Stroke

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]; Tarek Nafee, M.D. [3]; Sara Mehrsefat, M.D. [4]

Causes

The following table lists causes for stroke.

Cause
Disease	Lethal causes	Common causes	Less common causes
Transient ischemic attack (TIA)	Emboli from cardiac source (mostly secondary to AF)	Atherosclerotic plaque Thrombosis	Arterial dissection
Ischemic stroke	Atrial fibrillation Eclampsia Infective endocarditis Myocardial infarction Pulmonary embolism	Aneurysm Arteriovenous malformations Atherosclerosis Atrial fibrillation Embolism Hypertension Subarachnoid hemorrhage Thrombosis Transient ischemic attack Traumatic brain injury Warfarin	Takayasu arteritis Vasculitis Vasoconstriction Infective endocarditis Lacunar infarcts Left atrial myxoma
Intracerebral hemorrhage	---	Long-standing hypertension Cerebral amyloid angiopathy	Arteriovenous malformations (AVMs) Aneurysms Cocaine Amphetamines Vasculitis Liver disease Anticoagulant medication Thrombolytic therapy Brain tumor Hemorrhagic transformation of an ischemic stroke Moyamoya disease Tumors Encephalitis
Subarachnoid hemorrhage	Rupture of an aneurysm Saccular aneurysms (most common cause) Fusiform aneurysms Mycotic aneurysms	Rupture of an aneurysm Saccular aneurysms (most common cause) Fusiform aneurysms Mycotic aneurysms	Arteriovenous malformation Dural arteriovenous fistula Perimesencephalic Intracranial arterial dissection Amyloid angiopathy Cerebral venous thrombosis Cerebral vasculitis Reversible vasoconstriction syndrome Cerebral hyperperfusion syndrome after carotid endarterectomy Reversible posterior leukoencephalopathy syndrome Brain or cervical tumors Illicit drug use (cocaine, amphetamines)
Subdural hemorrhage	Rupture of bridging vessels	Trauma (motor vehicle accidents, falls, and assaults)	Aneurysmal subarachnoid hemorrhage Arteriovenous malformation Meningioma Dural metastases Coagulopathy Neurosurgical procedures Cocaine abuse
Epidural hemorrhage	Rupture of middle meningeal arteries	Trauma (motor vehicle accidents, falls, and assaults)
Intraparenchymal hemorrhage	---	Trauma (motor vehicle accidents, falls, and assaults)	Rupture of an aneurysm Saccular aneurysms (most common cause) Fusiform aneurysms Mycotic aneurysms Arteriovenous malformation
Intraventricular hemorrhage (IVH)	---	Secondary to intracerebral hemorrhage Trauma (motor vehicle accidents, falls, and assaults) Vascular malformations (usually arteriovenous malformations or arteriovenous fistulae)	Intraventricular tumors (papilloma, neurocytoma, meningioma, metastases, astrocytoma, ependymoma) Intraventricular aneurysms Moyamoya disease Pituitary apoplexy Vasculitis

Classification

Transient ischemic attack

• A transient ischemic attack is caused by the temporary disturbance of blood supply to a restricted area of the brain, resulting in brief neurologic dysfunction that usually persists for less than 24 hours.

Stroke

Stroke

Ischemic

Hemorrhagic

Large vessel thromboembolism

Cardioembolic

Small vessel or Lacunar infarct

Intra-axial

Extra-axial

Intracerebral (ICH)

Subarachnoid hemorrhage (SAH)

Subdural Hemorrhage

Epidural Hemorrhage

Intraparenchymal hemorrhage

Intraventricular hemorrhage (IVH)

Cerebral microbleeds

Differential diagnosis

Diseases	Diagnostic tests			Physical Examination					Symptoms				Past medical history	Other Findings
	CT /MRI	CSF Findings	Gold standard test	Motor Deficit	Sensory deficit	Speech difficulty	Gait abnormality	Cranial nerves	Headache	LOC	Motor weakness	Abnormal sensations
Brain tumour	✔	Cancer cells	MRI	✔	✔	✔	✔	✔	✔					Cachexia, gradual progression of symptoms
Hemorrhagic stroke	✔	Xanthochromia	CT scan without contrast	✔	✔	✔	✔	✔	✔	✔	✔		Hypertension	Neck stiffness
Subdural hemorrhage	✔		CT scan without contrast	✔	✔	✔	✔	✔	✔	✔	✔		Trauma/fall	Confusion, dizziness, nausea, vomiting
Neurosyphilis	✔	↑ Leukocytes and protein	CSF VDRL-specifc CSF FTA-Ab -sensitive	✔	✔	✔	✔		✔		✔	✔	STIs	Blindness, confusion, depression, Abnormal gait
Complex or atypical migraine			Clinical assesment			✔			✔			✔	Family history of migraine	Presence of aura, nausea, vomiting
Hypertensive encephalopathy	✔		Clinical assesment			✔	✔	✔	✔	✔			History of hypertension	Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy						✔	✔			✔			History of alcohal abuse	Ophthalmoplegia, confusion
CNS abscess	✔	↑ leukocytes, ↓ glucose and ↑ protien	MRI is more sensitive and specific	✔	✔	✔			✔	✔			History of drug abuse, endocarditis, ↓ immune status	High grade fever, fatigue,nausea, vomiting
Drug toxicity						✔	✔			✔				Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder			Diagnosis of exclusion	✔	✔	✔	✔		✔	✔	✔	✔		Tremors, blindness, difficulty swallowing
Electrolyte disturbance			Depends on the cause											Confusion, seizures
Meningitis or encephalitis		↑ Leukocytes, ↑ Protein ↓ Glucose	CSF analysis					✔	✔					Fever, neck rigidity
Multiple sclerosis exacerbation	✔	↑ CSF IgG levels (monoclonal bands)	Clinical assesment and MRI	✔	✔	✔	✔	✔			✔	✔	History of relapses and remissions	Blurry vision, urinary incontinence, fatigue
Seizure			Clinical assesment and EEG	✔					✔	✔		✔	Previous history of seizures	Confusion, apathy, irritability,
Hypoglycemia			Serum blood glucose HbA1c			✔	✔		✔	✔		✔	History of diabetes	Palpitations, sweating, dizziness, low serum, glucose

Epidemiology and Demographics

Stroke in USA

• Stroke is a leading cause of serious long-term disability
• In USA, the incidence and mortality rates of stroke has significantly decreased compared to previous years.
• From year 2003 to 2013, the mortality rates due to stroke declined by 18.5%.
• In 2013, stroke became the fifth leading cause of death.
• The case fatality rate of stroke is estimated to be 41.7 deaths per 100, 000 population
• The incidence of new (610, 000) or recurrent stroke (185, 000) is estimated to be 795000 people annually or 250 cases per 100, 000.
• It is estimated that one incidence of stroke happens every 4 sec with death occuring every 4 min.
• About 87% of all strokes are ischemic strokes
• Stroke costs the United States an estimated $34 billion each year

Worldwide

• According to WHO, the incidence of stroke is estimated to be 15 million people annually, worldwide..
• Out of these, 5 million die and 5 million are left permanently disbaled..

Age

• Stroke can occur in all age groups. However, the incidence of stroke is less among individuals age less than 40 years of age and the risk increases with increasing age.
• According to WHO, stroke also occurs in about 8% of children with sickle cell disease..
• In 2009, 34% of people hospitalized for stroke were younger than 65 years
• The incidence of stroke in people aged 18 to 50 years is estimated to be approximately 10%.

The rate of decline in mortality rates of stroke in different age groups is as follows:

• >65 years of age: from 534.1 to 245.2 per 100,000
• 45-65 years of age: from 43.5 to 20.2 per 100,000
• 18 to 44 years of age: from from 3.7 to 2.0 per 100,000

Gender

There is increased incidence of stroke in men as compared to women.

Race

• The risk of incidence of first stroke is twice in african american population as compared to whites with increased mortality rates.
• Hispanics’ risk for stroke falls between that of whites and blacks

Geographical distribution

• There is increased incidence and mortality rates of stroke in developing countries as compared to developed countries due to low socio economic status and heath facilites.
• In USA, the highest death rates from stroke are in the southeastern United States.