Overview of StrokeCerebral Infarction

A Case: Chief Complaint• 34 year old female presented to a

community hospital with abnormal language. Her husband reported that she had been normal 2 hours earlier at which time the patient is said to have demonstrated shaking of the arms and legs for several seconds of duration. Immediately thereafter the patient was unable to speak and there was paucity of movement on the right side of the body. There was no report of urinary or bowel incontinence and no report of tongue biting.

The Previous Medical History• Migraine Headaches• Frequent Urinary Tract Infections• Multiple episodes of epistaxis• Depression• Miscarriage

Current Medications• Venlafaxine, An antidepressive

medication. Works by inhibiting the re-uptake of serotonin, noradrenalin, and dopamine.

Social History• Married • Four living children. G5P5014• Does not smoke. No history of

tobacco use.• No history of recreational or illicit

drug use.• No history of alcohol abuse.• No recent travel abroad.

Stroke Epidemiology• First…………..180,000• Recurrent…….600,000• Incidence…….780,000/yr =1stk/40s• Prevalence…..6,500,000• Males…………2,600,000• Female……….3,900,000 •

Stroke Mortality• 3rd Leading Cause of Death in USA• 150,000 Deaths Yearly• One of Every 17 Deaths in 2005• 56,586 Males• 86,993 Females• Death Rate Declined in 2005 i.e.

29.7% to 13.5%

Stroke Morbidity• Leading cause of long term disability• 30% of survivors require assistance

with ADL ( activities of daily living)• 20% require assistance to ambulate• 16% must be institutionalized.• Health care and lost income cost

approach $41 billion

Stroke by Definition:• An acute on set of neurologic

dysfunction caused by impairment of blood flow the region of brain mapping to the impaired function.

• Manifest on Brain imaging.• Dysfunction last 24 hours.• If < 24 hours and no signature on

brain image: TIA (transient ischemic attack

• 0

Classification of Strokes• Hemorrhagic• 15-25 %• ICH• SDH• EDH

• Ischemic• 71- 83 %• Embolic • Cardiac Source• Non-cardiac Source

• Large Vessel Disease

• Small Vessel Disease

Ischemic Stroke Subtypes• Large Vessel• Small Vessel• Embolic (usually Cardioembolic)• Thrombotic (usually from Atherosclerotic

Cerebrovascular Disease)• Microangiopathic Brain Disease• Cortical• Subcortical

The Cerebral Circulation

Cardiac Related Stroke• Atrial Fibrillation• Cardiac Valve disease• MI (wall motion abnormality)• Septal Aneurysms• Patent Foramen Ovale• Atrial Septal Defect• Dilated Cardiomyopathy

Risk Factors• Hypertension• Heart Disease• Atrial fibrillation• Diabetes• Tobacco• Lipids• Abnormal

hematology• OSA

• Age• Race/ethnicity• Gender• Family history• genotype

CONGENITAL HYPERCOAGULABLE CONDITIONS

• Factor 5 Leiden mutation• G2021A mutation• Antithrombin 3• Protein C deficiency• Protein S deficiency

Inherited Disorders• Homocystinuria• Fabry’s Disease• Marfan’s Syndrome• Rendu-Osler-Weber Syndrome

34 year old female :Physical Examination

• VS: 98.6, 116/71, 23/min, 106/min• Oxygen Saturation 97%, room air• Mute, + commands, neck supple, no

bruits, fast RR (-)MRG, clear lungs, abd: benign, extremities: no CCE.

• ® Arm>>® Leg Weakness, ® face weakness, (left side normal), Deep Tendon Reflexes absent on the ®, Plantar Response: Up on the ® and Down on the left. Sensation: Normal.

Case laboratory studies• Serum glucose….106• Sodium…………..142• Creatinine………...0.7• WBC………………11,900/cu mm• Platelet count……..258000/cu mm• Hemacrit……….....42%• PT………………….12.9 sec• PTT…………………34.5 sec

Computed Tomography of the Head• Arrival to ER, Airway, Breathing,

Circulation, then…• Head CT is crucial in the management of

the stroke patient.• The study distinguishes hemorrhagic

strokes from ischemic strokes.• The HCT may or may not provide

additional diagnostic information• Diffusion weighted MRI: better stroke

detection in the first 12 hours.

Easter JS et al. N J Med 2010;362:2114-2120.

34 yo female• Dense MCA Sign

Head CTPerformed 3.5 hours past the onset of stroke symptoms

CT: Thrombosis in the Left Middle Cerebral Artery• Sources of emboli to the brain

Carotid AtherosclerosisCarotid DissectionIntracranial VasculopathyAtrial FibrillationCardiac Valve DiseaseRight-to-Left Cardiac ShuntHypercoagulable States

Acute Therapy• Intravenous TPA within 4.5 hrs. of

onset• Intra-arterial Thrombolysis within 6

hrs. of onset• Mechanical Embolectomy

Case Patient Acute Therapy

• Intravenous Heparin was started.• Patient transferred to tertiary care

hospital.• Neurological examination worsened.• Required intubation (protect airway.)• CT angiogram performed.

CT Angiogram of the BrainFilling defect noted in left middle

cerebral artery

Case Acute Care Continues

• Intra-arterial TPA was administered.• Endovascular mechanical retrieval

of clot was performed.• Flow through left MCA was restored.• Right hemiparesis persisted.• Chest x-ray read as right middle

lobe pneumonia.• Antibiotic started: patient to ICU.

Chest X-RayEndotracheal Tube is in place. Right middle

lobe infiltrate. Aspiration pneumonia? Or something else?

Additional Studies• Echocardiogram: Suggested Atrial

septal defect.• Hypercoagulopathy screen was

negative.• Lower extremity venous ultrasound

was negative.• Neck CT angiogram negative for

dissection.

Putting It All Together• Young female with stroke.• Likely an embolic stroke.• History of nose bleed.• History of miscarriage• Family History of AVM.• Abnormal chest x-ray.• Could be consistent with hereditary

hemorrhagic telangiectasia.• Chest CT: Hunt for pulmonary AVM

Contrast CT of the ChestCT Scan of the Torso Obtained 1 Week after Admission. The coronal-plane–formatted CT scan shows an arteriovenous malformation in the lung (arrow).

Cause of this Stroke• Most probably paradoxical through

the intrapulmonary shunt created by the pulmonary arteriovenous malformation.

• Pulmonary AVM is part and parcel of Rendu-Osler-Weber Syndrome i.e. HHT.

Rendu-Osler-Weber Syndrome• Autosomal Dominant• Telangiectasia of skin mucous

membrane, various organs.• Two different Gene Loci identified (a)

9q33-34 and (b) 12q13• Arises from spontaneous mutations

in 30% of cases.

Neurologic Manifestations of HHT• Headache• Dizziness• Seizure• Paradoxical Embolism Stroke• Transient Ischemic Attacks• ICH, SAH• Meningitis• Cerebral abscess

Treatment of HHT• Manage the complications. Notably,

our patient walked out of the hospital with improved speech and language.

• Early resection of lung AVM or embolization of the fistula.

• Periodic Transfusion and Iron Therapy

• ASA has been used for platelet sequestration.