|Ischemic Stroke |
|Lacunar infarct ||Small (< 1.5 cm) lesions in the basal ganglia, pons, cerebellum, or internal capsule; less often in deep cerebral white matter; prognosis generally good; clinical features depend on location, but may worsen over first 24–36 hours. ||MRI with diffusion-weighted sequences usually defines the area of infarction; CT is insensitive acutely but can be used to exclude hemorrhage. ||Antiplatelet; control risk factors (hypertension, tobacco use, hypercholesterolemia, and diabetes mellitus). |
|Carotid circulation obstruction ||See text—signs vary depending on occluded vessel. ||Noncontrast CT to exclude hemorrhage but findings may be normal during first 6–24 hours of an ischemic stroke; diffusion-weighted MRI is gold standard for identifying acute stroke; electrocardiography, carotid duplex studies, echocardiography, blood glucose, complete blood count, and tests for hyperlipidemia are indicated; ambulatory ECG monitoring, including extended monitoring in selected instances; CTA, MRA, or conventional angiography in selected cases; tests for hypercoagulable states in selected cases. || |
0–3 hours in United States: intravenous thrombolytics (approved in Europe for up to 4.5 hours).
0–6 hours: endovascular mechanical embolectomy.
6–24 hours: endovascular mechanical embolectomy in select cases.
Secondary prevention: antiplatelet agent is first-line therapy; anticoagulation without heparin bridge for cardioembolic strokes due to atrial fibrillation and other select cases when no contraindications exist; control risk factors as above.
|Vertebrobasilar occlusion ||See text—signs vary based on location of occluded vessel. ||As for carotid circulation obstruction. ||As for carotid circulation obstruction. |
|Hemorrhagic Stroke |
|Spontaneous intracerebral hemorrhage || |
Commonly associated with hypertension; also with bleeding disorders, amyloid angiopathy.
Hypertensive hemorrhage is located commonly in the basal ganglia, pons, thalamus, cerebellum, and less commonly the cerebral white matter.
|Noncontrast CT is superior to MRI for detecting bleeds of < 48 hours duration; laboratory tests to identify bleeding disorder: angiography may be indicated to exclude aneurysm or AVM in younger patients without hypertension. Do not perform lumbar puncture. || |
Lower systolic blood pressure to 140 mm Hg; cerebellar bleeds or hematomas with gross mass effect may require urgent surgical evacuation.
AVM: surgical resection indicated to prevent further bleeding; other modalities to treat nonoperable AVMs available at specialized centers.
|Subarachnoid hemorrhage ||Present with sudden onset of worst headache of life, may lead rapidly to loss of consciousness; signs of meningeal irritation often present; etiology usually aneurysm or AVM, but 20% have no source identified. ||CT to confirm diagnosis, but may be normal in rare instances; if CT negative and suspicion high, perform lumbar puncture to look for red blood cells or xanthochromia; angiography to determine source of bleed in candidates for treatment. || |
Lower systolic blood pressure to < 140 mm Hg immediately.
Aneurysm: prevent further bleeding by clipping aneurysm or coil embolization; nimodipine helps prevent vasospasm; once aneurysm has been obliterated intravenous fluids and induced hypertension to prevent vasospasm; angioplasty may also reverse symptomatic vasospasm.
AVM: as above.