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Stroke Management Overview

Jul 19, 2025

Overview

This lecture reviews the evolving management of stroke and transient ischemic attacks (TIA), emphasizing landmark studies, key stroke syndromes, modern diagnostic strategies, and current evidence-based acute interventions.

Stroke History & Landmark Trials

  • The NINDS trials (1995) first evaluated thrombolytic therapy (tPA) within 3 hours of stroke onset, sparking significant debate and evolving practices.
  • Subsequent trials have generally been neutral, but stroke intervention has grown into a major medical field.
  • In 2015, MR CLEAN, EXTEND IA, and ESCAPE trials shifted focus to endovascular neurointerventions, leveraging advanced imaging for treatment decisions.

Stroke Pathophysiology & Syndromes

  • Two main stroke types: ischemic (80-90%, due to vessel blockage) and hemorrhagic (due to bleeding).
  • Ischemic strokes can be thrombotic (local clot) or embolic (clot from elsewhere, commonly the heart).
  • Middle cerebral artery (MCA) stroke: contralateral face/arm > leg weakness, facial droop sparing the forehead, possible contralateral hemianopsia.
  • Anterior cerebral artery (ACA): contralateral leg > arm/face weakness.
  • Posterior cerebral artery (PCA): contralateral homonymous hemianopsia, visual agnosia, minimal motor involvement.
  • Vertebrobasilar artery: central vertigo and brainstem deficits.
  • Lacunar strokes: pure motor syndromes, no sensory loss.

TIA (Transient Ischemic Attack)

  • TIA: brief neurologic dysfunction from focal ischemia without infarction, confirmed with neuroimaging.
  • Symptoms usually resolve within 30 minutes; diagnosis is clinical and imaging-based.
  • Not all symptoms (e.g., syncope, paresthesia alone, amnesia) point to TIA/stroke.
  • Hypoglycemia and Todd’s paralysis are important mimics.

ED Evaluation & Initial Management

  • Rapid ABCs and check blood glucose in all suspected stroke/TIA cases.
  • Perform ECG to screen for atrial fibrillation and exclude acute coronary syndrome.
  • Head CT without contrast is essential prior to thrombolytic use.
  • CT perfusion or MR diffusion imaging helps identify infarct core and ischemic penumbra.

Acute Intervention & Blood Pressure Management

  • Do not acutely lower BP in ischemic stroke unless >220/120 mmHg, or >185/110 mmHg if considering tPA.
  • Nicardipine is the preferred antihypertensive; clivipidine is an alternative.
  • For hemorrhagic stroke, lower systolic BP to 160–180 mmHg is safe.
  • No thrombolytics should be given without imaging to rule out bleed.

Evolving Treatment Paradigms

  • Neuroimaging now guides intervention based on tissue viability (“core” vs “penumbra”) instead of strict timing.
  • Endovascular therapy is increasingly important for large vessel occlusion, sometimes without prior thrombolytics.
  • Mobile CT ambulances have not improved patient outcomes.

Key Terms & Definitions

  • Ischemic Stroke — brain damage due to blocked blood flow.
  • Hemorrhagic Stroke — brain injury from bleeding into/around the brain.
  • TIA (Transient Ischemic Attack) — brief neurologic deficit without infarction.
  • tPA (Tissue Plasminogen Activator) — clot-busting drug for ischemic stroke.
  • Ischemic Core — area of irreversibly infarcted brain tissue.
  • Ischemic Penumbra — brain at risk but potentially salvageable.
  • Lacunar Stroke — small vessel stroke causing pure motor or sensory symptoms.
  • Todd’s Paralysis — transient weakness after a seizure.

Action Items / Next Steps

  • Review stroke and TIA neuroanatomy and vascular distributions.
  • Familiarize yourself with current AHA stroke guidelines and exclusion criteria for thrombolytics.
  • Practice documenting a full neurologic exam and stroke workup.
  • Understand local protocols for acute imaging and stroke alerts.

Certainly! Here's a comprehensive, in-depth summary and review of the lecture on stroke and transient ischemic attacks (TIA), covering all key points and nuances:

Comprehensive Summary and Review: Stroke and TIA Management

1. Historical Context and Landmark Trials

  • NINDS Trials (1995):

    • First large randomized controlled trials evaluating thrombolytic therapy (tPA) for ischemic stroke within a 3-hour window.
    • These trials were groundbreaking but controversial due to issues like patient allocation, baseline morbidity, and defining what constitutes a "good outcome" after stroke treatment.
    • Outcome measures varied: complete neurologic recovery, improvement on modified Rankin Scale, or survival with some deficits.
    • Despite limitations, these trials launched the era of thrombolytic therapy and stroke intervention.

  • Subsequent Trials:

    • Since 1995, about 13 additional trials have been conducted, mostly neutral, not dramatically changing practice but expanding knowledge.

  • 2015 Trials (MR CLEAN, EXTEND IA, ESCAPE):

    • Marked a paradigm shift by introducing endovascular neurointervention (mechanical thrombectomy).
    • These trials used advanced imaging (CT perfusion, MR diffusion-weighted imaging) to identify ischemic penumbra and infarct core, moving beyond a strict time-based approach ("time is brain") to a neurogeographic risk-benefit analysis.
    • Demonstrated that some patients presenting beyond traditional time windows could still benefit from intervention if salvageable brain tissue was present.

2. Stroke Pathophysiology and Syndromes

  • Types of Stroke:

    • Ischemic Stroke (80-90%): Due to vessel occlusion, either thrombotic (local clot) or embolic (clot from heart or plaques).
    • Hemorrhagic Stroke: Due to bleeding into brain tissue.

  • Vascular Territories and Clinical Syndromes:

    • Middle Cerebral Artery (MCA):

      • Most common ischemic stroke location.
      • Contralateral weakness predominantly affecting face and arm more than leg.
      • Facial droop typically spares the forehead due to dual innervation (distinguishes from Bell’s palsy which affects the entire face).
      • Contralateral homonymous hemianopsia common.
      • Eyes tend to deviate toward the side of the lesion.
      • CT imaging shows large infarcts in MCA territory.

    • Anterior Cerebral Artery (ACA):

      • Less common.
      • Contralateral leg weakness > arm/face.
      • Sensory deficits in the same distribution.

    • Posterior Cerebral Artery (PCA):

      • Rare.
      • Contralateral homonymous hemianopsia, visual agnosia.
      • Minimal motor deficits.

    • Vertebrobasilar Artery:

      • Associated with brainstem symptoms, central vertigo.
      • Important to differentiate central vertigo from peripheral causes.

    • Lacunar Strokes:

      • Small vessel strokes affecting deep brain structures.
      • Present with pure motor hemiparesis or pure sensory symptoms without cortical signs.

3. Transient Ischemic Attack (TIA)

  • Definition:

    • Transient episode of neurologic dysfunction caused by focal ischemia without infarction (confirmed by imaging).
    • Symptoms typically last less than 30 minutes, often under 10 minutes, and always less than 24 hours.

  • Diagnostic Challenges:

    • Diagnosis often clinical and retrospective, as symptoms resolve before evaluation.
    • Requires neuroimaging to exclude infarction.
    • Many symptoms are not suggestive of TIA: syncope, isolated paresthesia, amnesia, tinnitus, loss of balance.
    • Important mimics include hypoglycemia and Todd’s paralysis (post-seizure transient weakness).

4. Emergency Department (ED) Evaluation

  • Initial Priorities:

    • ABCs (Airway, Breathing, Circulation).
    • Rapid blood glucose check to exclude hypoglycemia (a common stroke mimic).
    • ECG to detect atrial fibrillation (a major embolic source) and to identify concomitant acute coronary syndrome (up to 5% of stroke patients).

  • Neuroimaging:

    • Non-contrast head CT is mandatory before thrombolytic therapy to exclude hemorrhage.
    • Advanced imaging (CT angiography, CT perfusion, MR diffusion) increasingly used to assess infarct core and penumbra, guiding treatment decisions.

  • Neurologic Exam:

    • Detailed documentation including cranial nerves, motor/sensory deficits, presence of carotid bruits, and heart rhythm.

5. Acute Management and Blood Pressure Control

  • Blood Pressure (BP) in Ischemic Stroke:

    • Generally, do not lower BP acutely unless >220/120 mmHg.
    • If thrombolytics (tPA) are planned, BP must be lowered below 185/110 mmHg.
    • Preferred agents:
      • Nicardipine (calcium channel blocker) – well-studied, titratable.
      • Clevidipine – newer, more expensive, also titratable.
    • Oral ACE inhibitors (e.g., lisinopril) may be started later.

  • Blood Pressure in Hemorrhagic Stroke:

    • Target systolic BP 160-180 mmHg to reduce hematoma expansion.
    • Nicardipine or clevidipine preferred.

  • Rationale for Elevated BP in Stroke:

    • May be compensatory to maintain cerebral perfusion.
    • Stroke may impair cerebral autoregulation.
    • Anxiety and stress can also elevate BP.

6. Thrombolytic Therapy (tPA)

  • Indications:

    • Ischemic stroke within a defined time window (traditionally 3-4.5 hours).
    • No evidence of hemorrhage on CT.

  • Risks:

    • Intracranial hemorrhage (~6% risk).
    • Gastrointestinal bleeding.

  • Informed Consent:

    • Essential to discuss risks and benefits with patients/families.
    • Use clear, understandable language bridging complex literature and bedside communication.

  • Dosing and Agents:

    • Alteplase (tPA) is standard.
    • Emerging evidence suggests tenecteplase may be superior in some cases.

7. Endovascular Therapy

  • Mechanical Thrombectomy:
    • Indicated for large vessel occlusions (e.g., MCA).
    • Trials (MR CLEAN, EXTEND IA, ESCAPE) demonstrated improved outcomes.
    • Can be performed with or without prior tPA administration.
    • Represents a shift toward personalized, tissue-based treatment rather than strict time windows.

8. Mobile CT and Prehospital Stroke Care

  • Mobile CT Ambulances:
    • Equipped with CT scanners and remote radiology support.
    • Originated in Berlin (STEMO program).
    • Despite theoretical benefits, no proven improvement in clinical outcomes.
    • Very costly (~$2 million per unit).

9. Stroke Belt and Epidemiology

  • Geographic Disparities:
    • Southeastern U.S. ("Stroke Belt") has higher stroke mortality rates.
    • Contributing factors: poverty, limited access to comprehensive stroke care, poor primary care access, lifestyle factors.
    • Important for public health and resource allocation.

10. Differential Diagnosis and Mimics

  • Common Stroke Mimics:
    • Hypoglycemia (always check glucose first).
    • Todd’s paralysis (post-ictal weakness).
    • Syncope (rarely stroke).
    • Peripheral vertigo (vs. central vertigo from vertebrobasilar stroke).

11. Clinical Pearls and Practice Points

  • Facial Droop in Stroke vs Bell’s Palsy:

    • Stroke spares forehead (due to bilateral cortical innervation).
    • Bell’s palsy affects entire ipsilateral face.

  • Eyes Deviation:

    • In MCA stroke, eyes deviate toward the lesion side.

  • Stroke Syndromes and Neuroanatomy:

    • Understanding vascular territories is critical for diagnosis and localization.

  • Blood Pressure Management:

    • Avoid aggressive lowering unless indicated.
    • Use titratable IV agents when needed.

  • Imaging:

    • Always get non-contrast CT before thrombolytics.
    • Use advanced imaging to guide intervention decisions.

  • Informed Consent for tPA:

    • Discuss risks, benefits, and alternatives clearly.

  • Endovascular Therapy:

    • Increasingly important, especially for large vessel occlusions.

12. Future Directions

  • Stroke care is evolving from a time-based to a tissue-based approach, leveraging advanced imaging to identify salvageable brain tissue.
  • Endovascular interventions are becoming standard for select patients.
  • Ongoing research is refining thrombolytic agents and treatment windows.
  • Public health efforts are needed to address disparities in stroke outcomes, especially in high-risk regions.

Summary

This lecture provides a thorough overview of stroke and TIA, emphasizing the evolution of diagnosis and treatment from the landmark NINDS trials to modern endovascular therapies. It highlights the importance of understanding stroke syndromes based on vascular territories, the critical role of neuroimaging in guiding therapy, and the nuanced management of blood pressure and thrombolytics. The discussion also covers the challenges of diagnosing TIA, the pitfalls of stroke mimics, and the public health implications of geographic disparities in stroke mortality. The future of stroke care is promising, with personalized, tissue-based interventions improving patient outcomes.

If you want, I can help you create a detailed study guide or help clarify any specific section further!

Certainly! Here's a comprehensive, in-depth summary and review of the lecture on stroke and transient ischemic attacks (TIA), covering all key points and nuances:

Comprehensive Summary and Review: Stroke and TIA Management

1. Historical Context and Landmark Trials

  • NINDS Trials (1995):

    • First large randomized controlled trials evaluating thrombolytic therapy (tPA) for ischemic stroke within a 3-hour window.
    • These trials were groundbreaking but controversial due to issues like patient allocation, baseline morbidity, and defining what constitutes a "good outcome" after stroke treatment.
    • Outcome measures varied: complete neurologic recovery, improvement on modified Rankin Scale, or survival with some deficits.
    • Despite limitations, these trials launched the era of thrombolytic therapy and stroke intervention.

  • Subsequent Trials:

    • Since 1995, about 13 additional trials have been conducted, mostly neutral, not dramatically changing practice but expanding knowledge.

  • 2015 Trials (MR CLEAN, EXTEND IA, ESCAPE):

    • Marked a paradigm shift by introducing endovascular neurointervention (mechanical thrombectomy).
    • These trials used advanced imaging (CT perfusion, MR diffusion-weighted imaging) to identify ischemic penumbra and infarct core, moving beyond a strict time-based approach ("time is brain") to a neurogeographic risk-benefit analysis.
    • Demonstrated that some patients presenting beyond traditional time windows could still benefit from intervention if salvageable brain tissue was present.

2. Stroke Pathophysiology and Syndromes

  • Types of Stroke:

    • Ischemic Stroke (80-90%): Due to vessel occlusion, either thrombotic (local clot) or embolic (clot from heart or plaques).
    • Hemorrhagic Stroke: Due to bleeding into brain tissue.

  • Vascular Territories and Clinical Syndromes:

    • Middle Cerebral Artery (MCA):

      • Most common ischemic stroke location.
      • Contralateral weakness predominantly affecting face and arm more than leg.
      • Facial droop typically spares the forehead due to dual innervation (distinguishes from Bell’s palsy which affects the entire face).
      • Contralateral homonymous hemianopsia common.
      • Eyes tend to deviate toward the side of the lesion.
      • CT imaging shows large infarcts in MCA territory.

    • Anterior Cerebral Artery (ACA):

      • Less common.
      • Contralateral leg weakness > arm/face.
      • Sensory deficits in the same distribution.

    • Posterior Cerebral Artery (PCA):

      • Rare.
      • Contralateral homonymous hemianopsia, visual agnosia.
      • Minimal motor deficits.

    • Vertebrobasilar Artery:

      • Associated with brainstem symptoms, central vertigo.
      • Important to differentiate central vertigo from peripheral causes.

    • Lacunar Strokes:

      • Small vessel strokes affecting deep brain structures.
      • Present with pure motor hemiparesis or pure sensory symptoms without cortical signs.

3. Transient Ischemic Attack (TIA)

  • Definition:

    • Transient episode of neurologic dysfunction caused by focal ischemia without infarction (confirmed by imaging).
    • Symptoms typically last less than 30 minutes, often under 10 minutes, and always less than 24 hours.

  • Diagnostic Challenges:

    • Diagnosis often clinical and retrospective, as symptoms resolve before evaluation.
    • Requires neuroimaging to exclude infarction.
    • Many symptoms are not suggestive of TIA: syncope, isolated paresthesia, amnesia, tinnitus, loss of balance.
    • Important mimics include hypoglycemia and Todd’s paralysis (post-seizure transient weakness).

4. Emergency Department (ED) Evaluation

  • Initial Priorities:

    • ABCs (Airway, Breathing, Circulation).
    • Rapid blood glucose check to exclude hypoglycemia (a common stroke mimic).
    • ECG to detect atrial fibrillation (a major embolic source) and to identify concomitant acute coronary syndrome (up to 5% of stroke patients).

  • Neuroimaging:

    • Non-contrast head CT is mandatory before thrombolytic therapy to exclude hemorrhage.
    • Advanced imaging (CT angiography, CT perfusion, MR diffusion) increasingly used to assess infarct core and penumbra, guiding treatment decisions.

  • Neurologic Exam:

    • Detailed documentation including cranial nerves, motor/sensory deficits, presence of carotid bruits, and heart rhythm.

5. Acute Management and Blood Pressure Control

  • Blood Pressure (BP) in Ischemic Stroke:

    • Generally, do not lower BP acutely unless >220/120 mmHg.
    • If thrombolytics (tPA) are planned, BP must be lowered below 185/110 mmHg.
    • Preferred agents:
      • Nicardipine (calcium channel blocker) – well-studied, titratable.
      • Clevidipine – newer, more expensive, also titratable.
    • Oral ACE inhibitors (e.g., lisinopril) may be started later.

  • Blood Pressure in Hemorrhagic Stroke:

    • Target systolic BP 160-180 mmHg to reduce hematoma expansion.
    • Nicardipine or clevidipine preferred.

  • Rationale for Elevated BP in Stroke:

    • May be compensatory to maintain cerebral perfusion.
    • Stroke may impair cerebral autoregulation.
    • Anxiety and stress can also elevate BP.

6. Thrombolytic Therapy (tPA)

  • Indications:

    • Ischemic stroke within a defined time window (traditionally 3-4.5 hours).
    • No evidence of hemorrhage on CT.

  • Risks:

    • Intracranial hemorrhage (~6% risk).
    • Gastrointestinal bleeding.

  • Informed Consent:

    • Essential to discuss risks and benefits with patients/families.
    • Use clear, understandable language bridging complex literature and bedside communication.

  • Dosing and Agents:

    • Alteplase (tPA) is standard.
    • Emerging evidence suggests tenecteplase may be superior in some cases.

7. Endovascular Therapy

  • Mechanical Thrombectomy:
    • Indicated for large vessel occlusions (e.g., MCA).
    • Trials (MR CLEAN, EXTEND IA, ESCAPE) demonstrated improved outcomes.
    • Can be performed with or without prior tPA administration.
    • Represents a shift toward personalized, tissue-based treatment rather than strict time windows.

8. Mobile CT and Prehospital Stroke Care

  • Mobile CT Ambulances:
    • Equipped with CT scanners and remote radiology support.
    • Originated in Berlin (STEMO program).
    • Despite theoretical benefits, no proven improvement in clinical outcomes.
    • Very costly (~$2 million per unit).

9. Stroke Belt and Epidemiology

  • Geographic Disparities:
    • Southeastern U.S. ("Stroke Belt") has higher stroke mortality rates.
    • Contributing factors: poverty, limited access to comprehensive stroke care, poor primary care access, lifestyle factors.
    • Important for public health and resource allocation.

10. Differential Diagnosis and Mimics

  • Common Stroke Mimics:
    • Hypoglycemia (always check glucose first).
    • Todd’s paralysis (post-ictal weakness).
    • Syncope (rarely stroke).
    • Peripheral vertigo (vs. central vertigo from vertebrobasilar stroke).

11. Clinical Pearls and Practice Points

  • Facial Droop in Stroke vs Bell’s Palsy:

    • Stroke spares forehead (due to bilateral cortical innervation).
    • Bell’s palsy affects entire ipsilateral face.

  • Eyes Deviation:

    • In MCA stroke, eyes deviate toward the lesion side.

  • Stroke Syndromes and Neuroanatomy:

    • Understanding vascular territories is critical for diagnosis and localization.

  • Blood Pressure Management:

    • Avoid aggressive lowering unless indicated.
    • Use titratable IV agents when needed.

  • Imaging:

    • Always get non-contrast CT before thrombolytics.
    • Use advanced imaging to guide intervention decisions.

  • Informed Consent for tPA:

    • Discuss risks, benefits, and alternatives clearly.

  • Endovascular Therapy:

    • Increasingly important, especially for large vessel occlusions.

12. Future Directions

  • Stroke care is evolving from a time-based to a tissue-based approach, leveraging advanced imaging to identify salvageable brain tissue.
  • Endovascular interventions are becoming standard for select patients.
  • Ongoing research is refining thrombolytic agents and treatment windows.
  • Public health efforts are needed to address disparities in stroke outcomes, especially in high-risk regions.

Summary

This lecture provides a thorough overview of stroke and TIA, emphasizing the evolution of diagnosis and treatment from the landmark NINDS trials to modern endovascular therapies. It highlights the importance of understanding stroke syndromes based on vascular territories, the critical role of neuroimaging in guiding therapy, and the nuanced management of blood pressure and thrombolytics. The discussion also covers the challenges of diagnosing TIA, the pitfalls of stroke mimics, and the public health implications of geographic disparities in stroke mortality. The future of stroke care is promising, with personalized, tissue-based interventions improving patient outcomes.

If you want, I can help you create a detailed study guide or help clarify any specific section further!

Full transcript