History

Fact Explanation
weakness of legs and arm pattern of weakness depend on the place of the ischemia. When anterior cerebral artery is involved contralateral side weakness of the leg and arm occur, but leg weakness is more than arm. When middle cerebral artery is involved weakness of the leg and arm occur, but arm weakness is more than leg. [1],[2],[3],[4]
speech Dysarthria occurs when infarct occurs in posterior inferior carebral artery. when middle cerebral artery is involved dysphasia(dominant hemisphere) or apraxia( non -dominant hemisphere) can occur.[1],[2],[3],[4]
behavior abnormalities when anterior circulation is involved higher function get altered.[1],[2],[3],[4]
memory impairment when anterior circulation is involved higher function get altered.[1],[2],[3],[4]
Dysphagia occurs when infarct occurs in posterior inferior carebral artery.[1],[2],[3],[4]
seizures In 2-23% of patients, seizures occur after ischemic stroke within the first days.[1],[2],[3],[4]
onset of symptoms vascular pathologies have an acute onset of symptoms. [1],[2],[3],[4]
history of cardiovascular diseases hypertension, dyslipidaemia, diabetes and myocardial infartion increase the risk of infarction.[1],[2],[3],[4]
alcohol intake heavy alcohol consumption of >5 units/day increase the risk by 1.6. [1],[2],[3],[4]
Smoking habbits smoking increase the risk by 1.6. Smoking reduces the amount of oxygen in the blood, causing the heart to work harder and allowing blood clots to form more easily. [1],[2],[3],[4]
Family history there are rare genetic causes for infarction [1],[2],[3],[4]
History of bleeding disorders patient with bleeding disorders can get cerebral hemorrhage, which can cause acute stroke. [1],[2],[3],[4]
History of recent trauma patient with a history of recent trauma can have undiagnosed cerebral hemorrhage , which can cause acute stroke. [1],[2],[3],[4]
References
  1. FELDMANN E., GORDON N., BROOKS J. M., BRASS L. M., FAYAD P. B., SAWAYA K. L., NAZARENO F., LEVINE S. R.. Factors associated with early presentation of acute stroke. Stroke [online] 1993 December, 24(12):1805-1810 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.24.12.1805
  2. MORRIS D. L., ROSAMOND W., MADDEN K., SCHULTZ C., HAMILTON S.. Prehospital and Emergency Department Delays After Acute Stroke : The Genentech Stroke Presentation Survey. Stroke [online] 2000 November, 31(11):2585-2590 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.31.11.2585
  3. LACY C. R., SUH D.-C., BUENO M., KOSTIS J. B.. Delay in Presentation and Evaluation for Acute Stroke : Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke [online] 2001 January, 32(1):63-69 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.32.1.63
  4. HARRAF F, SHARMA AK, BROWN MM, LEES KR, VASS RI, KALRA L. A multicentre observational study of presentation and early assessment of acute stroke BMJ [online] 2002 Jul 6, 325(7354):17 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC116666

Examination

Fact Explanation
ABC As this is an emergency patients' airway, breathing and circulation has to assessed first. If there is a impairment in any of them immediate resuscitation has to be carried out. [5]
Level of consciousness according to the National Institutes of Health Stroke Scale (NIHSS) level of consciousness is assessed using alertness, ability to answer questions regarding the month and his/her age and the ability in eye opening, gripping and releasing the non-paretic hand. [5]
Cranial Nerves This helps to localize the ischemia. Seen in Vertebrobasilar artery occlusions. [5]
Cerebellar Signs and Gait This helps to localize the ischemia. Seen in Vertebrobasilar artery occlusions. Gait apraxia can be seen in anterior cerebral artery occlusions [5]
Neurological examination of limbs - motor & reflexes when assessing the motor function of the upper and lower limbs weakness is shown according to the place of occlusion. This helps in localizing the occlusion. [1],[2],[3],[4]
Neurological examination of limbs - sensory when assessing the sensory function of the upper and lower limbs sensory loss is shown according to the place of occlusion. This helps in localizing the occlusion. When infarct occur in lacunar circulation pure sensory stroke can occur without any motor weakness [1],[2],[3],[4]
eye examination visual disturbance also differ with the site of the occlusion. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery.[1],[2],[3],[4]
References
  1. FELDMANN E., GORDON N., BROOKS J. M., BRASS L. M., FAYAD P. B., SAWAYA K. L., NAZARENO F., LEVINE S. R.. Factors associated with early presentation of acute stroke. Stroke [online] 1993 December, 24(12):1805-1810 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.24.12.1805
  2. MORRIS D. L., ROSAMOND W., MADDEN K., SCHULTZ C., HAMILTON S.. Prehospital and Emergency Department Delays After Acute Stroke : The Genentech Stroke Presentation Survey. Stroke [online] 2000 November, 31(11):2585-2590 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.31.11.2585
  3. LACY C. R., SUH D.-C., BUENO M., KOSTIS J. B.. Delay in Presentation and Evaluation for Acute Stroke : Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke [online] 2001 January, 32(1):63-69 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.32.1.63
  4. HARRAF F, SHARMA AK, BROWN MM, LEES KR, VASS RI, KALRA L. A multicentre observational study of presentation and early assessment of acute stroke BMJ [online] 2002 Jul 6, 325(7354):17 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC116666
  5. JAUCH E. C., SAVER J. L., ADAMS H. P., BRUNO A., CONNORS J. J., DEMAERSCHALK B. M., KHATRI P., MCMULLAN P. W., QURESHI A. I., ROSENFIELD K., SCOTT P. A., SUMMERS D. R., WANG D. Z., WINTERMARK M., YONAS H.. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke [online] December, 44(3):870-947 [viewed 16 September 2014] Available from: doi:10.1161/STR.0b013e318284056a

Differential Diagnoses

Fact Explanation
CNS infection can present with weakness and other symptoms of infarct. these patients have fever and onset of symptom is sub acute. [1]
Cerebral Neoplasms patients have early morning headache and it relieved by vomitting. onset of symptom is sub acute or sub acute. [2]
Hemiplegic migraine patient have a history of headache/ migraine. [3]
Hemorrhagic stroke presentation and risk factors are similar to infarct. CT is a important finding in differentiating. [4]
Transient Global Amnesia It presents classically with an abrupt onset of severe anterograde amnesia. It is usually accompanied by repetitive questioning. The patient does not have any focal neurological symptoms. Patients remain alert, attentive, and cognition is not impaired. [5]
Seizure As seizure can be a presenting symptom in stroke it is important to know whether the patient have a seizure disorder. If patient have a previous history of seizures, diagnosis of seizures is more likely [6]
Hypoglycemia Hyperglycemia with hyperosmolar state may be associated with focal neurologic deficits simulating stroke but focal seizures are reported in this condition as well. Focal neurologic signs with hyperglycemia may include aphasia, homonymous hemianopia, hemisensory deficits, hemiparesis, unilateral hyperreflexia, and the presence of a Babinski sign. [7]
References
  1. DREVETS DA, LEENEN PJ, GREENFIELD RA. Invasion of the Central Nervous System by Intracellular Bacteria Clin Microbiol Rev [online] 2004 Apr, 17(2):323-347 [viewed 12 September 2014] Available from: doi:10.1128/CMR.17.2.323-347.2004
  2. SCHUBART JR, KINZIE MB, FARACE E. Caring for the brain tumor patient: Family caregiver burden and unmet needs Neuro Oncol [online] 2008 Jan, 10(1):61-72 [viewed 12 September 2014] Available from: doi:10.1215/15228517-2007-040
  3. ROSS RT. Hemiplegic Migraine Can Med Assoc J [online] 1958 Jan 1, 78(1):10-16 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829626
  4. NAIDECH AM. Intracranial Hemorrhage Am J Respir Crit Care Med [online] 2011 Nov 1, 184(9):998-1006 [viewed 12 September 2014] Available from: doi:10.1164/rccm.201103-0475CI
  5. OWEN D, PARANANDI B, SIVAKUMAR R, SEEVARATNAM M. Classical diseases revisited: transient global amnesia Postgrad Med J [online] 2007 Apr, 83(978):236-239 [viewed 15 September 2014] Available from: doi:10.1136/pgmj.2006.052472
  6. SCHARFMAN HE. The Neurobiology of Epilepsy Curr Neurol Neurosci Rep [online] 2007 Jul, 7(4):348-354 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492886
  7. HATZITOLIOS A, SAVOPOULOS C, NTAIOS G, PAPADIDASKALOU F, DIMITRAKOUDI E, KOSMIDOU M, BALTATZI M, KARAMITSOS D. Stroke and conditions that mimic it: a protocol secures a safe early recognition Hippokratia [online] 2008, 12(2):98-102 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464301

Investigations - for Diagnosis

Fact Explanation
Non contrast CT Done to exclude hemorrhagic stroke. Widely used because it is better tolerated and easier to perform than MRI. [1],[2],[3]
MRI With its newest sequence DWI (diffusion - weighted imaging) has a great sensitivity than CT to differentiate hemorrhage from a infarct. Not widely used because it is slow and difficult to scan unstable, critically ill patient. [1],[2],[3]
ECG Done to evaluate conduction defect in heart as arrhythmia can cause emboli that can lead to cerebral infarction. [1],[2],[3]
Doppler studies of MCA Transcranial Doppler (TCD) can demonstrate arterial occlusion and subsequent recanalization in acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA). [4]
CT Angiography This is a method for rapidly and reliably confirming intracranial vessel occlusion before thrombolytic treatment is desirable. [4],[5]
References
  1. BAMFORD J. ASSESSMENT AND INVESTIGATION OF STROKE AND TRANSIENT ISCHAEMIC ATTACK J Neurol Neurosurg Psychiatry [online] 2001 Apr, 70(Suppl 1):i3-i6 [viewed 12 September 2014] Available from: doi:10.1136/jnnp.70.suppl_1.i3
  2. DUNBABIN DW, SANDERCOCK PA. Investigation of acute stroke: what is the most effective strategy? Postgrad Med J [online] 1991 Mar, 67(785):259-270 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399026
  3. TWOMEY C. Investigating stroke. Br Med J [online] 1978 Aug 26, 2(6137):637-638 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1607555
  4. BURGIN W. S., MALKOFF M., FELBERG R. A., DEMCHUK A. M., CHRISTOU I., GROTTA J. C., ALEXANDROV A. V.. Transcranial Doppler Ultrasound Criteria for Recanalization After Thrombolysis for Middle Cerebral Artery Stroke. Stroke [online] 2000 May, 31(5):1128-1132 [viewed 15 September 2014] Available from: doi:10.1161/01.STR.31.5.1128
  5. VERRO P., TANENBAUM L. N., BORDEN N. M., SEN S., ESHKAR N.. CT Angiography in Acute Ischemic Stroke: Preliminary Results. Stroke [online] 2002 January, 33(1):276-278 [viewed 15 September 2014] Available from: doi:10.1161/hs0102.101223

Investigations - Fitness for Management

Fact Explanation
ECG Done to evaluate the cardiac function of the patient. infaction, conduction defects are identified. [1],[2],[3]
lipid profile Done to evaluate the dyslipidemia. As dyslipidemia is a risk factor for infarction it is important to identify undiagnosed dyslipidemia. [1],[2],[3]
fasting glucose done to identify undiagnosed diabetes or evaluate the current diabetes status.[1],[2],[3]
FBC This is done to identify any infections or anemia. this is important in planning management.[1],[2],[3]
Renal function test Done to evaluate the renal function. Important in planing the management. [1],[2],[3]
Toxicology Screen Urine toxicology studies done to identify cocaine[1],[2],[3]
Coagulation Profile These are done to identify coagulopathy. They are useful prior to the use of fibrinolytics or anticoagulants. However rt-PA administration on who are not on anticoagulants or anti thrombotics where there isn't any suspicion of coagulation abnormality, shouldn't be delayed by this[1],[2],[3]
Cardiac biomarkers Done to evaluate the cardiac function of the patient and to possibility of myocardial infarction. [1],[2],[3]
References
  1. BAMFORD J. ASSESSMENT AND INVESTIGATION OF STROKE AND TRANSIENT ISCHAEMIC ATTACK J Neurol Neurosurg Psychiatry [online] 2001 Apr, 70(Suppl 1):i3-i6 [viewed 12 September 2014] Available from: doi:10.1136/jnnp.70.suppl_1.i3
  2. DUNBABIN DW, SANDERCOCK PA. Investigation of acute stroke: what is the most effective strategy? Postgrad Med J [online] 1991 Mar, 67(785):259-270 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399026
  3. TWOMEY C. Investigating stroke. Br Med J [online] 1978 Aug 26, 2(6137):637-638 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1607555

Investigations - Followup

Fact Explanation
Lipid profile Done to evaluate the dyslipidemia. This is important to modify the management accordingly.[1],[2],[3]
Glucose level Done to evaluate the diabetic control of the patient.[1],[2],[3]
ECG done to evaluate the cardiac function.[1],[2],[3]
Coagulation profile When anticoagulants are prescribed routine coagulation profile is necessary to identify coagulation problems and adjust the dose. [1],[2],[3]
References
  1. BAMFORD J. ASSESSMENT AND INVESTIGATION OF STROKE AND TRANSIENT ISCHAEMIC ATTACK J Neurol Neurosurg Psychiatry [online] 2001 Apr, 70(Suppl 1):i3-i6 [viewed 12 September 2014] Available from: doi:10.1136/jnnp.70.suppl_1.i3
  2. DUNBABIN DW, SANDERCOCK PA. Investigation of acute stroke: what is the most effective strategy? Postgrad Med J [online] 1991 Mar, 67(785):259-270 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399026
  3. TWOMEY C. Investigating stroke. Br Med J [online] 1978 Aug 26, 2(6137):637-638 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1607555

Investigations - Screening/Staging

Fact Explanation
NIH Stroke Score This is a systematic clinical assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Consist of a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items.A score >10 suggests 80% likelihood of occlusions of the proximal vessels. [1]
References
  1. GOLDSTEIN L. B., SAMSA G. P.. Reliability of the National Institutes of Health Stroke Scale: Extension to Non-Neurologists in the Context of a Clinical Trial. Stroke [online] 1997 February, 28(2):307-310 [viewed 16 September 2014] Available from: doi:10.1161/01.STR.28.2.307

Management - General Measures

Fact Explanation
stop smoking Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but effective treatments and helpful resources exist. [1]
physical activities Activity limitations are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training. [2]
diet Healthy diet should be taken with low fats, sugar and salt; and rich in fruits and vegetables. if patient is having difficulty in chewing or swallowing diet has to be changed accordingly. [3]
Rehabilitation The rehabilitation process involves six major areas of focus; preventing, recognizing, and managing comorbid illness and medical complications; training for maximum independence; facilitating maximum psychosocial coping and adaptation by patient and family; preventing secondary disability by promoting community reintegration, including resumption of home, family, recreational, and vocational activities; enhancing quality of life in view of residual disability; and preventing recurrent stroke and other vascular conditions such as myocardial infarction that occur with increased frequency in patients with stroke. To attain these goals, rehabilitation interventions should assist the patient in achieving and preserving maximum feasible functional independence. [4]
Patient education As the patient may have long term disabilities, patient and family have to be educated regarding that and about the risk factors of stroke in order to prevent it among relatives. [5]
Palliative Care Primary palliative care should begin at the diagnosis. This includes patients for whom some reversibility is a realistic goal but for whom the stroke itself or its treatments pose significant burdens and may result in reduced quality of life. Palliative care should also be available to those stroke patients with significant functional impairments who have progressive chronic comorbidities, who are unlikely to recover, and for whom intensive palliative care is the predominant focus and goal for the remainder of their lives. [6]
References
  1. OCKENE I. S., MILLER N. H.. Cigarette Smoking, Cardiovascular Disease, and Stroke : A Statement for Healthcare Professionals From the American Heart Association. Circulation [online] 1997 November, 96(9):3243-3247 [viewed 12 September 2014] Available from: doi:10.1161/01.CIR.96.9.3243
  2. GORDON N. F.. Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation [online] 2004 April, 109(16):2031-2041 [viewed 12 September 2014] Available from: doi:10.1161/01.CIR.0000126280.65777.A4
  3. GREENLUND K. J., GILES W. H., KEENAN N. L., CROFT J. B., MENSAH G. A., HUSTON S. L.. Physician Advice, Patient Actions, and Health-Related Quality of Life in Secondary Prevention of Stroke Through Diet and Exercise * The Physician's Role in Helping Patients to Increase Physical Activity and Improve Eating Habits. Stroke [online] 2002 February, 33(2):565-571 [viewed 12 September 2014] Available from: doi:10.1161/hs0202.102882
  4. GRESHAM G. E., ALEXANDER D., BISHOP D. S., GIULIANI C., GOLDBERG G., HOLLAND A., KELLY-HAYES M., LINN R. T., ROTH E. J., STASON W. B., TROMBLY C. A.. Rehabilitation. Stroke [online] 1997 July, 28(7):1522-1526 [viewed 12 September 2014] Available from: doi:10.1161/01.STR.28.7.1522
  5. EVANS R. L., MATLOCK A. L., BISHOP D. S., STRANAHAN S., PEDERSON C.. Family intervention after stroke: does counseling or education help?. Stroke [online] 1988 October, 19(10):1243-1249 [viewed 15 September 2014] Available from: doi:10.1161/01.STR.19.10.1243
  6. HOLLOWAY R. G., ARNOLD R. M., CREUTZFELDT C. J., LEWIS E. F., LUTZ B. J., MCCANN R. M., RABINSTEIN A. A., SAPOSNIK G., SHETH K. N., ZAHURANEC D. B., ZIPFEL G. J., ZOROWITZ R. D.. Palliative and End-of-Life Care in Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke [online] December, 45(6):1887-1916 [viewed 16 September 2014] Available from: doi:10.1161/STR.0000000000000015

Management - Specific Treatments

Fact Explanation
acute management Assess the patient's air way, breathing, circulation and resuscitation has to be done first. Once the diagnosis of ischemic stroke has been made 300mg of asprin is given. Thrombolytic therapy(ateplase) is most beneficial if given with in first 90 minutes. [1]
Hypertention management Antihypertensive therapy is effective in reducing the risk of recurrent stroke. Careful identification of hypertensive patients with stroke and TIA, with initiation of single or combination therapy, is essential for secondary stroke prevention. [2]
antiplatelet drugs Antiplatelet therapy plays an important role in the long-term prevention of ischemic stroke and vascular events in patients who have experienced acute ischemic stroke or TIA. The most commonly used antiplatelet therapies are aspirin, ER-dipyridamole + low-dose aspirin, and the ADP receptor antagonist clopidogrel. [2]
Anticoagulation Warfarin is effective in the primary prevention of thromboembolic stroke in patients with atrial fibrillation. Warfarin is used by consensus only in patients with atrial fibrillation or a similar, definite cardiac source of embolus. [2]
Lipid lowering drugs the vast majority of patients with previous ischemic stroke or TIA are likely to benefit from statin use. [2]
Intra arterial reperfusion Localized administration of the fibrinolytic agent may reduce the total systemic exposure, and thus reduce the risk of bleeds, while allowing a longer therapeutic window. However, a con of this technique is the longer delay in the initiation of treatment [1],[2]
Mechanical Thrombectomy An alternative for those whom where fibrinolysis is ineffective or contraindicated, which includes the use of catheters to directly deliver a clot disruption or retrieval device during angiography to the thromboembolus which is occluding the cerebral artery.[1],[2]
Fever Control Antipyretics for febrile stroke patients, since hyperthermia accelerates ischemic neuronal injury[1],[2]
Cerebral Oedema Control In emergency situations, mannitol and other therapies may be used to reduce intracranial pressure (ICP). However, prompt neurosurgical assistance should be sought when indicated. Patient positioning, hyperosmolar therapy, hyperventilation, and, barbiturate coma may also be considered where appropriate. In patients with large hemispheric infarctions associated with life-threatening edema, hemicraniectomy may decrease resultant mortality and disability. [1],[2]
Seizure control Secondary prevention of seizures in means of standard antiepileptic drugs is recommended where primary prophylaxis in poststroke seizures is not. [1],[2]
Neuro Protective Measures The rationale for the use of these is that reduction of the excitatory neurotransmitter release by neurons in ischemic penumbra may enhance the survival of them. However, neuroprotective agents in ischemic stroke is yet to be supported by randomized, placebo-controlled studies.[1],[2]
References
  1. JAUCH E. C., SAVER J. L., ADAMS H. P., BRUNO A., CONNORS J. J., DEMAERSCHALK B. M., KHATRI P., MCMULLAN P. W., QURESHI A. I., ROSENFIELD K., SCOTT P. A., SUMMERS D. R., WANG D. Z., WINTERMARK M., YONAS H.. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke [online] December, 44(3):870-947 [viewed 12 September 2014] Available from: doi:10.1161/STR.0b013e318284056a
  2. KIRSHNER H. S., BILLER J., CALLAHAN A. S.. Long-Term Therapy to Prevent Stroke. The Journal of the American Board of Family Medicine [online] 2005 November, 18(6):528-540 [viewed 12 September 2014] Available from: doi:10.3122/jabfm.18.6.528