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STROKE - Comprehensive PG-Level MPT Exam Guide

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1. DEFINITION

• Stroke is the #1 cause of adult disability globally
• Affects ~800,000 people/year in the USA; one stroke every 40 seconds
• 87% ischemic | 10% intracerebral hemorrhage | 3% subarachnoid hemorrhage

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2. ANATOMY OF STROKE

Cerebrovascular Supply

Anterior Circulation (Carotid System)

• Internal Carotid Artery (ICA) divides into:
  • Anterior Cerebral Artery (ACA) - supplies medial frontal lobe, medial parietal lobe, anterior corpus callosum
  • Middle Cerebral Artery (MCA) - supplies lateral frontal, parietal, temporal cortex; basal ganglia; internal capsule (largest territory)

Posterior Circulation (Vertebrobasilar System)

• Vertebral Arteries unite to form Basilar Artery
  • Posterior Inferior Cerebellar Artery (PICA) - lateral medulla + inferior cerebellum
  • Anterior Inferior Cerebellar Artery (AICA) - middle cerebellar peduncle + lateral pons
  • Superior Cerebellar Artery (SCA) - upper cerebellum
  • Posterior Cerebral Artery (PCA) - occipital lobe, thalamus, medial temporal lobe

Circle of Willis

• Anterior Communicating Artery (ACoA)
• Posterior Communicating Arteries (PCoA) x2

Note: The anatomy of the Circle of Willis is highly variable; incomplete circles reduce collateral flow during occlusion.

Arterial Territory Clinical Correlations

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3. CLASSIFICATION OF STROKE

TYPE A: ISCHEMIC STROKE (87%)

Subtypes by Etiology (TOAST Classification):

1. Large-artery atherosclerosis - carotid/vertebral stenosis >50%; risk: HTN, DM, dyslipidemia
2. Cardioembolism - AF, valvular disease, LV thrombus, dilated cardiomyopathy
3. Small-vessel (lacunar) - lipohyalinosis of penetrating arteries; pure motor, pure sensory, ataxic hemiparesis
4. Other determined etiology - dissection, vasculitis, hypercoagulable states, sickle cell disease
5. Cryptogenic - no identified cause

Pathophysiology:

• Ischemic penumbra - zone of reversibly damaged but salvageable tissue surrounding infarcted core; the target of reperfusion therapy
• Core: irreversible necrosis within minutes (CBF <10 mL/100g/min)
• Penumbra: functionally silent but viable (CBF 10-20 mL/100g/min) - survives 3-6 hours
• Cytotoxic edema, excitotoxicity (glutamate release), free radical injury, mitochondrial failure

Temporal Subtypes:

• TIA - no infarction on imaging (tissue-based definition)
• Stroke in evolution - worsening deficits over minutes to hours (20% anterior, 40% posterior circulation)
• Completed stroke - stable deficits

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TYPE B: HEMORRHAGIC STROKE

B1. Intracerebral Hemorrhage (ICH) - 10%

• Hypertensive ICH - putamen (most common ~35%), thalamus, pons, cerebellum; from Charcot-Bouchard microaneurysms in penetrating arteries
• Cerebral Amyloid Angiopathy (CAA) - lobar hemorrhage, typically in elderly; beta-amyloid deposition in vessel walls
• Other causes: AVM, anticoagulation, tumor, cavernoma

• Sudden onset headache, vomiting, focal deficits, rapid deterioration
• Putaminal: contralateral hemiplegia, gaze deviation toward lesion
• Thalamic: sensory loss, "wrong-way eyes" (medial deviation), small pupils
• Pontine: pinpoint pupils, quadriplegia, coma
• Cerebellar: ataxia, vertigo, nausea - can cause obstructive hydrocephalus

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B2. Subarachnoid Hemorrhage (SAH) - 3%

• "Thunderclap headache" - sudden, maximal-intensity, "worst headache of my life"
• Often precipitated by Valsalva (straining, coughing, coitus, weight lifting)
• Nuchal rigidity, photophobia, altered consciousness
• CN III palsy (posterior communicating artery aneurysm - "surgical" CN III palsy with pupil dilation)

• Hunt-Hess Scale (I-V) - clinical severity
• Fisher Scale (CT blood distribution)
• WFNS Scale - World Federation of Neurosurgeons

1. Re-bleeding (highest risk first 24 hours)
2. Vasospasm (days 4-14 post-SAH) - treat with nimodipine
3. Hydrocephalus
4. Hyponatremia (SIADH/cerebral salt wasting)
5. Cardiac arrhythmias / "neurogenic pulmonary edema"

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B3. Subdural and Epidural Hematoma

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TYPE C: TRANSIENT ISCHEMIC ATTACK (TIA)

• Tissue-based definition: no infarction on MRI DWI
• Risk of stroke: 10% at 2 days; 15% at 90 days post-TIA
• ABCD2 Score for risk stratification (Age, BP, Clinical features, Duration, Diabetes)
• Differential: migraine, Todd's paralysis (post-ictal), hypoglycemia, subdural hematoma, conversion disorder

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4. RISK FACTORS

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5. DIAGNOSIS & ASSESSMENT

"Time is Brain" - 1.9 million neurons die per minute during stroke

Prehospital Stroke Scales

• FAST: Face droop, Arm weakness, Speech difficulty, Time to call 911
• Cincinnati Prehospital Stroke Scale (CPSS): Face, Arm, Speech (sensitivity ~66%, specificity ~87%)
• Los Angeles Prehospital Stroke Screen (LAPSS): Age >45, no seizure history, ambulatory at baseline, glucose 60-400 mg/dL + asymmetric exam (sensitivity 91%, specificity 97%)
• Melbourne Ambulance Stroke Screen: Age ≥45, no seizure, not bedridden, glucose 50-400 mg/dL + unilateral facial droop/grip/arm drift/speech (sensitivity 90%)

Emergency Assessment Protocol (Door-to-Needle ≤60 min)

1. ABCs - Airway, Breathing, Circulation
2. IV access - establish immediately
3. Pulse oximetry - supplement O2 only if SpO2 <94% (routine O2 NOT indicated)
4. Cardiac monitoring - detect AF
5. Bedside glucose - rule out hypoglycemia (<60 mg/dL - give IV dextrose)
6. Non-contrast CT brain - within 25 minutes of arrival (exclude hemorrhage)
7. ECG - detect AF, acute MI
8. Labs: CBC, coagulation screen (PT/INR/aPTT), metabolic panel, type & screen

NIH Stroke Scale (NIHSS)

• 0 = normal; 1-4 = minor; 5-15 = moderate; 16-20 = moderate-severe; 21-42 = severe
• Guides thrombolysis eligibility and outcome prediction
• Online calculator: mdcalc.com/nih-stroke-scale-score-nihss

Neuroimaging

• Exclude hemorrhage (hyperacute sensitivity ~98% for SAH within 6h)
• ASPECTS score for MCA territory (Alberta Stroke Program Early CT Score; 0-10, >6 favors thrombolysis)
• Early ischemic changes: loss of grey-white differentiation, sulcal effacement, hyperdense artery sign

• DWI (Diffusion Weighted Imaging) - detects ischemia within minutes; gold standard
• ADC map - restricted diffusion confirms acute infarct (dark on ADC)
• FLAIR - fluid-attenuated inversion recovery; helps with timing (FLAIR-DWI mismatch)
• MRA - vessel occlusion, stenosis, aneurysm
• PWI (Perfusion Weighted Imaging) - defines penumbra (PWI-DWI mismatch = salvageable tissue)

• CTA - rapid vessel imaging for LVO (Large Vessel Occlusion) prior to thrombectomy
• DSA (digital subtraction angiography) - gold standard for aneurysm, AVM

• Carotid Doppler / MRA for stenosis (before discharge in TIA)
• Echocardiography (TTE/TEE) for cardioembolic source
• Holter monitoring (24-72 hr or prolonged) for paroxysmal AF
• Hypercoagulability screen in young stroke

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6. MANAGEMENT

6A. Acute Ischemic Stroke Management

General Supportive Care ("Bundle")

• Maintain SpO2 >94%
• Treat fever (target normothermia; fever worsens outcome)
• Blood glucose: target 140-180 mg/dL; avoid hypo/hyperglycemia
• Blood pressure: do NOT aggressively lower unless >185/110 mmHg (pre-thrombolysis target <185/110); permissive hypertension up to 220/120 in non-thrombolysis candidates
• Cardiac monitoring for 24-48 hrs
• DVT prophylaxis (compression stockings, early mobilization)
• Swallowing assessment before oral feeds (28-65% develop dysphagia post-stroke)
• Foley catheter if needed; early removal to prevent UTI
• Antiepileptics only for clinical seizures (prophylaxis not recommended)

Reperfusion Therapy

• Indication: Ischemic stroke within 4.5 hours of onset with disabling symptoms
• Dose: 0.9 mg/kg IV (max 90mg); 10% as bolus over 1 min, remaining 90% over 1 hour
• Door-to-needle target: ≤60 min (AHA/ASA Class IB)
• Key Contraindications: active hemorrhage, recent surgery/trauma (<3 months), prior ICH, BP >185/110 (untreated), INR >1.7, platelets <100,000, blood glucose <50 or >400
• Risk of symptomatic ICH after tPA: 2-7%
• Tenecteplase (TNK) - newer single-bolus alternative; non-inferior to alteplase in many trials, easier administration

• Indication: Large Vessel Occlusion (ICA, MCA M1/M2), NIHSS ≥6, ASPECTS ≥6, within 24 hours (with favorable imaging - DAWN/DEFUSE criteria)
• First-line for LVO; superior to tPA alone
• Technique: stent retrievers (Solitaire, Trevo) or aspiration catheters (ADAPT)
• mTICI 2b/3 = successful reperfusion
• Recent advances: Extended window to 24h in selected patients (DAWN trial: 6-24h; DEFUSE-3: 6-16h)

Secondary Prevention (Post-stroke)

• Antiplatelet therapy:
  • Aspirin 160-325 mg within 24-48h (not for hemorrhagic stroke)
  • Dual antiplatelet (aspirin + clopidogrel) for 21 days in minor stroke/TIA (POINT/CHANCE trials)
• Anticoagulation for AF: start within 4-14 days depending on stroke size; NOACs preferred (dabigatran, rivaroxaban, apixaban) over warfarin
• Statins: high-intensity (atorvastatin 80mg) for ischemic stroke
• Antihypertensives: ACE inhibitor + thiazide diuretic combination; target BP <130/80
• Carotid endarterectomy (CEA) or carotid artery stenting (CAS) for symptomatic stenosis >70%

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6B. Hemorrhagic Stroke Management (ICH)

• Specialized neurosurgery unit
• Reverse coagulopathy: Vitamin K + Prothrombin Complex Concentrate (PCC) preferred over FFP (faster INR correction, lower infection risk, lower volume); FFP if PCC unavailable
• For dabigatran: Idarucizumab (Praxbind); for anti-Xa agents: Andexanet alfa
• Blood pressure: For SBP 150-220 mmHg, lower to target 140 mmHg (safe, possibly beneficial per INTERACT-2)
• Blood glucose: avoid hypo/hyperglycemia
• Seizures: treat with antiepileptics (prophylaxis debated)
• Elevated ICP: HOB elevation 30°, mannitol, hypertonic saline, intubation/sedation, hemicraniectomy

• Cerebellar hemorrhage >3cm with neurological deterioration or brainstem compression - urgent surgical evacuation
• Hydrocephalus - EVD (External Ventricular Drain)
• ICH with structural cause (AVM, aneurysm) - definitive treatment of cause

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6C. SAH Management

• Secure aneurysm: surgical clipping or endovascular coiling (coiling preferred where feasible - ISAT trial)
• Nimodipine 60mg q4h for 21 days - reduces vasospasm and improves outcomes
• Induced hypertension + euvolemia (triple-H therapy now modified)
• Treat hydrocephalus with EVD/VP shunt

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7. PHYSIOTHERAPY ASSESSMENT & REHABILITATION (MPT Focus)

Physiotherapy Assessment Tools

Brunnstrom Stages of Recovery

1. Stage I - Flaccidity, no voluntary movement
2. Stage II - Spasticity appears, minimal voluntary movement, synergy patterns begin
3. Stage III - Spasticity peaks, full voluntary control of synergy patterns
4. Stage IV - Spasticity decreasing, movement outside synergy patterns possible
5. Stage V - Spasticity minimal, complex movement combinations
6. Stage VI - Near normal motor function

Physiotherapy Management

Acute Phase (Days 1-7)

• Early mobilization within 24-48h if medically stable (avoid very early intensive mobilization - A-VERY EARLY trial)
• Positioning: prevent aspiration, contracture, pressure ulcers; trunk symmetry
• Passive ROM, splinting (prevent contracture of spastic limbs)
• Chest physiotherapy if respiratory compromise
• Dysphagia management: oral hygiene, positioning, texture modification

Subacute Phase (Days 7 - Weeks)

• Task-specific training (NDT/Bobath concept)
• Constraint-Induced Movement Therapy (CIMT) - restraint of unaffected limb, forced use of affected arm (2+ weeks, 6 hrs/day); highest evidence for upper limb
• Bilateral arm training
• Gait training: treadmill, partial body weight support treadmill training (PBWSTT)
• Mirror Therapy - visual feedback, reduces pain, improves upper limb motor function
• Strengthening: progressive resistance training (PRT)
• Balance and coordination training

Chronic Phase (3 months+)

• Community reintegration, vocational rehabilitation
• Home exercise program
• Secondary prevention education

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8. RECENT ADVANCES (2023-2026)

Medical Advances

1. Tenecteplase (TNK): Single IV bolus thrombolytic; non-inferior to alteplase; increasingly adopted (simpler to administer, favorable pharmacokinetics)
2. Extended thrombectomy window (up to 24h): Based on DAWN (6-24h, clinical-imaging mismatch) and DEFUSE-3 (6-16h, perfusion mismatch) trials - paradigm shift
3. Blood pressure targets in ICH: 2025 ESO updated guidelines on BP management in acute ischemic stroke and ICH (PMID: 42095756)
4. Remote Ischemic Conditioning (RIC): Limb ischemia/reperfusion cycles before/during/after stroke to reduce infarct size; systematic review 2024 (PMID: 38457772) shows benefit when combined with reperfusion therapy
5. Neuroprotective agents: Continuing trials (citicoline, albumin, NXY-059 - limited success so far)
6. Andexanet alfa + Idarucizumab: Reversal agents for NOAC-related hemorrhagic stroke
7. AI-assisted imaging: Automated ASPECTS scoring, LVO detection on CTA, perfusion analysis

Rehabilitation Advances

1. Robot-Assisted Therapy (RAT): Devices (Lokomat, Armeo, Myomo) provide high-intensity, repetitive, task-specific training; Cochrane 2025 (PMID: 39932103) confirms improvement in upper limb function and gait vs. conventional therapy; combined RAT + VR shows synergistic benefits (2024)
2. Virtual Reality (VR): Cochrane SR 2025 (PMID: 40537150) - VR improves upper limb function, gait and balance in chronic stroke; high engagement, neural reorganization via immersive feedback; Fugl-Meyer Assessment shows clinically meaningful gains
3. Non-Invasive Brain Stimulation (NIBS):
   • rTMS (repetitive Transcranial Magnetic Stimulation): high-frequency over ipsilesional M1 or inhibitory stimulation of contralesional M1; improves hand function
   • tDCS (Transcranial Direct Current Stimulation): anodal (excitatory) over ipsilesional motor cortex; meta-analysis 2023 shows benefit for dysphagia (PMID: 38082316)
4. Brain-Computer Interface (BCI): EEG-controlled robotic hand; patient generates motor intention → device moves limb → reinforces neuroplasticity
5. Functional Electrical Stimulation (FES): Stimulates peripheral nerves to produce functional movement; Bioness H200 (hand), L300 (foot drop)
6. Telerehabilitation: Remote PT delivery post-COVID expansion; equivalent outcomes to in-person therapy in chronic stroke
7. High-dose high-repetition training: Mounting evidence that dose (number of repetitions) is the key driver of recovery; 300-400 reps/session target
8. Stem cell therapy: Early-phase trials (MASTERS-2, SB623) showing safety; not yet standard care

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9. COMPLICATIONS OF STROKE (PG Level)

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10. PROGNOSTIC FACTORS

• Older age
• High NIHSS score (>20 = severe)
• Large infarct volume
• Fever, hypotension, hypoxia, hypoglycemia/hyperglycemia (correct urgently)
• Comorbid ischemic heart disease or diabetes
• Hemorrhagic transformation of infarction
• Modified Rankin Scale (mRS): 0 = no symptoms → 6 = death

• 0 = No symptoms
• 1 = No significant disability (able to carry out all usual duties)
• 2 = Slight disability (unable to carry out all previous activities, independent in ADLs)
• 3 = Moderate disability (requires some help, able to walk unassisted)
• 4 = Moderately severe (unable to walk without assistance, requires help with ADLs)
• 5 = Severe disability (bedridden, incontinent, requires constant nursing)
• 6 = Death

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11. QUICK EXAM SUMMARY TABLE

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• Bradley and Daroff's Neurology in Clinical Practice (9780323642613)
• Tintinalli's Emergency Medicine, Comprehensive Study (9781260019933)
• ROSEN's Emergency Medicine (9780323757898)
• Frameworks for Internal Medicine (9781496359308)
• Cochrane SR: Physical rehabilitation after stroke (PMID: 39932103, 2025)
• Cochrane SR: Virtual reality stroke rehabilitation (PMID: 40537150, 2025)
• ESO Guidelines: BP management in acute stroke (PMID: 42095756, 2026)
• Remote Ischemic Conditioning SR (PMID: 38457772, 2024)

Recent evidence note: The 2025 Cochrane review (PMID: 39932103) provides updated evidence that physical rehabilitation approaches significantly improve gait and upper limb function. The 2025 Cochrane VR review (PMID: 40537150) confirms VR as an effective adjunct. The 2026 ESO guideline update on blood pressure management revises targets for both ischemic stroke and ICH.