149 STROKEJoel Stein, MD

SynonymsCerebrovascular accidentBrain attack

ICD-9 Codes430 Subarachnoid hemorrhage431 Intracerebral hemorrhage432 Other and unspecified intracranial hemorrhage433 Occlusion and stenosis of precerebral arteries434 Occlusion of cerebral arteries435 Transient cerebral ischemia436 Acute but ill defined cerebrovascular disease437 Other and ill defined cerebrovascular disease438 Late effects of cerebrovascular disease

DEFINITIONStroke is an acquired injury of the brain caused by occlusion of a blood vessel or inadequate blood supply leading to infarction, or a hemorrhage within the parenchyma of the brain.

SYMPTOMSWeakness, difficulty in speaking or swallowing, aphasia, cognitive disturbance, sensory loss and visual disturbance are the most common presenting symptoms of stroke, and deficits in these areas often persist even after initial rehabilitation. Urinary urgency, increased muscle tone, fatigue, depression, and pain are symptompsthat may be manifested after a stroke has already occured. Reflex sympathetic dystrophy (also known as complex regional pain syndrome type 1) may occur after stroke, although most post-stroke pain results from mechanical (e.g. joint subluxation) or central (e.g. thalamic pain syndromes) causes.

PHYSICAL EXAMINATIONA full neurologic examination is appropriate. This includes evaluation of mental status, cranial nerves, sensation, deep tendon reflexes, abnormal reflexes (e.g. babinski), motor strength and coordination, muscle tone and functional mobility (sitting, transfers, and ambulation). The protean manifestations of stroke can cause many different combinations of abnormalities in these aspects of the neurologic examination. An assessment of mood and affect is important, given the high prevalence of post-stroke depression. Range of motion in affected limbs should be measured; ankle plantar flexion contractures and upper limb contractures are common in hemiplegic stroke and interfere with rehabilitation efforts. Skin is examined for any areas of breakdown. Limb swelling is common and should be noted. The fit and function of leg braces, upper extremity splints, slings, wheelchairs, and ambulatory aids are assessed as part of the routine physical examination.

FUNCTIONAL LIMITATIONSDifficulties in walking, performing activities of daily living, speaking, and swallowing are common manifestations of stroke. Cognitive impairments (memory, attention, visual-spatial perception) and impaired communication due to aphasia or dysarthria may be present. The impairments seen in stroke are based on the anatomy of the stroke; aphasia is generally a result of left hemisphere damage, and neglect and attentional deficits are more common with right hemisphere strokes. Impaired sexual function should be identified because patients may not volunteer function impairment in this area unless the physician inquires.As a result of these impairments, many individuals may be unable to drive or to use public transportation. Communication difficulties can lead to social isolation. Some individuals require ongoing supervision because of cognitive limitations. In severe cases, individuals with aphasia or cognitive impairments may not be able to live independently. Incontinence due to destrusor instability and urinary urgency can interfere with leaving the home and contribute to skin breakdown and social isolation.Depression is common after stroke, affecting as many as 40% of stroke survivors. Depression should be identified as a treatable complication of stroke rather than accepted as a consequence of funtional loss. Among stroke survivors older than 65 years who were evaluated 6 months after a stroke, 30% were unable to walk without some assistance, 26% were dependent for activities of daily living, and 26% were institutionalized in a nursing home.1

DIAGNOSTIC STUDIESIn the acute setting, computed tomography is often the first diagnostic test performed because of the rapidity with which it can be obtained, its widespread availability, and its high sensitivity for cerebral hemorrhage. Magnetic resonance imaging provides greater anatomic resolution and avoids radiation exposure. With newer magnetic resonance imaging sequences, such as diffusion-weighted imaging abnormalities can be demostrated at an earlier stage than with computed tomography, providing important information for acute treatments such as thrombolysis.2 Magnetic resonance angiography, computed tomographic angiography, non invasive flow studies, holter monitoring, and echocardiography are important studies to help determine the cause of a stroke and to determine the best treatment for prevention of recurrent stroke. In selected patients (particularly young individuals or those without typical risk factors), an evaluation for hypercoagulable states is indicated.In patients with prior stroke, diagnostic studies are typically directed to complications of stroke, such as persistent dysphagia or urinary incontinence. Video fluoroscopic swallowing studies can be useful un swallowing disorders. Urodynamic studies may be useful in the assessment of urinary symptoms, particularly if initial treatment with anticholinergic medications is unsuccessful.

Differential DiagnosisHemiplegic migrainePost-seizure (Todd) paralysisBrain neoplasmMultiple sclerosis

TREATMENTInitialWhen ischemic stroke is diagnosed within the first 3 hours, thrombolytic therapy has been shown to reduce disability.3 In the other cases, intravenous heparin is commonly administered when an embolic etiology is suspected. Aspirin (between 80 and 325 mg) has been found to be effective when it is used in the acute setting.Secondary prevention depends on the cause of the stroke. Warfarin (coumadin) is commonly used for the secondary prevention of embolic stroke, with the most estensive evidence for prevention of stroke in atrial fibrillation.4 Antiplatelet agents, including aspirin, clopidogrel (plavix), or a combination of aspirin and dipyridamole (aggrenox), are used for prevention of most non-cardioembolic strokes or when antocoagulation is desirable but contraindicated because of commorbid conditions. Risk factor modification, including treatment of hypertension, diabetes, hyperlipidemia, and obesity as well as smoking cessation and exercise should be addressed for all stroke survivors.5Treatment of cerebral hemorrhage is based in part on the presumed cause. For hypertensive hemorrhages control of blood pressure with antihypertensive medications is the mainstay of treatment. For all causes of cerebral hemorrhage, avoidance of anticoagulants, antiplatelet medications and alcohol is important.6Medications for the management of stroke and its complicatons on an outpatient basis are shown in table 149-1. Anticholinergic medications are useful for bladder destrusor instability. Antispasticity medications are of limited efficacy in many cases ( see chapter 144). For sexual dysfunction in men, phosphodiesterase type 5 inhibitors may be effective. Treatment with selective serotonin reuptake inhibitors for post stroke depression is widely employed, although a wide range of antidepressant medications can be effetive. Psychostimulants may be useful for impaired attention. Anticonvulsants are used for central pain syndromes, but with variable benefit.

RehabilitationThe rehabilitation program needs to be customized on the basis of the severity and nature of the impairments caused by the stroke. For individuals with moderate to severe stroke, a comprehensive multidiciplinary inpatient rehabilitation program in a rehabilitation hospital is often appropriate.7 For these individuals, rehabilitation commonly continues through home care or outpatient services. Patients with more isolated and less severe deficits may be discharged directly from the acute care hospital to home and participate in an outpatient rehabilitation program.8

ExerciseTherapeutic exercise programs are usually functionally oriented, with an emphasis on restoration of functional mobility and ability to perform activities of daily living (Fig. 149-1). Instruction in compensatory techniques and family teaching are important in assisting individuals to return home. These is growing evidence of the impact of therapeutic exercise on cortical reorganization after stroke, with associated improvements in motor control and functional use.9 Newer approaches being studied to enhance motor abilities include constraint-induced movement therapy, robot assisted exercise training, virtual reality exercise training, and partial body weight-supported treadmill training.10-15 These novel techniques appear to improve motor function, but the optimal exercise program to facilitate recovery remains to be defined. Table 149-1 Medication Commonly Used for Treatment of Stroke and Its Complications

Class of MedicationExamples Indication

AnticholinergicOxybutynin (Distropan)Tolterodine (Detrol)Bladder detrusor instability

AntispasticityBaclofen (Lioresal)Tizanloine (Zanaflex)Diazepam (Valium)Dantrolene (Dantrium)Muscle spasticity

Phosphodiesterase type S inhibitorsSildenafil (Viagra)Vardenafil (Levitra)Erectile dysfunction

Selective serotonin reuptake inhibitorsFluoxetine (Prozac)Paroxetine (Paxil)Sertraline (Zoloft)Post-stroke depression

Stimulants Methylphenidate (Ritalin)Dextroamphetamine (Dexedrine)Impaired attention arousal

AnticonvulsantsGabapentin (Neurontin)Carbamazepine (Tegretol)Central pain syndromes, seizure disorders

DysphagiaManagement of dysphagia may include the use of nasogastric or gastrostomy tube feedings, modified diets (e.g., thickened liquids, pureed foods), and swallowing therapy (e.g., the use of compensatory strategies, such as tucking the cin during swallowing).

CommunicationThe rehabilitation of aphasia relies on extensive speech therapy as its mainstay; selected patients benefit from communication aids, such as a picture board. Speech therapy may provide significant benefit for dysarthria as well, with improved intelligibility resulting. Severely dysarthric or anarthric patients may benefit from the use of computer-based communication aids, including those with speech synthesis, as well as low-tech solutions such as spelling boards.

Figure 149-1. the time course of recovery after stroke is shown as the cumulative percentage of stroke survivors in each category who have reached their best function in activities of daily living relative to initial functional disability: mild disability, moderate disability, severe disability and x very severe disability. (Reprinted with permission from Jorgensen HS, Nakayama H, Raaschou HO, et al. Outcome and time course of recovery in stroke. Part II. Time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995;76:406-412)

CognitionCognitive abilities are frequently affected by stroke; alterations in memory, attention, insight, and problem solving are common. Neuropsychological testing may be useful indefining the precise nature of these deficits and in helping to develop a remediation plan. Speech-language and occupational therapy approaches include both attempts at remediation and teaching of compensatory techniques. Family education and training are important components of cognitive rehabilitation. Recognition and treatment of post stroke depression is very important because depression can contribute to reduced cognitive performance after stroke.16

BracingLower extremity bracing is frequently helpful in restoration of mobility in hemiparetic stroke survivors. Most commonly, a plastic ankle-foot orthosis is used, although other braces are appropriate in selected circumstances. Bracing is helpful as a compensation for impaired ankle dorsiflexion, controlling ankle inversion and plantar flexor spasticity as well as providing some stabilization at the knee.

Ambulatory Aids and WheelchairsBecause of hemiparesis, many stroke survivors require ambulatory aids, which may include a straight cane, a four-pronged (quad) cane, a hemi-walker, or, in some cases, a conventional walker. Wheelchairs are often needed for more severely impaired stroke survivors or for moderately impaired stroke survivors for longer distance travel. A hemi-wheelchair is lower to the ground and allows use of the nonparetic leg to assist with propulsion. On occasion, a one-arm drive wheelchair is useful; it allows control of both wheelchair wheels from one side. Active, nonambulatory individuals may benefit from a power wheelchair.

Shoulder SubluxationShoulder Subluxation commonly occurs in the setting of hemiplegia after stroke, although the presence of pain is highly variable. Arm boards and the selective use of slings help in reducing subluxation. Electrical stimulation may have a beneficial effect as well.17

SplintsSplint for proper positioning of the hemiplegic arm and ankle-foot are important to prevent contracture. These are particularly important when spasticity is present.

Vocational RehabilitationAlthough stroke is predominantly a disease of older individuals, a significant portion of stroke survivors are of working age. Once activities of daily living have been mastered, vocational counseling may assist individuals seeking to return to work. Coordination with the rehabilitation team is important because retraining for certain job tasks may involve a multidisciplinary effort. Accommodations in the workplace may be necessary, and the Americans with Disabilities Act may require the employer to provide reasonable accommodation for individuals with disabilities. See chapter 150 for more details. ProceduresPhenol or botulinum toxin injections may be useful in the management of spasticity after stroke. These injections are described in greater detail in Chapter 144.

SurgerySelected patient require craniotomy in the acute phase for evacuation of a large intracerebral hematoma or for severe swelling with increased intracranial pressure. Carotid endarterectomy in appropriately selected patients has been shown to reduce the risk of recurrent stroke.18 Carotid stenting is being studied as an alternative to endarterectomy for the treatment of carotid stenosi. Intrathecal baclofen has been found to be effective in treatment of post stroke spasticity,19,20 but it is infrequently use for hemiplegic stroke at this time. In patients with chronic impairments from stroke, tendon lengthening procedures are occasionally needed for contractures.An experimental implantable cerebral cortical stimulator system has been found to facilitate motor recovery when it is used in conjuction with exercise therapy in pilot studies.21 A multicenter study of this device is currently in progress.

POTENTIAL DISEASE COMPLICATIONSSeizures can develop as an early or a late complication of stroke; strokes involving the cerebral cortex and hemorrhagic stroke carry greater risk. The risk of deep venous thrombosis is substantially elevated in hemiplegic stroke, and prophylactic treatment with subcutaneous heparin or low molecular weight heparin is advisable during the initial recovery phase.22 The ideal duration of prophylaxis for deep venous thrombosis after stroke has not been established; in most cases, this is discontinued after a period of several weeks. Stroke reccurence is a feared complication of stroke, and individuals with a history of stroke remain at increased risk for reccurent stroke despite risk factor reduction. Aspiration pneumonia can occur as a complication of dysphagia, although this risk tends to abate over time except in the most severe cases. POTENTIAL TREATMENT COMPLICATIONSBoth anticoagulants antiplatelet medications can contribute to bleeding complications. Aspirin can cause gastritis. Clopidogrel has been associated with thrombotic thrombocytopenic purpura. The combined used of aspirin and clopidogrel appears to increase the risk of gastrointestinal hemorrhage without providing significant improvement in stroke prevention.23Anticholinergic medications commonly cause dry mouth and may precipitate urinary retention. Antispasticity medications can cause sedation and may exacerbate. Cognitive impairments. Sildenafil is known to be hazardous when it is use concurrently with nitrates and should be avoided in patients receiving these medications. Selective serotonin reuptake inhibitors can cause gastrointestinal symptoms (especially nause and anorexia) as well as interfere with libido and sexual function. Psychostimulants can cause anorexia, insomnia, anxiety, or agitation and should be slowly titrated upward. Gabapentin is usually well tolerated, although occasional sedation has been reported. Carbamazepine may cause leukopenia.

REFERENCES1. Kelley-Hayes M, Beiser A, Kase CS, et al. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis 2003;12:119-1262. Lansberg MG. Albers GW, Beaulieu C, Marks MP. Comparison of diffusion-weighted MRI and CT in acute stroke. Neurology 2000;54:1557-15613. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Eng J Med 1995;333:1581-15874. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990;323:1505-15115. Stein J, Silver JK, Frates EP. Life After Stroke: The Guide to Recovering Your Health and Precventing Another Stroke. Baltimore, Johns Hopkins University Press, 20066. Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med 1995;333:1392-14007. Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation settings. JAMA 1997;277:396-4048. Mayo NE, Wood-Dauphinee S, Cote R, et al. Theres no place like home: an evaluation of early supported discharge for stroke. Stroke 2000;31:1016-10239. Liepert J, Bauder H, Miltner WH, et al. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000;31:1210-121610. Dromerick AW, Edwards DF, Hahn M. Does the application of constraint induced movement therapy during acute rehabilitation reduce arm impairment after stroke. Stroke 2000;31:2894-298811. Fasoli SE, Krebs HI, Stein J, et al. Effects of robotic therapy on motor impairment and recovery in chronic stroke. Arch Phys Med Rehabil 2003;84:477-48212. Stein J, Hughes R, Fasoli S, et al. Clinical applications of robots in rehabilitation. Crit Rev Phys Rehabil Med 2005;17:217-23013. Hesse S, Bertelt C, Jahnke MT, et al. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke 1995;26:976-98114. Hesse S, Bertelt C, Schaffrin A, et al. Restoration of gait in nonambulatory hemiparetic patients by treadmill training with partial bodyweight support. Arch Phys Med Rehabil 1994;75:1087-109315. You SH, Jang SH, Kim YH, et al. Virtual reality-induced cortical reorganization and associated locomotor recovery in chronic stroke: an experimenter-blind randomized study. Stroke 2005;36:1166-117116. Kimura M, Robinson RG, Kosier JT. Treatment of cognitive impairment after poststroke depression: a double-blind treatment trial. Stroke 2000;31:1482-148617. Chantraine A, Baribeault A, Uebelhart D, Gremion G. Shoulder pain and dysfunction in hemiplegia: effects of functional electrical stimulation. Arch Phys Med Rehabil 1999;80:328-33118. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415-142519. Francisco GE, Boake C. Improvement in walking speed in post-stroke spastic hemiplegia after intrathecal baclofen therapy: a preliminary study. Arch Phys Med Rehabil 2003;84:1194-119920. Meythaler JM, Guin-Renfroe S, Brunner RC, Hadley MN. Intrathecal baclofen for spastic hypertonia from stroke: Stroke 2001;32:2099-210921. Brown JA, Lutsep H, Gramer SC, Weinand M. Motor cortex stimulation for enhancement of recovery after stroke: case report. Neurol Res 2003;25:815-81822. Gresham G, Duncan PW, Stason WB; Post-stroke Rehabilitation Guideline panel. Clinical Practice Guideline Number 16. Post-Stroke Rehabilitation. Rockville, Md, U.S. department of Health and Human Services, Agency for Health Care Policy and Research.199523. Hankey GJ, eikelboom JW. Adding aspirin to clopidogrel after TIA and ischemic stroke: benefits do not match risks. Neurology 2005;64:1117-1121