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Here are your comprehensive Stroke Notes β 20-Mark Question format, compiled from Harrison's Principles of Internal Medicine 22E and Goldman-Cecil Medicine.
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Stroke Medicine Notes
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STROKE β Comprehensive Medicine Notes
1. DEFINITION
A stroke (CVA) is the sudden onset of a focal neurological deficit due to either:
- Ischaemia (87%) β occlusion of a cerebral artery
- Haemorrhage (13%) β rupture of a cerebral vessel
A TIA = same symptoms but resolving within 24 h with no infarction on imaging.
2. EPIDEMIOLOGY
- Second leading cause of death worldwide; leading cause of adult disability
- Ischaemic stroke ~87%; ICH ~10%; SAH ~3%
- Incidence doubles per decade after age 55
- Risk of stroke after TIA: 10β15% in 3 months; highest in first 48 h
3. RISK FACTORS
Modifiable: Hypertension (most important), atrial fibrillation, diabetes, dyslipidaemia, smoking, obesity, OCP, excess alcohol
Non-modifiable: Age, male sex, family history, prior stroke/TIA, ethnicity
4. CLASSIFICATION
| Type | Subtype | Frequency | Mechanism |
|---|---|---|---|
| Ischaemic | Large-vessel atherothrombosis | ~20% | In-situ thrombosis / artery-to-artery embolism |
| Ischaemic | Cardioembolic | ~25% | AF, MI, valvular disease |
| Ischaemic | Small-vessel (lacunar) | ~20% | Lipohyalinosis of perforators; HTN |
| Ischaemic | Cryptogenic | ~30% | No cause found |
| Haemorrhagic | ICH | ~10% | HTN, amyloid angiopathy |
| Haemorrhagic | SAH | ~3% | Ruptured aneurysm |
5. PATHOPHYSIOLOGY
Ischaemic Cascade
- CBF = 0 β brain death in 4β10 minutes
- CBF <16β18 mL/100g/min β infarct core (irreversible)
- CBF 18β20 mL/100g/min β ischaemic penumbra (salvageable with reperfusion)
Cascade: ATP depletion β NaβΊ/KβΊ-ATPase failure β depolarisation β glutamate excitotoxicity β NMDA activation β CaΒ²βΊ influx β free radicals + NOS activation β apoptosis + BBB breakdown β cerebral oedema
Haemorrhagic Stroke
Rupture of small penetrating arteries (lipohyalinosis from chronic HTN) β haematoma β mass effect β raised ICP β herniation.
6. STROKE SYNDROMES
MCA (Most Common)
Complete occlusion:
- Contralateral hemiplegia + hemianesthesia (face + arm > leg)
- Homonymous hemianopia
- Gaze deviation ipsilateral (toward lesion)
- Dominant: global aphasia | Non-dominant: neglect, anosognosia
Superior MCA: Broca's aphasia + right arm weakness
Inferior MCA: Wernicke's aphasia + superior quadrantanopia
ACA
- Contralateral weakness: leg > arm
- Abulia, personality change, urinary incontinence
PCA
- Contralateral homonymous hemianopia with macular sparing
- Thalamic pain syndrome
- Left PCA + splenium: alexia without agraphia
Basilar Artery
- Locked-in syndrome (bilateral pontine): quadriplegia, preserved vertical gaze only
- Top-of-basilar: somnolence, visual hallucinations, oculomotor disturbance
Lateral Medullary (Wallenberg) β PICA
- Ipsilateral: Facial pain/numbness (V), Horner's, ataxia, dysphagia (IX/X), nystagmus
- Contralateral: Loss of pain/temperature (spinothalamic)
Lacunar Syndromes
| Syndrome | Deficit | Location |
|---|---|---|
| Pure Motor Hemiparesis | Face + arm + leg, no sensory | Post. limb IC / pons |
| Pure Sensory Stroke | Hemisensory loss | Ventral thalamus (VPL) |
| Ataxic Hemiparesis | Ipsilateral ataxia + mild contralateral hemiparesis | Pons / IC |
| Dysarthria-Clumsy Hand | Dysarthria + hand clumsiness | Pons / genu IC |
7. CLINICAL PRESENTATION
Sudden onset of focal deficit β the hallmark. Key symptoms:
- Sudden unilateral weakness/numbness
- Speech disturbance (aphasia/dysarthria)
- Visual loss or field defect
- Severe sudden headache β suggests SAH/ICH
- Dizziness, ataxia, diplopia
FAST: Face drooping Β· Arm weakness Β· Speech difficulty Β· Time
Features favouring haemorrhage: Depressed consciousness, high BP, headache/vomiting, worsening after onset
8. INVESTIGATIONS
Immediate:
- Non-contrast CT brain (FIRST; excludes haemorrhage β mandatory before tPA)
- Serum glucose (exclude hypoglycaemia)
- ECG (AF), FBC, coagulation, electrolytes, renal function
Imaging:
- MRI DWI β most sensitive (bright within minutes; dark on ADC)
- CT/MR angiography β identifies LVO (essential if thrombectomy considered)
- CT/MR perfusion β delineates penumbra vs. core; guides treatment >4.5 h
- Echo (TTE/TOE) β cardiac source; 24β72h Holter for paroxysmal AF
- Carotid duplex USS
If young/cryptogenic: Thrombophilia screen (protein C/S, antithrombin III, APS antibodies, Factor V Leiden)
Lumbar puncture: Only if SAH suspected with normal CT (look for xanthochromia)
9. ABCDΒ² SCORE (TIA Risk Stratification)
| Parameter | Score |
|---|---|
| Age β₯60 years | 1 |
| BP β₯140/90 mmHg | 1 |
| Clinical: unilateral weakness | 2 |
| Clinical: speech disturbance (no weakness) | 1 |
| Duration β₯60 min | 2 |
| Duration 10β59 min | 1 |
| Diabetes mellitus | 1 |
| Total | 0β7 |
- 0β3: Low risk | 4β5: Moderate risk | 6β7: High risk (~8% 2-day risk)
- Score β₯4 β urgent hospital assessment
10. MANAGEMENT
A. General Acute Measures
- ABCs; treat hypoglycaemia immediately; target glucose 7.8β10 mmol/L
- Do NOT lower BP acutely unless >220/120 mmHg (or >185/110 if tPA planned)
- Aspiration precautions; SALT swallow assessment
- DVT prophylaxis: LMWH + pneumatic compression
- Admit to dedicated Stroke Unit (β mortality + dependency by 25β30%)
B. IV Thrombolysis β Alteplase (tPA)
- Dose: 0.9 mg/kg IV (max 90 mg); 10% bolus, rest over 60 min
- Window: Within 4.5 hours of onset
- "Time is brain": ~1.9 million neurons lost per minute
Absolute contraindications: ICH on CT, BP >185/110 (untreatable), recent stroke/surgery <3 months, active bleeding, INR >1.7, platelets <100,000, glucose <50 mg/dL, CT showing >β
MCA territory hypodensity
Tenecteplase (0.25 mg/kg bolus, max 25 mg) is increasingly used as simpler alternative.
C. Endovascular Thrombectomy (EVT)
- For Large Vessel Occlusion (LVO) β ICA, M1/M2 MCA, basilar artery
- Window: up to 24 h with penumbral imaging (DAWN, DEFUSE-3)
- 2015 landmark trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME): NNT β 2.6 to prevent dependency
- Can combine with tPA ("bridging therapy")
D. Antithrombotic Treatment
- Aspirin 300 mg within 24β48 h (after excluding haemorrhage and tPA window passed)
- DAPT (aspirin + clopidogrel) Γ 21 days for minor stroke/high-risk TIA (POINT, CHANCE)
- Anticoagulation (NOT acute): Start 2β14 days post-stroke for AF/cardioembolic; DOACs preferred
E. Haemorrhagic Stroke (ICH)
- Reverse anticoagulation: Vit K + PCC (warfarin); andexanet alfa (anti-Xa); idarucizumab (dabigatran)
- BP target: SBP <140 mmHg (INTERACT-2, ATACH-2)
- Surgical evacuation: cerebellar haematoma >3 cm, selected lobar ICH
11. SECONDARY PREVENTION
| Intervention | Drug / Target |
|---|---|
| Antiplatelet | Aspirin 75 mg/day OR clopidogrel 75 mg/day |
| AF anticoagulation | DOAC (apixaban/rivaroxaban/dabigatran); INR 2β3 if warfarin |
| Statin | Atorvastatin 80 mg; target LDL <70 mg/dL (SPARCL) |
| BP | <130/80 mmHg; ACE inhibitor + thiazide (PROGRESS) |
| Carotid CEA | Symptomatic 70β99% stenosis within 2 weeks (NASCET) |
| PFO closure | Young cryptogenic stroke (CLOSE, REDUCE, RESPECT) |
Lifestyle: Quit smoking, limit alcohol, exercise β₯150 min/week, Mediterranean diet, weight loss, HbA1c <7%
12. KEY TRIALS
| Trial | Topic | Finding |
|---|---|---|
| NINDS 1995 | tPA β€3 h | Improved outcomes; βICH 6.4% vs 0.6% |
| ECASS-3 2008 | tPA 3β4.5 h | Extended window; benefit maintained |
| MR CLEAN 2015 | Thrombectomy | Superior to medical Rx for LVO |
| DAWN/DEFUSE-3 | EVT 6β24 h | Penumbral imaging guides late window |
| CHANCE/POINT | DAPT Γ 21 d | Reduces recurrence post-TIA/minor stroke |
| SPARCL 2006 | Atorvastatin 80 mg | β recurrent stroke 16% |
| NASCET 1991 | CEA 70β99% | 5-yr risk 9% vs 26% without CEA |
| PROGRESS 2001 | Perindopril Β± indapamide | 28% RRR recurrent stroke |
| INTERACT-2 | BP in ICH | SBP <140 β better functional outcome |
13. STROKE MIMICS (Differentials)
Hypoglycaemia (most common), Todd's paralysis, hemiplegic migraine, brain tumour, PRES, subdural haematoma, functional neurological disorder, MS relapse
14. COMPLICATIONS
Early: Cerebral oedema/herniation, haemorrhagic transformation, seizures, aspiration pneumonia, DVT/PE
Late: Post-stroke depression (30%), vascular dementia, spasticity, central post-stroke pain (thalamic), pressure ulcers
15. PROGNOSIS
- ~25% die within 1 year of first stroke
- ~50% survivors have permanent disability
- ICH 30-day mortality ~40β50%
- Best outcomes: stroke unit admission + rapid reperfusion
- Assessed by modified Rankin Scale (mRS): 0 = no symptoms β 6 = death
Sources: Harrison's Principles of Internal Medicine 22E (2025, McGraw Hill) | Goldman-Cecil Medicine International Edition
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