Stroke

Hemorrhagic vs ischemic Posted by Ahmad Azizov on October 16, 2020

Stroke

Strokes happen when the brain cannot get enough blood to a part of the brain due to a vascular problem. There are 3 main types of strokes:

  • Ischemic (2 subtypes) - 75% of the time
    • Embolic
      • Occlusion caused by something, not from the brain 
      • Causes 
        • Afib plaque 
        • Carotid artery plaque 
        • Vegetation from heart valves
      • Risk factors 
        • Obesity 
        • Smoking 
        • Hypertension 
        • Dyslipidemia 
        • Diabetes 
        • Age 
        • Infection 
    • Thrombotic 
      • Occlusion in the blood vessel
      • Brain parts distal to the occlusion will die off 
      • Caused by a plaque (similar to an MI) 
      • Risk factors 
        • Obesity 
        • Smoking 
        • Hypertension 
        • Dyslipidemia 
        • Diabetes 
        • Age 
  • Hemorrhagic (intracerebral) - 25% of the time 
    • Poor outcome 
    • Will require a neurosurgeon 

Pathophysiology 

Strokes can affect one or multiple of the arteries within the circle of Willis

Patients who end up with strokes tend to have common presentations. These are the following:

  • Vasculapaths
  • Patients with afib
    • Often not on anticoagulation 
  • Young women post-trauma
    • Neck pain with a focal neurologic concussion 
  • Patients with a thunderclap headache 
    • Worst headache of life with sudden onset 
    • Sometimes seen with Cushing's syndrome 
      • Bradycardia 
      • Hypertension 
      • Herniation soon to follow 

Management

When a patient suspected to have had a stroke presents to the ED the first test that is needed is a non-contrast CT scan of the brain. This scan is quicker than contrast CT and helps to see blood. If blood is seen on CT, then this is a hemorrhagic stroke. If there is no stroke, then this is an ischemic stroke. 

Picture 1. Intracranial hemorrhage on a non-contrast CT brain

  • Hemorrhagic stroke - poor outcome 
    • Lower blood pressure 
    • Call neurosurgery 
      • Endovascular hemorrhage 
      • Clip
      • Craniotomy - remove the skull to reduce the intracranial hemorrhage 
    • Administer free frozen plasma 
      • Only helps if the INR is high 
  • Ischemic stroke
    • tPA 
      • Used to dissolve clots 
      • Indications 
        • Non-hemorrhagic stroke newer than 3 hours for diabetics, 4.5 hours for non-diabetics (neurologists can override these) 
        • Time starts from last time seen well (if you slept at 10 pm, by morning time no tPA)
      • Contraindications 
        • Previous hemorrhagic strokes 
        • Risk of bleeding (watch for GI bleeds) 
        • Less than 2 weeks from a surgery
      • Acute management if no tPA 
        • Antiplatelets 
          • ASA 325mg 
        • Control of diabetes 
          • Avoid hypoglycemia especially 
        • Permissive hypertension 
          • 220/120
          • Maintains tissue perfusion in the brain 
      • Chronic management
        • Low molecular weight heparin 
        • Anticoagulation if afib or aflutter present 
        • ASA 81 daily and possible add dipyridamole
        • High potency statins 
          • Atorvastatin 
          • Rosuvastatin 
        • Hemoglobin a1c should be under <8%
        • Control blood pressure 
        • Lifestyle changes 
          • Stop smoking 
    • ECG/Telemetry/Holter monitoring
      • Check for arrhythmias
      • Afib or aflutter 
        • This means a CHADs2 score of 2 or higher 
        • Anticoagulation 
        • Warfarin 
          • No need to bridge with heparin
        • NOACs
    • Transthoracic echo 
      • Thrombus can be seen 
        • Warfarin
          • Will need a heparin bridge 
        • NOACs
    • Carotid U/S
      • Carotid artery stenosis
      • If stenosis <70% with no symptoms 
        • Treat medically 
      • If stenosis >80% or greater than 70% stenosis with symptoms 
        • Carotid endarterectomy (within 2 weeks) or stenting (for sicker patients) 

All information provided on this website is for educational purposes and does not constitute any medical advice. Please speak to you doctor before changing your diet, activity or medications. 


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Written by
Ahmad Azizov
Writing since 2020 April

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