124 Strokes and TIAs

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Hemorrhagic Stroke

• Results from the rupture of a blood vessel in the brain, leading to bleeding into surrounding brain tissue
• Accounts for only 15% of all strokes but has a higher mortality rate than ischemic strokes

Clinical Presentation

• Sudden onset of symptoms
• Symptoms may include:
  • Headache: “Worst headache of life” (thunderclap headache associate with subarachnoid hemorrhage)
  • Nausea and vomiting: due to increased intracranial pressure (ICP)
  • Neurologic deficits: Contralateral hemiparesis, sensory deficits, facial weakness
  • Altered mental status: Ranges from confusion to coma
  • Seizures may occur 
  • Nystagmus
  • Visual field defects
  • Aphasia
  • Loss of consciousness in severe cases

Labs, Studies, and Physical Exam Findings

• Physical Exam:
  • Blood pressure
  • Assess Glasgow Coma Scale (GCS) for neurologic function. The scores range from 3 to 15:

• Mild impairment: 13–15
• Moderate impairment: 9–12
• Severe impairment/coma: ≤8
• Eye Opening (E): Spontaneous (4) to none (1).

• Verbal Response (V): Oriented (5) to no response (1).
• Motor Response (M): Obeys commands (6) to no response (1)
• Bloodwork:
  • PT/PTT and INR 
  • CBC
  • CMP
  • Imaging:

• Non-contrast CT: First-line test to identify intracranial bleeding
• MRI: Used for chronic hemorrhages or to evaluate further if needed
• Angiography: Necessary if arteriovenous malformation (AVM) or aneurysm is suspected
  • AVM is is an abnormal connection between arteries and veins, bypassing the capillary system 
  • An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall 
• Lumbar Puncture:
  • Indicated if subarachnoid hemorrhage (SAH) is strongly suspected but CT is negative
  • Findings:
    • Xanthochromia: Yellow discoloration of cerebrospinal fluid (CSF) due to bilirubin, confirming SAH
    • Elevated Opening Pressure: Indicates increased intracranial pressure (ICP)

Treatment

• Medical Management:
  • Lower Intracranial Pressure (ICP): Mannitol or hypertonic saline
  • Blood pressure control: Target systolic BP <140 mmHg
  • Reverse anticoagulation 
• Surgical Management:
  • Craniotomy: For large bleeds or herniation risk
  • Clipping/coiling: For ruptured aneurysms

Ischemic Stroke

• Occurs due to obstruction of blood flow
• Accounts for 85% of strokes

Risk Factors

• Age >55 years
• Male sex
• Hypertension
• Diabetes mellitus
• Smoking
• Hypercholesterolemia
• Atrial fibrillation
• Carotid artery stenosis
• Family history of stroke or TIA

Clinical Presentation

• Sudden onset of neurologic deficits, dependent on the affected area of the brain
  • Motor deficits: Contralateral hemiplegia or hemiparesis
  • Sensory deficits: Contralateral numbness or loss of sensation
  • Speech disturbances:
    • Aphasia: If dominant hemisphere is involved
    • Dysarthria: Motor speech impairment
  • Vision changes: Loss of vision, diplopia, or visual field defects
  • Cognitive/mental status changes: Confusion, disorientation
  • Coordination/balance issues: Ataxia, vertigo
• Symptoms tend to be unilateral

Labs, Studies, and Physical Exam Findings

• Physical Exam Findings
  • BP
  • Carotid bruit: Suggests carotid stenosis
• Imaging:
  • Non-contrast CT: First-line to exclude hemorrhage
  • MRI: Gold standard for identifying ischemia
  • Carotid ultrasound: Checks for stenosis or plaque
  • Echocardiogram: To detect embolic sources
  • ECG/Holter monitor: For atrial fibrillation or arrhythmias
  • Bloodwork: Lipid panel, PT/PTT

Treatment

• Acute Management:
  • tPA (Alteplase): Administer within 4.5 hours of symptom onset if no contraindications. Emergency Room door to tPA treatment should be under 60 minutes.
    • Absolute Contraindications
      • Intracranial hemorrhage confirmed or suspected on imaging
      • Active bleeding or bleeding disorders
      • Recent major surgery or trauma (within 14 days)
      • Severe uncontrolled hypertension (BP >185/110 mmHg)
      • Intracranial neoplasm, arteriovenous malformation, or aneurysm
      • Recent stroke or head trauma (within 3 months)
      • Platelet count <100,000 or abnormal coagulation:
      • INR >1.7 or PT >15 seconds
    • Relative Contraindications
      • Pregnancy or recent delivery (within 7 days)
      • Minor or rapidly improving stroke symptoms
      • Seizure at stroke onset
      • Recent gastrointestinal or genitourinary bleeding 
      • Recent lumbar puncture or arterial puncture in a non-compressible site

• Endovascular therapy: Mechanical thrombectomy for large vessel occlusion

• Post-Stroke Management:
  • Antiplatelet therapy for non-cardiogenic small vessel clots which are platelet rich:
  • Anticoagulant therapy for cardiogenic fibrin rich clots:
    • Heparin, followed by long-term warfarin or direct oral anticoagulants
  • Blood pressure control
  • Statins: To lower cholesterol and reduce vascular risk

Comparison of Hemorrhagic vs. Ischemic Stroke

Feature	Hemorrhagic Stroke	Ischemic Stroke
Cause	Vessel rupture, bleeding	Vessel occlusion, ischemia
Frequency	15%	85%
Symptoms	Headache, nausea, vomiting, AMS	Focal neurologic deficits
Imaging	CT to detect bleeding	CT to rule out bleeding
Treatment	BP control, surgery	tPA, thrombectomy, aspirin
Prognosis	Higher mortality	Better outcomes with timely tx

Transient Ischemic Attack (TIA)

• A temporary disruption of blood flow to the brain, causing stroke-like symptoms without permanent tissue damage
• Symptoms resolve within 24 hours, typically within minutes to hours
• 10-15% risk of stroke within 3 months

Clinical Presentation

• Sudden onset of neurologic deficits that vary depending on the area of the brain affected
  • Motor deficits: Contralateral hemiparesis or weakness
  • Sensory deficits: Contralateral numbness or tingling
  • Visual symptoms: Temporary vision loss or diplopia
  • Speech disturbances: Aphasia or dysarthria
  • Coordination issues: Dizziness, poor balance, or ataxia
  • Cognitive/mental status changes: Transient confusion or disorientation
• Symptoms completely resolve within 24 hours, usually without intervention

Risk Factors

• Age >55 years
• Male sex
• Hypertension
• Diabetes mellitus
• Smoking
• Hypercholesterolemia
• Atrial fibrillation
• Carotid artery stenosis
• Family history of stroke or TIA

Labs, Studies, and Physical Exam Findings

• Physical Exam:
  • Neurologic exam: Assess motor, sensory, speech, and cognitive function
  • Carotid bruit: Suggests carotid stenosis

• Imaging:
  • Non-contrast CT or MRI: Rule out ischemic or hemorrhagic stroke
  • Carotid ultrasound: carotid stenosis
  • CT or MR angiography: Evaluate cerebral vasculature
• Cardiac Testing:
  • Echocardiogram: To detect cardiac sources of emboli
  • ECG/Holter monitor: For arrhythmias such as atrial fibrillation
• Bloodwork:
  • Lipid panel: Assess cholesterol levels
  • PT/PTT and INR: Evaluate clotting function
  • CBC: Identify anemia or other blood disorders

Treatment

• Acute Management:
  • Antiplatelet therapy for non-cardiogenic small vessel clots which are platelet rich:
    • Aspirin, Clopidogrel (Plavix), or Ticlopidine
  • Anticoagulant therapy for cardiogenic fibrin rich clots:
    • Heparin, followed by long-term warfarin or direct oral anticoagulants
  • Blood pressure control
  • Statins: To lower cholesterol and reduce vascular risk
• Surgical Management:
  • Carotid endarterectomy: For carotid stenosis >70%
• Lifestyle Modifications:
  • Smoking cessation
  • Weight loss
  • Regular exercise
  • Healthy diet

Stroke Mimics

• Hypoglycemia
• Seizures 
• Migraines
• Conversion disorder 
• Intracranial tumors or abscesses
• Infections (e.g., encephalitis, meningitis)
• Multiple sclerosis (acute demyelinating events)