparesis (worse in the arm and face than in the leg). Cortical Sensory Loss Graphestesia, stereognosis, extinction Warning: all cortical signs can be seen in subcortical lesions!

Diagnostic Evaluations Hyper Acute: CT Head/MRI Brain, Accucheck Only. CTA Head or MRA head and neck to see of they qualify for Intervention. Brain function: Perfusion scans : CTP, MRP

Diagnostic Evaluations to find the etiology of stroke Acute to evaluate for Cause of stroke. Athero thrombotic: Catotid/vertebral or intracranial atherosclerosis Cardioembolic: TTE, ECG, Tele. Lacunar strokes: risk factors, absence of other etiologies, Lipids, HbA1c Stroke of other determined etiologies: Dissections. Hypercoagulability panel. Vasculitis , Urine Tox Screen, Troponins, Genetic testing Etc. Cryptogenic strokes.

Other Available diagnostic Options

Cardiac Extended Cardiac Monitoring Event monitor: Who TEE: Why not all and start with it Cardiac MRI: …hMMM Loop Recorders ..

Blood Work Hyper coag Work up Vasculi… work up Homocysteine…

DSA: 4 Vessel Angio When do we do it: Dissection ?? Vasculi…. Intracranial atherooo CVT causing venous infarcts….. Renal Injections to look for FMD

Other Uncommon Work up ECHO: bubbles in 2 second cycle ECHO: bubbles in 8th cycle What about TCD??

LE Duplex for PFO for paradoxical emboli CT Chest to look for Pul AVM’s CT or MRV of pelvis for venous thrombosis

Hmm How about Undetected CA No Clear guidelines

Vessel Wall Imaging Extracranial: Intracranial:

Treatments for secondary Prevention: Antiplatelet therapy- small vessel or large vessel embolic disease ASA 81 mg vs. 325 mg Clopidogrel 75 mg ASA plus Extended Release Dipyridamol 25/200 mg BID (Aggrenox) Anticoagulation- Best for Cardio embolic disease or thrombotic disease. Warfarin New Oral Anticoagulants or NOACs (Dabigatran, Apixaban, Edoxaban, and Rivaroxaban) Risk Factor Control: Treat all other identified causes:

What About ICH Most common cause of spontaneous ICH Lobar ICH ICH in Children Intra cranial ICH

Most common cause of spontaneous ICH: Hypertensive Lobar ICH: Amyloid ICH in Children: AVM Intra cranial ICH: Traumatic

Other causes Hemorrhagic infarction (including venous sinus thrombosis) Septic embolism, mycotic aneurysm Brain tumor Bleeding disorders, liver disease, anticoagulants, thrombolytic therapy Central nervous system (CNS) infection (eg, herpes simplex encephalitis) Moyamoya Vasculitis Drugs (cocaine, amphetamines)

ACUTE Imaging CT brain CTA ?? Almost always done may not need it Repeat HCT in 6 hrs Other options CTV, MRI, MRV.

Questions