Stroke - CVA Cerebral Vascular Accident

Types of Stroke 
Ischemic cerebrovascular disease (generally thromboembolic disease)
1.  Thrombotic disease (atherothrombotic disease)

2.  Embolic stroke - much less common than thrombosis, most brain infarcts under age 35

3. Intracranial Hemorrhagic Stroke

 hypertensive hemorrhage
 subarachnoid hemorrhage - berry aneurysm rupture
 other hemorrhage - vascular malformations , atherosclerotic aneurysms , mycotic
aneurysms
 Lobar Intracerebral Hemorrhage

4.  Venous sinus thrombosis

Anterior circulatory occlusion
Internal carotid artery occlusion
Sx: contralateral weakness or numbness, dysphasia, apraxia, confusion if the dominant
hemisphere is involve. Transient blurring of vision or ipsilateral blindness (amaurosis fugax),
homonymous visual field loss, ipsilateral headache.

Anterior cerebral artery occlusion

Sx: paralysis of opposite foot & leg, paresis of opposite arm, urinary incontinentce, mental
impairment, slowness, delay, lack of spontaneity, impairment of gait & stance (apraxia),
cortical sensory loss over toes, foot, & leg.
Middle cerebral artery occlusion
Sx: 
paralysis & sensory impairment of contralateral face, arm & leg; 
aphasia in left CVA, 
paralysis of conjugate gaze to the opposite site; homonymous hemianopia (often superior
homonymous quadratanopia); Cheyne-Stokes respiration; 
pure motor hemiplegia in internal capsule posterior limb CVA; 
ataxia of contralateral limb in parietal lobe involvement;

Sx of Upper division occlusion: hemiparesis & sensory loss, arm & face affected more than
leg; Broca's aphasia, hemineglect.

Sx of Lower division occlusion: Wenicke's aphasia or nondominant behavior disorder without

hemiparesis;

Sx of Penetrating Artery occlusion:  pure motor hemiparesis

Stroke
From Wikipedia, the free encyclopedia
For other uses, see  Stroke (disambiguation).

Stroke

Classification and external resources

CT scan slice of the brain showing a right-hemispheric ischemic stroke (left

side of image).

ICD-10 I61.-I64.

ICD-9 434.91

OMIM 601367

DiseasesDB 2247

MedlinePlus 000726

eMedicine neuro/9 emerg/558emerg/557 pmr/187

MeSH D020521

A stroke, known medically as a cerebrovascular accident (CVA), is the rapidly developing loss
of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack
of blood flow) caused by blockage (thrombosis, arterial embolism), or ahemorrhage (leakage of blood).
[1]
 As a result, the affected area of the brain is unable to function, leading to inability to move one or more
limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side
of the visual field.[2]

A stroke is a medical emergency and can cause permanent neurological damage, complications, and

even death. It is the leading cause of adult disability in the United States and Europe and it is the number
two cause of death worldwide.[3] Risk factors for stroke includeadvanced age, hypertension (high blood
pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette
smoking and atrial fibrillation.[4] High blood pressure is the most important modifiable risk factor of stroke.
[2]

A stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"). Post-stroke

prevention may involve the administration of antiplatelet drugs such as aspirin and dipyridamole, control
and reduction of hypertension, the use of statins, and in selected patients with carotid endarterectomy,
the use of anticoagulants.[2] Treatment to recover any lost function is stroke rehabilitation, involving health
professions such as speech and language therapy, physical therapy and occupational therapy.

Contents
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[edit]Definition

The traditional definition of stroke, devised by the World Health Organization in the 1970s,[5] is a
"neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death
within 24 hours". This definition was supposed to reflect the reversibility of tissue damage and was
devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides
stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve
completely within 24 hours.[2] With the availability of treatments that, when given early, can reduce stroke
severity, many now prefer alternative concepts, such as brain attack andacute ischemic
cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome respectively), that
reflect the urgency of stroke symptoms and the need to act swiftly. [6]

[edit]Classification
A slice of brain from the autopsy of a person who suffered an acutemiddle cerebral artery (MCA) stroke

Strokes can be classified into two major categories: ischemic and hemorrhagic. [7] Ischemic strokes are
those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which
result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused
by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia
("hemorrhagic transformation"). It is unknown how many hemorrhages actually start as ischemic stroke. [2]

[edit]Ischemic stroke
Main articles:  Cerebral infarction and  Brain ischemia

In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain
tissue in that area. There are four reasons why this might happen:

1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)

2. Embolism (obstruction due to an embolus from elsewhere in the body, see below), [2]
3. Systemic hypoperfusion (general decrease in blood supply, e.g. in shock)[8]
4. Venous thrombosis.[9]

Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 30-
40% of all ischemic strokes.[2][10]

There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project
classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial
symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior
circulation infarct (TACI), partial anterior circulation infarct(PACI), lacunar infarct (LACI) or posterior
circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain
affected, the underlying cause, and the prognosis.[11][12] The TOAST (Trial of Org 10172 in Acute Stroke
Treatment) classification is based on clinical symptoms as well as results of further investigations; on this
basis, a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large
artery, (2) embolism of cardiac origin, (3) occlusion of a small blood vessel, (4) other determined cause,
(5) undetermined cause (two possible causes, no cause identified, or incomplete investigation). [2][13]
[edit]Hemorrhagic stroke
Main articles:  Intracranial hemorrhage  and intracerebral hemorrhage

CT scan showing an intracerebral hemorrhage with associated intraventricular hemorrhage.

Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made
between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the
skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal
hemorrhage orintraventricular hemorrhage (blood in the ventricular system). The main types of extra-axial
hemorrhage are epidural hematoma (bleeding between thedura mater and the skull), subdural
hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia
mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g. headache,
previous head injury).

[edit]Signs and symptoms

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress
further. The symptoms depend on the area of the brain affected. The more extensive the area of brain
affected, the more functions that are likely to be lost. Some forms of stroke can cause additional
symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures.
Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and
cerebral venous thrombosis and occasionally intracerebral hemorrhage.

[edit]Early recognition
Various systems have been proposed to increase recognition of stroke by patients, relatives and
emergency first responders. A systematic review, updating a previous systematic review from 1994,
looked at a number of trials to evaluate how well different physical examination findings are able to predict
the presence or absence of stroke. It was found that sudden-onset face weakness, arm drift (e.g. if a
person, when asked to raise both arms, involuntarily lets one arm drift downward) and abnormal speech
are the findings most likely to lead to the correct identification of a case of stroke (+ likelihood ratio of 5.5
when at least one of these is present). Similarly, when all three of these are absent, the likelihood of
stroke is significantly decreased (– likelihood ratio of 0.39).[14] While these findings are not perfect for
diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very
valuable in the acute setting.

Proposed systems include FAST (face, arm, speech, and time), [15] as advocated by the Department of
Health (United Kingdom) and The Stroke Association, the American Stroke Association
(www.strokeassociation.org) , National Stroke Association (US www.stroke.org), the Los Angeles
Prehospital Stroke Screen (LAPSS)[16] and the Cincinnati Prehospital Stroke Scale (CPSS).[17] Use of
these scales is recommended by professional guidelines.[18]

For people referred to the emergency room, early recognition of stroke is deemed important as this can
expedite diagnostic tests and treatments. A scoring system called ROSIER (recognition of stroke in the
emergency room) is recommended for this purpose; it is based on features from the medical history and
physical examination.[18][19]

[edit]Subtypes

If the area of the brain affected contains one of the three prominent central nervous system pathways—
the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:

 hemiplegia and muscle weakness of the face

 numbness
 reduction in sensory or vibratory sensation

In most cases, the symptoms affect only one side of the body (unilateral). Depending on the part of the
brain affected, the defect in the brain is usually on the opposite side of the body. However, since these
pathways also travel in the spinal cord and any lesion there can also produce these symptoms, the
presence of any one of these symptoms does not necessarily indicate a stroke.

In addition to the above CNS pathways, the brainstem also consists of the 12 cranial nerves. A stroke
affecting the brain stem therefore can produce symptoms relating to deficits in these cranial nerves:

 altered smell, taste, hearing, or vision (total or partial)

 drooping of eyelid (ptosis) and weakness of ocular muscles
 decreased reflexes: gag, swallow, pupil reactivity to light
 decreased sensation and muscle weakness of the face
 balance problems and nystagmus
 altered breathing and heart rate
 weakness in sternocleidomastoid muscle with inability to turn head to one side
 weakness in tongue (inability to protrude and/or move from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the
following symptoms:

 aphasia (inability to speak or understand language from involvement of Broca's or Wernicke's

area)
 apraxia (altered voluntary movements)
 visual field defect
 memory deficits (involvement of temporal lobe)
 hemineglect (involvement of parietal lobe)
 disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe)
 anosognosia (persistent denial of the existence of a, usually stroke-related, deficit)

If the cerebellum is involved, the patient may have the following:

 trouble walking
 altered movement coordination
 vertigo and or disequilibrium
[edit]Associated symptoms
Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in
thrombosis because of the increased intracranial pressure from the leaking blood compressing on the
brain.

If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an
embolic stroke