Cardiovascular accident

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Cerebrovascular Accident (CVA) - Stroke

Definition

A stroke, or cerebrovascular accident (CVA), is defined as an abrupt onset of a neurologic deficit attributable to a vascular cause - specifically, acute infarction of brain tissue, spinal cord, or retina resulting in neurologic deficits. The diagnosis is clinical, supported by brain imaging. If neurologic deficits resolve within 24 hours with no evidence of infarction on imaging, the event is called a transient ischemic attack (TIA) rather than a stroke.

Harrison's Principles of Internal Medicine 22E, p. 3472
Frameworks for Internal Medicine, p. 574

Epidemiology

Stroke is the second leading cause of death worldwide - 7.1 million deaths in 2020
A stroke occurs approximately every 40 seconds in the United States
Prevalence is ~15% in adults over 80 years
The 30-day mortality rate is ~10%; 1-year mortality ~20%; 5-year mortality ~40%
Overall disease burden will continue to rise as the population ages

Classification

Strokes fall into two broad categories:

1. Ischemic Stroke (~80% of all strokes)

Caused by a reduction in blood flow lasting longer than several seconds. Neurons lack glycogen, so energy failure occurs rapidly. Types include:

Thrombotic stroke - occlusion from atherosclerotic disease within the cerebral vessel itself
Embolic stroke - embolus from a proximal arterial source (e.g., carotid artery) or from the heart (e.g., atrial fibrillation, cardiac thrombus)
Small-vessel (lacunar) disease - occlusion of small penetrating arteries, typically from hypertension or diabetes

2. Hemorrhagic Stroke (~20% of all strokes)

Caused by bleeding directly into or around the brain. Subdivided into:

Intracerebral hemorrhage (ICH) - bleeding into the brain parenchyma (~10-15% of all strokes); most common cause is hypertension
Subarachnoid hemorrhage (SAH) - bleeding between the arachnoid and pia mater (~5% of all strokes); most common cause is aneurysm rupture

Hemorrhagic stroke is associated with significantly higher acute morbidity and mortality (30-day mortality approaching 50%, vs ~10% for ischemic stroke).

Pathophysiology

Ischemic injury: Cerebral ischemia causes neurologic symptoms within seconds. If flow cessation lasts minutes, brain infarction (irreversible cell death) occurs. Focal ischemia results from vessel thrombosis or embolism.

Hemorrhagic injury: Blood causes injury through mechanical compression of brain tissue and local toxicity from blood breakdown products, plus raised intracranial pressure.

A generalized reduction in cerebral blood flow (e.g., cardiac arrest, sepsis) can produce hypoxic-ischemic encephalopathy or border-zone infarctions - distinct from focal stroke.

Risk Factors

Risk Factor	Notes
Hypertension	Strongest risk factor; present in most stroke patients (SBP ≥140 or DBP ≥90 mmHg)
Smoking	Doubles lifetime stroke risk; >1 pack/day = 6x greater risk; smokers + hypertension = 20x risk
Atrial fibrillation	Major source of cardioembolic stroke
Diabetes mellitus	Independent risk factor
Dyslipidemia	Contributes to atherosclerosis
Physical inactivity / poor nutrition	Modifiable lifestyle factors
Older age, family history	Non-modifiable
Chronic kidney disease	Associated with increased risk

Good news on smoking: the risk of CVA declines rapidly after cessation and at 5 years equals that of a nonsmoker - emphasizing it is never too late to quit.

Textbook of Family Medicine 9e; Frameworks for Internal Medicine, p. 574

Clinical Features - Warning Signs (FAST)

The FAST acronym is used to teach recognition to the lay public:

F - Facial weakness (asymmetry, droop)
A - Arm weakness (unilateral)
S - Speech abnormality (dysarthria, aphasia)
T - Time (treatments are highly time-sensitive - call emergency services immediately)

Other common symptoms:

Loss of sensory/motor function on one side (hemiparesis in ~85% of ischemic strokes)
Visual changes (hemianopia, monocular blindness)
Gait disturbance, ataxia
Sudden severe headache ("thunderclap" - classic for SAH)

Stroke Syndromes by Vascular Territory

Territory	Key Features
Middle Cerebral Artery (MCA)	Contralateral face/arm > leg weakness & sensory loss; aphasia (dominant hemisphere); neglect, anosognosia (non-dominant); homonymous hemianopia
Anterior Cerebral Artery (ACA)	Contralateral leg > arm weakness; frontal lobe signs
Posterior circulation (vertebrobasilar)	Diplopia, vertigo, dysphagia, ipsilateral cranial nerve deficits + contralateral limb weakness; "crossed" deficits
Lacunar (small vessel)	Pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis - no cortical signs

Differential Diagnosis

Conditions that can mimic stroke or TIA:

Seizure / Todd's paralysis (postictal paresis)
Intracranial tumor or subdural hematoma
Migraine (hemiplegic migraine)
Hypoglycemia
Metabolic encephalopathy
Conversion disorder

Diagnosis

Brain imaging is mandatory to distinguish ischemic from hemorrhagic stroke - this cannot be done on clinical grounds alone, and the treatment differs fundamentally.

Non-contrast CT - First-line; highly sensitive for acute hemorrhage, widely available, fast
MRI (DWI) - More sensitive than CT for ischemic stroke, especially in the posterior fossa and within the first few hours
Lumbar puncture - If CT is negative but SAH is suspected (xanthochromia or RBCs in CSF)

Management

Figure: Medical management of stroke and TIA - from Harrison's Principles of Internal Medicine 22E

Acute Ischemic Stroke

ABCs + stabilization - Airway, breathing, circulation; check glucose (hypoglycemia can mimic stroke)
Thrombolysis - IV recombinant tPA (rtPA/alteplase) within the treatment window (generally 4.5 hours of onset) in eligible patients
Mechanical thrombectomy - Endovascular clot removal for large vessel occlusion; highly effective up to 24 hours in selected patients
Blood pressure management - BP is often elevated acutely; permissive hypertension in most ischemic strokes (do not lower aggressively unless giving tPA or BP is extreme)
Antiplatelet therapy - Aspirin 325 mg within 24-48 hours (not if tPA given)

Acute Hemorrhagic Stroke

Blood pressure lowering - Aggressive BP control is indicated
Reverse anticoagulation if applicable (vitamin K, reversal agents)
Surgical options - Consider surgery for hypertensive ICH in selected cases; aneurysmal SAH treated with surgical clipping or endovascular coiling

General In-Hospital Care (all stroke types)

Deep venous thrombosis prophylaxis
Dysphagia screening before oral intake
Physical, occupational, and speech therapy
Evaluation for inpatient rehabilitation
Discharge planning and secondary prevention

Secondary Prevention

Targeted to the underlying stroke mechanism:

Cause	Prevention Strategy
Atrial fibrillation (17% of ischemic strokes)	Oral anticoagulation (warfarin or DOAC)
Carotid atherosclerosis (4%)	Carotid endarterectomy (CEA) or stenting if significant stenosis
Other (large artery, small vessel, cryptogenic) (64%)	Antiplatelet therapy, statin, BP control, lifestyle modification
Aneurysmal SAH	Surgical clipping or endovascular coiling

All patients benefit from: aggressive hypertension control, statin therapy, smoking cessation, diabetes management, and physical activity.

Prognosis

30-day mortality: ~10% overall (ischemic); approaching 50% for hemorrhagic
1-year mortality: ~20%; 5-year mortality: ~40%
Worse prognosis with: older age, comorbid ischemic heart disease or diabetes, larger infarct size
Long-term functional outcomes among survivors are similar between hemorrhagic and ischemic stroke

Harrison's Principles of Internal Medicine 22E, p. 3472-3474 | Frameworks for Internal Medicine, pp. 574-576 | Textbook of Family Medicine 9e

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