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Stroke Syndromes - Comprehensive Review

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1. Epidemiology & Overview

• 795,000 strokes/year in the United States (one stroke every 40 seconds; one death every 4 minutes)
• 77% are first-ever strokes; 23% recurrent
• Ischemic strokes: 87% of all strokes
• Intracerebral hemorrhage (ICH): 10%
• Subarachnoid hemorrhage (SAH): 3%
• Age-adjusted stroke death rate fell 28.7% from 2004-2014 with improved stroke units, thrombolysis, and thrombectomy

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2. Vascular Anatomy - The Essential Framework

Table 1: Cerebrovascular Anatomy - Circulation, Arteries, and Brain Regions Supplied

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3. Stroke Classification

Table 2: Stroke Classification

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4. ISCHEMIC STROKE SYNDROMES

Key principle (Rosen's): Anterior circulation strokes produce contralateral hemiparesis of face and body. Vertebrobasilar strokes produce ipsilateral cranial nerve deficits + contralateral hemiparesis ("crossed deficits").

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4.1 Anterior Cerebral Artery (ACA) Infarction

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4.2 Middle Cerebral Artery (MCA) Infarction

Aphasia localizes to the dominant cerebral cortex in MCA distribution. Dysarthria is a motor deficit. Dysphagia is difficulty swallowing - these three terms are commonly confused. - Rosen's Ch. 87

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4.3 Posterior Cerebral Artery (PCA) Infarction - Distal Posterior Circulation

"One of the more unique facets of this syndrome is that the patient may be unaware of any visual problem (visual neglect)." - Rosen's Ch. 87

PCA stroke: ipsilateral CN III palsy + contralateral homonymous hemianopsia - Rosen's Key Concepts

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4.4 Basilar Artery Occlusion - Middle Posterior Circulation

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4.5 Vertebrobasilar Infarction - Proximal Posterior Circulation

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4.6 Cerebellar Infarction

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4.7 Wallenberg Syndrome (Lateral Medullary Syndrome)

Caused by occlusion of the posterior inferior cerebellar artery (PICA) or vertebral artery

"Wallenberg syndrome causes vertigo, Horner syndrome, ipsilateral facial numbness, loss of corneal reflex, along with contralateral loss of pain and temperature." - Rosen's Key Concepts

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4.8 Lacunar Infarction

• Infarction of small penetrating arteries (terminal small vessels)
• Strongly associated with chronic hypertension (80-90%) and diabetes
• Size: few mm to 2 cm
• Most common sites: basal ganglia, thalamus, pons, internal capsule
• Mechanism: lipohyalinosis (hypertensive vasculopathy) or small emboli

Prognosis generally more favorable than other stroke syndromes. - Tintinalli's Ch. 167

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4.9 Stroke in Young Adults (15-45 years old)

• 3-4% of all strokes occur in this age group
• Average age of first stroke is becoming younger

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4.10 Carotid & Vertebral Artery Dissection

• Accounts for 2% of all strokes and up to 25% of strokes in young adults
• Trauma (even minor: chiropractic manipulation, sneezing, sport) in ~40% of cases

• Headache: frontotemporal region; may mimic SAH ("thunderclap")
• Partial Horner's syndrome (miosis + ptosis) in ~25%
• Cranial nerve palsies in ~12%
• Leads to anterior circulation symptoms

• Dizziness/vertigo (58%), headache (51-65%), neck pain (46-66%)
• Headache typically occipital
• Symptoms: facial paresthesia, ataxia, limb weakness, dysarthria, hearing loss
• Leads to posterior circulation symptoms / Wallenberg syndrome

TIAs preceding stroke in dissection patients are often misdiagnosed. - Rosen's Key Concepts

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5. HEMORRHAGIC STROKE SYNDROMES

5.1 Intracerebral Hemorrhage (ICH)

• 10-15% of all acute strokes; ~65,000 patients/year
• 30-day mortality: up to 50% (half die in first 2 days)
• Only 1 in 5 survivors are living independently at 6 months

1. Hypertensive vasculopathy - lipohyalinosis of deep penetrating arteries; deep locations
2. Cerebral amyloid angiopathy - amyloid deposition in vessel walls; lobar, in elderly

Table 3: Common Sites of Hypertensive ICH (Box 87.1 - Rosen's)

Spontaneous ICH may be clinically indistinguishable from ischemic infarction. CT is mandatory to differentiate. - Tintinalli's Ch. 167

5.2 Subarachnoid Hemorrhage (SAH)

• Characterized by sudden severe occipital or nuchal headache
• "Thunderclap" headache - worst headache of life, maximal at onset
• Associated with Valsalva activities (defecation, sex, weight lifting, coughing)
• Preretinal hemorrhage on fundoscopy is a hallmark finding

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6. Stroke Mimics

Table 4: Stroke Mimics and Distinguishing Features (Tintinalli's Table 167-5)

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7. Clinical Features - Examination Approach

Anterior vs. Posterior Circulation Strokes

Key Physical Examination Points (Rosen's)

• Gaze preference - suggests cortical or brainstem involvement (toward the lesion in cortical strokes)
• Central vs. peripheral CN VII weakness - peripheral lesion: cannot wrinkle forehead; central: forehead spared
• Pronator drift - sensitive sign of contralateral motor weakness
• Double simultaneous extinction - tests sensory neglect; patient feels each side alone but not both together
• Graphesthesia - number scratched on forearm; tests parietal lobe cortical sensation
• Gait testing - critical but commonly omitted; detects subtle ataxia and focal cerebellar lesions

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8. Anterior vs. Posterior Circulation: Summary Comparison

Table 5: Clinical Features by Vascular Territory

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9. Stroke Progression Patterns

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10. Stroke Diagnostic Flowchart

SUSPECTED STROKE
      │
      ▼
ABC + Vital Signs + Bedside glucose
(Treat hypoglycemia immediately)
      │
      ▼
Activate Stroke Team (immediately upon arrival)
      │
      ▼
Focused History: Last known well time, symptom onset, 
medications (anticoagulants), recent procedures/trauma
      │
      ▼
Neurological Exam: NIHSS score
      │
      ├─── Posterior signs (CN deficits, ataxia, 
      │    crossed findings, vertigo, diplopia)?
      │         └── Consider vertebrobasilar syndrome
      │              → MRI-DWI preferred over CT
      │
      ▼
Non-contrast CT Head (within 20 min of arrival)
      │
      ├── Hemorrhage on CT?
      │         YES → Hemorrhagic Stroke
      │               ├── ICH: BP control, reverse anticoagulation
      │               │   (PCC > FFP for warfarin; Vit K)
      │               └── SAH: Neurosurgical consult
      │
      └── No hemorrhage on CT?
                │
                ▼
           Ischemic Stroke
                │
                ▼
      Within 4.5 hours of symptom onset?
          AND eligible for tPA?
                │
           YES  │  NO
                │    └── General supportive care
                │        Antiplatelet therapy
                │        BP permissive unless >220/120
                ▼
      IV Alteplase (tPA)
      0.9 mg/kg (max 10 mg IV bolus + 90% over 60 min)
      Door-to-needle: ≤60 min (target ≤45 min)
                │
                ▼
      Emergent Large Vessel Occlusion (LVO)?
      CT Angiography
                │
                ▼
      Mechanical Thrombectomy (if LVO confirmed)
      Up to 24 hrs in selected patients (DAWN/DEFUSE3)
                │
                ▼
      Admit to Stroke Unit / ICU

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11. Key Time Targets (AHA/ASA - Tintinalli's Table 167-8)

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12. NIHSS - National Institutes of Health Stroke Scale

• Score range: 0-42 (0 = normal; higher = more severe)
• Rapid (5-10 minutes); high interrater reliability
• Important caveat: Weighted toward anterior circulation strokes - posterior strokes (CN deficits, ataxia) receive fewer points; ataxia scored as absent if weakness is present
• Also has a bias toward detecting left hemisphere strokes

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13. Prognosis & Complications

Factors worsening acute stroke prognosis (Rosen's):

• Fever
• Hypotension
• Hypoxia
• Hypoglycemia or Hyperglycemia

ICH-specific risks (Rosen's):

• IV tPA: symptomatic intracranial hemorrhage in 2-7%; asymptomatic hemorrhage in 30-45% (>10 cerebral microbleeds)
• Risk lowest with: low NIHSS, no hypertension, no diabetes, age < 70 years

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Quick Reference: Wallenberg Syndrome Summary

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Key Concepts Summary (Rosen's Chapter 87)

1. Anterior circulation strokes → contralateral hemiparesis of face and body
2. Vertebrobasilar strokes → ipsilateral CN deficits + contralateral hemiparesis (crossed deficits)
3. PCA stroke → ipsilateral CN III palsy + contralateral homonymous hemianopsia
4. Wallenberg syndrome → vertigo + Horner's + ipsilateral facial numbness + corneal reflex loss + contralateral pain/temperature loss
5. Cervical artery dissection is the leading determined cause of stroke in young patients; TIAs often misdiagnosed
6. IV tPA dose: 0.9 mg/kg (10% bolus + 90% over 1 hour); window = 4.5 hours
7. Avoid overly aggressive BP management in acute ischemic stroke
8. ICH reversal: prefer PCC over FFP (faster INR correction, lower infection risk, lower volume)
9. Fever, hypotension, hypoxia, and glucose abnormalities worsen prognosis

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STROKE SYNDROMES

Complete Chapter Review

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SECTION 1: EPIDEMIOLOGY

• 795,000 strokes/year in the United States - one stroke every 40 seconds; one death every 4 minutes
• 77% are first-ever strokes; 23% recurrent events
• Estimated cost: $33.9 billion in total expenditures (2012-2013)
• Age-adjusted stroke death rate fell 28.7% from 2004-2014 due to stroke units, thrombolysis, and endovascular thrombectomy
• About 240,000 TIAs/year in the United States

• Ischemic: 87% of all strokes
• ICH: 10%
• SAH: 3%

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SECTION 2: PATHOPHYSIOLOGY & ANATOMY

1. Loss of oxygen and glucose - failure of high-energy phosphate production
2. Mediators of secondary cellular injury - glutamate excitotoxicity, free radicals
3. Edema and mass effect - exacerbate initial insult

The Ischemic Penumbra

Vascular Anatomy

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Table 1: Cerebrovascular Anatomy - Circulation, Arteries & Brain Regions

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SECTION 3: STROKE CLASSIFICATION

Table 2: Complete Stroke Classification (Tintinalli's Table 167-2)

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SECTION 4: CLINICAL FEATURES

History - Key Distinguishing Features

Table 3: Stroke Symptoms - Traditional vs. Non-Traditional (Tintinalli's Table 167-4)

Women tend to report more severe but diffuse nontraditional symptoms compared to men. - Tintinalli's Ch. 167

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SECTION 5: ISCHEMIC STROKE SYNDROMES

Fundamental rule: Anterior circulation = contralateral hemiparesis face + body. Vertebrobasilar = ipsilateral CN deficits + contralateral motor/sensory (crossed deficits).

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5.1 Anterior Cerebral Artery (ACA) Infarction

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5.2 Middle Cerebral Artery (MCA) Infarction

Aphasia localizes to the dominant cerebral cortex in MCA distribution. Dysarthria is a purely motor speech deficit. Dysphagia is difficulty swallowing - all three are frequently confused. - Rosen's Ch. 87

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5.3 Posterior Cerebral Artery (PCA) Infarction

PCA stroke: ipsilateral CN III palsy + contralateral homonymous hemianopsia. - Rosen's Key Concepts

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5.4 Basilar Artery Occlusion

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5.5 Vertebrobasilar Infarction

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5.6 Wallenberg Syndrome (Lateral Medullary Syndrome)

"Wallenberg syndrome causes vertigo, Horner syndrome, ipsilateral facial numbness, loss of corneal reflex, along with contralateral loss of pain and temperature." - Rosen's Key Concepts

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5.7 Cerebellar Infarction

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5.8 Lacunar Infarction

Prognosis generally more favorable than other stroke syndromes. - Tintinalli's Ch. 167

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5.9 Stroke in Young Adults (15-45 years)

• 3%-4% of all strokes; average age of first stroke getting younger
• Must search for less common, often reversible, causes

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5.10 Carotid and Vertebral Artery Dissection

• 2% of all strokes; up to 20-25% of strokes in young adults
• Neck trauma in ~40% (often minor: chiropractic manipulation, sneezing, sports)
• First symptom: unilateral headache (68%), neck pain (39%), face pain (10%)
• Median delay from neck pain to neurologic symptoms: 4 days; from headache: 15 hours

• Frontotemporal headache; may mimic SAH (thunderclap quality)
• Partial Horner's syndrome (miosis + ptosis) in ~25%; rarely, full Horner's
• Cranial nerve palsies in ~12%
• Anterior circulation symptoms; can lead to retinal infarction

• Occipital headache (51-65%); neck pain (46-66%); dizziness/vertigo (58%)
• Posterior circulation symptoms: facial paresthesia, ataxia, limb weakness, hearing loss
• May cause Wallenberg syndrome

TIAs preceding stroke in cervical dissection are often misdiagnosed. - Rosen's Key Concepts

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SECTION 6: HEMORRHAGIC STROKE SYNDROMES

6.1 Intracerebral Hemorrhage (ICH)

• 10%-15% of all strokes; ~65,000 patients/year
• 30-day mortality: up to 50%; half die in first 2 days
• Only 1 in 5 survivors are living independently at 6 months
• ~40% show significant hemorrhage expansion in the first few hours

1. Hypertensive vasculopathy - lipohyalinosis of deep penetrating vessels; deep ICH
2. Cerebral amyloid angiopathy - amyloid in vessel walls; lobar ICH; elderly patients

Table 4: Sites of Hypertensive ICH and Presentations (Rosen's Box 87.1)

ICH may be clinically indistinguishable from ischemic stroke. CT is mandatory to differentiate the two. - Tintinalli's Ch. 167

ICH Score (Prognostic Tool) - Rosen's Table 87.3

6.2 Subarachnoid Hemorrhage (SAH)

• Thunderclap headache: "worst headache of my life," maximal at onset
• Often associated with Valsalva activities: defecation, sexual activity, weight lifting, coughing
• Severe occipital or nuchal headache that is sudden
• Preretinal (subhyaloid) hemorrhage on fundoscopy is pathognomonic
• Meningismus may develop within hours

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SECTION 7: STROKE MIMICS

Table 5: Stroke Mimics and Distinguishing Features (Tintinalli's Table 167-5)

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SECTION 8: PREHOSPITAL STROKE SCALES

Table 6: Prehospital Stroke Scales (Tintinalli's Table 167-3)

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SECTION 9: NIHSS - National Institutes of Health Stroke Scale

• Score range: 0-42 (0 = normal; higher = more severe)
• Duration: 5-10 minutes; high interrater reliability
• 15-item, 11-category neurologic evaluation
• Caveat 1: Weighted toward anterior circulation strokes - posterior strokes (CN deficits, ataxia) get fewer points; ataxia scored absent if weakness present
• Caveat 2: Bias toward detecting left hemisphere strokes

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SECTION 10: DIAGNOSTIC EVALUATION

Neuroimaging

• First-line imaging; must be done within 20 minutes of ED arrival
• Differentiates ischemic stroke from ICH and mass lesions
• Ischemic stroke: gross changes NOT seen for 6-12 hours
• Subtle early ischemic changes seen in up to 67% within first 3 hours:
  • Hyperdense artery sign (acute thrombus in vessel)
  • Sulcal effacement
  • Loss of insular ribbon
  • Loss of gray-white interface
  • Mass effect; acute hypodensity

• High-quality images of large vessels; detects LVO (large vessel occlusion)
• Identifies secondary causes of ICH: aneurysm, AVM, fistula
• Spot sign on CTA = contrast extravasation in ICH → high risk of hemorrhage expansion

• DWI (Diffusion-Weighted Imaging): Detects ischemia within minutes of onset
• FLAIR: Detects parenchymal edema; typically becomes positive 4-6 hours after onset
• DWI-FLAIR mismatch = ischemia on DWI but FLAIR negative = suggests stroke onset within 4.5 hours (useful for wake-up strokes)

ASPECTS Score (Alberta Stroke Program Early CT Score)

• 10-point scale assessing early ischemic changes in MCA territory on NCCT
• Score ≥6 = relatively preserved brain tissue = favorable for intervention
• Score <6 = extensive early ischemic changes = less benefit from thrombectomy

Laboratory Studies

• CBC, BMP, coagulation studies, type and screen
• ECG (AF, MI, arrhythmias)
• If ICH: drug screen (cocaine), look for coagulopathy

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SECTION 11: TIME TARGETS

Table 7: NINDS Stroke Evaluation Targets (Rosen's Table 87.4 / Tintinalli's Table 167-8)

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SECTION 12: MANAGEMENT

12.1 General Supportive Care (All Stroke Patients)

Table 8: Core ED Interventions for Suspected Acute Stroke (Tintinalli's Table 167-7)

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12.2 Blood Pressure Management

• Do NOT treat unless SBP >220 mmHg or DBP >120 mmHg
• The elevated BP is a compensatory response (Cushing's) maintaining cerebral perfusion
• Exception: Treat if concurrent AMI, aortic dissection, hypertensive encephalopathy, severe CHF

• Must achieve SBP <185 mmHg AND DBP <110 mmHg before giving tPA
• If BP does not decline to this level → DO NOT administer rtPA

Table 9: BP Management Algorithms (Tintinalli's Tables 167-9 & 167-10 / Rosen's Box 87.2)

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12.3 Reperfusion Therapy - IV Thrombolytics

Key Trials for IV Alteplase

Table 10: Major Clinical Trials for IV tPA in Acute Ischemic Stroke

Alteplase Dosing

• Dose: 0.9 mg/kg IV (maximum 90 mg total)
• Administration: 10% of total dose as IV bolus over 1 minute; remaining 90% infused over 60 minutes
• Do NOT use abbreviations (rtPA, tPA); use full name "alteplase" to avoid medication errors

Tenecteplase (TNK)

• Single IV bolus (0.25 mg/kg; max 25 mg)
• EXTEND-IA TNK trial and others: similar functional outcome, sICH, and mortality vs. alteplase at 90 days
• Higher reperfusion rates before thrombectomy vs. alteplase in LVO patients
• Moderate-to-high quality evidence supports use; AHA/ASA now recommends as alternative

AHA/ASA Inclusion Criteria for IV Alteplase (Tintinalli Table 167-11 / Rosen's Table 87.5)

• Age ≥18 (no upper age limit)
• Diagnosis of acute ischemic stroke with measurable neurologic deficit
• Time of onset clearly established <3h (or last known well time)

• Age ≤80 (per older criteria; see Note below)
• No history of BOTH diabetes mellitus AND prior stroke
• NIHSS ≤25
• No oral anticoagulants
• No imaging evidence of ischemia >1/3 of MCA territory

• Last known well >4.5 hours (or unknown onset without imaging selection)
• Acute intracranial hemorrhage or history of prior ICH
• Evidence of SAH
• Recent brain imaging showing extensive clear hypodensity (obvious early ischemia)
• Recent ischemic stroke or severe head trauma within 3 months
• Acute posttraumatic brain infarction
• Intracranial or intraspinal surgery within 21 days
• GI or GU bleeding within 3 months
• Active arterial puncture at non-compressible site within 7 days
• SBP persistently >185 mmHg or DBP >110 mmHg despite treatment
• Platelet count <100,000/mm³
• INR >1.7 or aPTT >40s or PT >15s
• Blood glucose <50 mg/dL (normalize first)
• Current use of GP IIb/IIIa inhibitors
• Known or suspected aortic arch dissection
• Intra-axial or extra-axial neoplasm (some exceptions)

Post-tPA Complications

• Symptomatic ICH: 2%-7%; greatest risk with most severe strokes
• Asymptomatic ICH: 30%-45% (>10 cerebral microbleeds)
• Cerebral microbleeds (CMBs): If >10 on prior MRI, risk of sICH = 30%-47%; benefits of tPA uncertain
• PH2 hemorrhage (>30% of infarcted tissue + mass effect): ~50% mortality

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12.4 Endovascular Therapy - Mechanical Thrombectomy

AHA/ASA Indications for Stent Retriever Thrombectomy (0-6 hours) - Tintinalli Table 167-13

1. Prestroke mRS 0-1 (no significant prior disability)
2. Acute ischemic stroke receiving IV rtPA within 4.5h OR not eligible for rtPA
3. Causative occlusion of ICA or proximal MCA (M1)
4. Age ≥18
5. NIHSS ≥6
6. ASPECTS ≥6
7. Treatment (groin puncture) initiable within 6 hours of symptom onset

Positive Thrombectomy Trials (0-6 hours)

Extended Window Thrombectomy Trials (6-24 hours)

Both DAWN and DEFUSE 3 used perfusion imaging to identify salvageable tissue (penumbra mismatch). AHA/ASA recommends extended window thrombectomy ONLY if strict inclusion/exclusion criteria of DAWN or DEFUSE 3 are met.

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12.5 Antiplatelet Therapy

• Recommended within 24-48 hours of ischemic stroke onset
• Combined International Stroke Trial (IST, n=19,435) + Chinese Acute Stroke Trial (CAST, n=20,665): significant reduction in mortality and morbidity at 4 weeks and 6 months
• DO NOT give within 24 hours of tPA

• POINT trial and CHANCE trial: for minor stroke or high-risk TIA, dual antiplatelet for 21 days reduces early recurrent stroke but ↑ bleeding risk
• NOT for moderate-severe stroke; most benefit in lacunar or minor stroke

• Previously recommended by guidelines; current ACEP 2016 policy states ABCD2 should NOT be used alone to identify TIA patients safe for discharge (inadequate LR+ and LR-)

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12.6 Anticoagulation

• Acute anticoagulation (heparin) in acute ischemic stroke: NOT recommended routinely
• Benefits do NOT outweigh risk of symptomatic ICH in acute stroke
• Exception: specific situations (stroke with concurrent AMI, dissection) - consult stroke specialist

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12.7 Other Ischemic Stroke Management

• Fever (>38°C) significantly worsens outcome
• Identify and treat source; acetaminophen for antipyresis
• Avoid ibuprofen (no temperature lowering + bleeding risk)
• Physical cooling is second-line only
• Hypothermia induction: no benefit; increased infection risk

• For high-grade ICA lesions after TIA: best performed within 2 weeks of TIA (surgical benefit greatest)
• CREST trial: Carotid stenting vs. endarterectomy - similar functional outcomes up to 10 years
• Stenting preferred in: age <70, high surgical risk

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SECTION 13: HEMORRHAGIC STROKE MANAGEMENT

13.1 ICH Management Principles

1. Prevent hemorrhage expansion (~20%-30% expand in first hours)
2. Prevent secondary brain injury: airway + breathing + circulation
3. Airway management: balance between aspiration prevention vs. loss of serial neurological exam

13.2 Blood Pressure in ICH

• Intensive lowering did NOT significantly reduce death or severe disability
• BUT improved functional outcomes at 90 days

• No difference in death/disability
• ↑ Renal adverse events in intensive group (9.0% vs. 4.0%)

13.3 Anticoagulation Reversal

Table 11: Anticoagulation Reversal in ICH

PCC preferred over FFP: faster INR correction, lower infection risk, lower administered volume. - Rosen's Key Concepts

13.4 ICP Management in ICH

• Indications for ICP monitoring: GCS ≤8; clinical transtentorial herniation; intraventricular hemorrhage or hydrocephalus
• External ventricular drain: for hydrocephalus, especially IVH blocking 3rd/4th ventricles
• Target CPP: 50-70 mmHg
• Medical therapy:
  • Mannitol (0.25-1 g/kg IV): osmotic agent; safe but limited outcome improvement
  • Hypertonic saline (HTS) 3% or 23.4%: more effective than mannitol (meta-analysis); 23.4% HTS for herniation reversal
  • Elevate head of bed 30°; maintain normothermia; avoid hypotonic fluids

13.5 Seizures in ICH

• Up to 16% risk of clinical seizures within 1 week (majority at onset)
• No prophylactic antiseizure medication recommended
• Treat clinical seizures with anticonvulsants
• Continuous EEG monitoring for ICH patients with mental status out of proportion to brain injury
• Levetiracetam 1000-1500 mg IV for electrographic seizures

13.6 Surgical Management of ICH

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SECTION 14: TIA MANAGEMENT

• ~240,000 TIAs/year; ~10% stroke risk within 3 months; 50% of those in first 2 days
• Patients with DWI-negative TIA have much lower recurrence risk

• Aspirin + Clopidogrel for 21 days (POINT trial, CHANCE trial)
• Then transition to single antiplatelet

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SECTION 15: CEREBELLAR/BRAINSTEM STROKE TREATMENT

• MRI-DWI mandatory (CT has up to 25% false-negative rate for posterior fossa)
• Close monitoring for rapid deterioration from edema and brainstem compression
• Serial exams: watch for gaze palsy, worsening ataxia, deteriorating consciousness
• Neurosurgical consultation if cerebellar hemorrhage or large cerebellar infarct
• Posterior fossa decompression may be lifesaving for large cerebellar stroke with edema

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SECTION 16: STROKE IN SPECIAL POPULATIONS

Stroke with Concurrent AMI

• Aspirin appropriate for both; consult cardiology before tPA
• Recent STEMI involving left anterior, right, or inferior myocardium is NOT a contraindication to tPA

Stroke with Coagulopathy

• Consult hematology + stroke neurology
• Admit to comprehensive stroke center

Young Adults (18-50 years)

• Younger victims have MORE FAVORABLE morbidity/mortality after IV thrombolysis, thrombectomy, and decompressive surgery for large MCA strokes
• Treat aggressively
• Increasing incidence linked to: ↑ hyperlipidemia, diabetes, obesity, recreational drug use

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MASTER FLOWCHART: ACUTE STROKE MANAGEMENT IN THE ED

PATIENT ARRIVES WITH SUSPECTED STROKE
              │
              ▼
    ┌─────────────────────────────────────┐
    │  IMMEDIATE ACTIONS (0-5 min)        │
    │  • ABC + Vital Signs                │
    │  • Bedside glucose (treat <60 dextrose)│
    │  • IV access + cardiac monitor + SpO₂│
    │  • ACTIVATE STROKE TEAM NOW         │
    │  • Last known well TIME documented  │
    └─────────────────────────────────────┘
              │
              ▼
    ┌─────────────────────────────────────┐
    │  HISTORY & EXAM (5-15 min)          │
    │  • Time of onset (last known well)  │
    │  • Medications (anticoagulants?)    │
    │  • NIHSS score                      │
    │  • Posterior vs. anterior signs?    │
    └─────────────────────────────────────┘
              │
              ▼
    ┌─────────────────────────────────────┐
    │  NCCT HEAD (within 20 min)          │
    └─────────────────────────────────────┘
              │
    ┌─────────────┴──────────────┐
    │                            │
    ▼                            ▼
HEMORRHAGE                 NO HEMORRHAGE
    │                            │
    │                            ▼
    │                 ISCHEMIC STROKE
    │                            │
    │              ┌─────────────┴───────────────┐
    │              │                             │
    │              ▼                             ▼
    │     Within 4.5 hours?             Beyond 4.5 hours
    │       AND eligible?                 OR unknown onset
    │              │                             │
    │         YES  │  NO                         │
    │              │   └──────────────────┐      │
    │              │         BP <185/110? │      │
    │              │              YES     │      │
    │              ▼                      │      │
    │     IV ALTEPLASE                    │      │
    │     0.9 mg/kg (max 90mg)            │      │
    │     Bolus 10% over 1 min            │      │
    │     + infusion 90% over 60 min      │      │
    │              │                      │      │
    │              └──────────┬───────────┘      │
    │                         │                  │
    │              CTA HEAD/NECK                 │
    │              (LVO screen)                  │
    │                         │                  │
    │              LVO present? (ICA or M1)      │
    │           NIHSS ≥6, ASPECTS ≥6             │
    │                         │                  │
    │                YES       │   NO             │
    │                ▼         │    ▼             │
    │         MECHANICAL       │  SUPPORTIVE      │
    │         THROMBECTOMY     │  CARE            │
    │         (0-6h standard   │  + Aspirin       │
    │          6-24h if DAWN/  │  in 24-48h       │
    │          DEFUSE3 criteria│                  │
    │          met)            │                  │
    │                          │                  │
    │              PERFUSION IMAGING:             │
    │              DWI-FLAIR mismatch?            │
    │              → May extend tPA window        │
    │              for wake-up stroke             │
    │                                             │
    ▼
HEMORRHAGIC STROKE
    │
    ├── ICH
    │    • Reverse anticoagulation
    │    │  (Warfarin: PCC + Vit K; DOAC: specific reversal)
    │    • BP: target SBP <140-160 mmHg
    │    │  (Nicardipine or Labetalol IV)
    │    • ICP management if indicated
    │    │  (HOB 30°; Mannitol or HTS 3%)
    │    • Seizure treatment (no prophylaxis)
    │    • Cerebellar hemorrhage >3cm
    │    │  or brainstem compression → Neurosurgery
    │    • NO early DNR (wait ≥day 2)
    │    • Admit ICU / Stroke Unit
    │
    └── SAH
         • Neurosurgical consultation STAT
         • Nimodipine (vasospasm prevention)
         • Avoid anticoagulants/antiplatelets
         • BP control; aneurysm securing

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MASTER COMPARISON TABLE: All Major Stroke Syndromes

Table 12: Comprehensive Stroke Syndrome Summary

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PROGNOSTIC FACTORS

Factors Worsening Acute Stroke Prognosis (Rosen's Key Concepts)

Factors Worsening sICH Risk After tPA

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ANTERIOR vs. POSTERIOR CIRCULATION: FINAL COMPARISON

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