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Ischemic stroke

Based on duration of symptoms

Based on cause)

TIA

Acute Ischemic stroke

abc

Site of Infarction	Specific area involved	Physical exam findings
Site of Infarction	Specific area involved	Motor strength	Reflexes	cranial nerves involved	Sensations	Coordination	Babinski's sign	Pupils	pupillary reflex
Cerebral cortex	Frontal lobe Perietal lobe temporal lobe Occipital lobe	++	+	++	+	+	++	+	+
Brain stem	*Midbrain Pons Medulla	++	++	++	+	+	++	+	+
Cerebellum	Community-acquired, ingestion of undercooked poultry	++	+	++	+	+	++	+	+
"Central pathway involved"	*Spinothalamic tract Corticospinal tract Medial leminscus	±	+	++	++	+	++	+	+

Prognosis of ischemic stroke 1)a)age, stroke severity, stroke mechanism, infarct location, comorbid conditions, clinical findings, and related complication; b) interventions such as thrombolysis, stroke unit care, and rehabilitation can play a major role in the outcome of ischemic strok c)acute phase of stroke, the strongest predictors of outcome are stroke severity and patient age. 2):Bruno A, Biller J, Adams HP Jr, Clarke WR, Woolson RF, Williams LS, et al. Acute blood glucose level and outcome from ischemic stroke.aird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group Acute stroke: usefulness of early CT findings before thrombolytic therapy

3)Poor prognostic factors: Severe middle cerebral artery infarction

Large area of brain involvement
Other co morbid conditons
Advanced age
Severe hemiplegia

4)Good prognostic factors: 5)NIHSS score predicts early mortality predicts prognosis; The NIHSS score strongly predicts the likelihood of a patient's recovery after stroke. A score of > or =16 forecasts a high probability of death or severe disability whereas a score of < or =6 forecasts a good recovery. 6)The 1-year mortality in first-time stroke sufferers is 14% to 24% in persons aged 40 to 69 years, and the 1-year mortality increases to 22% to 27% in patients aged 70 years and older. (Find citation)

CDC Stroke kills almost 130,000 Americans each year—that’s 1 out of every 20 deaths.1 On average, one American dies from stroke every 4 minutes.2 Every year, more than 795,000 people in the United States have a stroke. About 610,000 of these are first or new strokes. About 185,00 strokes—nearly one of four—are in people who have had a previous stroke.2 About 87% of all strokes are ischemic strokes, when blood flow to the brain is blocked.2 Stroke costs the United States an estimated $34 billion each year.2 This total includes the cost of health care services, medications to treat stroke, and missed days of work. Stroke is a leading cause of serious long-term disability.2 Classification of Ischemic Stroke: According to the causative agent:

Thrombotic
Embolic
Small vessel disease
Systemic hypoperfusion
Crytogenic-Undetermined etiology

Toast classification of ischemic stroke: According to anatomical location:

Cortical

frontal, parietal, temporal and occipital lobes
disrupt higher cognitive function.

Subcortical

internal capsule, thalamus, basal ganglia, brainstem and cerebellum.

Watershed areas

According to vessel involved:

Anterial cerebral artery
Middle cerebral artery
Posterior cerebral artery

According to duration of symptoms:

Acute
subacute
Chronic

According to clinical presentaion

Pure Motor
Pure Sensory
Mixed

Class I
"1."(Level of Evidence: ) "
"2."(Level of Evidence: ) "

Class IIa
"1."(Level of Evidence: ) "

Class IIb
"1."(Level of Evidence:) "
"2."(Level of Evidence:) "

Stroke epidemiology PMID: 26673558 In 2013, stroke fell from the fourth to the fifth leading cause of death in the United States, behind diseases of the heart, cancer, chronic lower respiratory diseases, and unintentional injury. ●● From 2003 to 2013, the relative rate of stroke death fell by 33.7% and the actual number of stroke deaths declined by 18.2%. Yet each year, ≈795 000 people continue to experience a new or recurrent stroke (ischemic or hemorrhagic). Approximately 610 000 of these are first events and 185 000 are recurrent stroke events. In 2013, stroke caused ≈1 of every 20 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke, and someone dies of one approximately every 4 minutes. ●● The decline in stroke mortality over the past decades, a major improvement in population health observed for both sexes and all race and age groups, has resulted from reduced stroke incidence and lower case fatality rates. The significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. The hypertension control efforts initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality, with lower blood pressure distributions in the population. Control of diabetes mellitus and high cholesterol and smoking cessation programs, particularly in combination with hypertension treatment, also appear to have contributed to the decline in stroke mortality. ●● Approximately 10% of all strokes occur in people 18 to 50 years of age. Between 1995 and 2008, National Health Interview Survey data reveal that hospitalizations for ischemic stroke increased among adolescents and young adults (aged 5–44 years), whereas subarachnoid hemorrhage hospitalizations decreased during that same time period. ●● Stroke death rates declined more among people aged ≥65 years (−54.1%; from 534.1 to 245.2 per 100 000) than among those aged 45 to 64 years (−53.6%; from 43.5 to 20.2 per 100 000) or those aged 18 to 44 years (−45.9%; from 3.7 to 2.0 per 100 000).

Common complications


Duration	Complications
Common complications
Early complications	Suppurative complications Tonsillar abscess Sinusitis Otitis media Necrotizing fasciitis Meningitis Jugular vein thrombophlebitis Non suppurative complications Acute rheumatic fever (ARF) Scarlet fever Streptococcal toxic shock syndrome Acute glomerulonephritis Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)
Late complications	Pneumonia Encephalitis Aseptic meningitis Guillain barre syndrome Transverse myelitis Myositis and rhabdomyolysis

Adenovirus	Laryngotracheitis Bronchitis Pneumonia Otitis media Meningoencephalitis Hepatitis Myocarditis Nephritis Neutropenia Disseminated intravascular coagulation
Cocksackie A virus	Aseptic meningitis Myocarditis Acute flaccid paralysis Conjunctival ulceration Brainstem encephalitis
Ebstein barr virus	Airway obstruction Splenic rupture X-linked lymphoproliferative disease Lymphomatoid granulomatosis
Less common complications
Gonococcus	Disseminated gonorrhea Meningitis Endocarditis
Diphtheria	Airway obstruction Myocarditis Polyneuropathies 10th cranial nerve disorder 9th cranial nerve disorder Peripheral motor neuropathy Diaphragm paralysis Neurogenic bladder dysfunction Acute renal failure Septicemia
Heamophilis influenza	Retropharyngeal abcess Epiglottitis
Fusobacterium necrophorum	Peritonsillar abscess Lemierre's syndrome
Parainfluenza virus	Retropharyngeal abcess Pneumonia


Pathogen	Complications
Diphtheria	A B C D
Gonococcus	A B C D
'	A B C D
Cocksackie A virus	A B C D
Ebstein barr virus	A B C D
Gonococcus	B C D
HIV	B C D

MRI syphilis 17628376

Among women the median prevalence of genital warts was 1.1% (range 0.8 to 2.3) across all jurisdictions, compared to 4.0% (range 2.9 to 4.7) for MSM and 4.9% (range 3.3 to 5.5) for MSW.


Varicella containing vaccines	Indications	Efficacy and immunogenicity	Recommended dose
Varicella vaccine (Varivax)	Approved for persons 12 months and older	Detectable antibody 97% of children 12 months through 12 years following 1 dose 99% of persons 13 years and older after 2 doses 70% to 90% effective against any varicella disease 90%-100% effective against severe varicella disease	2 doses separated by at least 4 weeks
Measles-mumps-rubella-varicella vaccine (ProQuad)	Approved for children 12 months through 12 years Do not use for persons 13 years and older	Efficacy of MMRV vaccine was inferred from that of MMR vaccine and varicella vaccine on the basis of noninferior immunogenicity Formal studies to evaluate the clinical efficacy of MMRV vaccine have not been performed^[1]	May be used for both first and second doses of MMR and varicella vaccines Minimum interval between doses is 3 months
Herpes zoster vaccine (Zostavax)	Approved for persons 50 years and older	Vaccine recipients 60 to 80 years of age had 51% fewer episodes of zoster Efficacy declines with increasing age Significantly reduces the risk of postherpetic neuralgia Reduces the risk of zoster 69.8% in persons 50 through 59 years of age	Single dose at age 60 years or older (whether or not they report a prior episode of herpes zoster)
New Herpes zoster vaccine (Shingrix)	Adults aged 50 years or older (first pivotal phase 3 trial) Adults aged 70 years and over (second pivotal phase 4 trial)	89% (95% confidence interval: 69– 97) efficacious in preventing PHN in people aged 70 years 91% (95% confidence interval: 76– 98) efficacious in people aged 50 years and over.	Two doses

20 mg/kg/dose twice daily (max = 500 mg/dose)