Although stroke was once thought of as an incurable and static disease, numerous advances have been made over the past decade in the prevention, diagnosis, management, and rehabilitation of this disorder. In particular, the treatment and rehabilitation paradigm has improved significantly as a result of advances in acute interventions, risk reduction, medical devices, therapeutic modalities and exercise, robotics, diagnostic imaging techniques, and our overall understanding of the disease process itself. This resulted in a 35% reduction in the population-based death rate due to stroke between 1998 and 2008. Even with this progress, stroke remains a leading cause of death and disability in the world. Multidisciplinary stroke rehabilitation remains the primary treatment for post-stroke disability and should begin as soon as possible to optimize functional recovery and avoid potential complications and setbacks.
ACUTE DIAGNOSIS & MANAGEMENT OF STROKE
Stroke is a sudden-onset neurologic dysfunction resulting from focal disruption to the cerebrovascular system that requires rapid diagnosis and intervention. Acute neurologic symptoms are a medical emergency that justify immediate transport to the emergency department of an acute-care hospital for evaluation and treatment. It is vital to differentiate hemorrhagic from nonhemorrhagic (thrombotic or thromboembolic) strokes as soon as possible after onset of symptoms. Noncontrast computed tomography (CT) scan (Figure 14–1) is highly sensitive for acute bleeding and is commonly used for this purpose. Intravenous tissue plasminogen activator (tPA) should be considered for selected patients with acute thrombotic stroke within 3 hours of symptom onset, but other acute interventions can also be considered after that timeline.
Computed tomography image showing evidence of an acute ischemic stroke in the left middle cerebral artery distribution.
A thorough neurologic examination, combined with immediate neuroimaging study is indicated to evaluate acute neurologic symptoms suggestive of stroke. Magnetic resonance imaging (MRI) (Figure 14–2) is more sensitive for detecting posterior fossa lesions and acute ischemia within 24 hours of the stroke, especially using diffusion-weighted studies (Figure 14–2C). Patients with cardioembolic strokes caused by atrial fibrillation or associated with a proven embolic source in the heart and great vessels should be considered for anticoagulant therapy. Acute strokes that occur simultaneously in two areas of the brain subserved by different blood vessels are considered to be embolic until proven otherwise. Magnetic resonance angiography can help identify and characterize occlusion or stenosis of major cerebral vessels and the presence of cerebral aneurysms of moderate or large size. (Figure 14–3).
Magnetic resonance imaging scan showing an acute right deep cerebral white matter infarction involving the right corona radiata and periventricular regions. A: T2 imaging. B: Fluid-attenuated inversion recovery imaging. C: Diffusion-weighted imaging.
Magnetic resonance angiography imaging showing (A) ...