Skip to content

Stroke, Acute (Cerebrovascular Accident [CVA])

BASICS

  • Definition: Sudden onset of focal neurologic deficit due to ischemia/infarction or hemorrhage in the brain.
  • Types:
  • Ischemic (thrombotic/embolic) – 87%
  • Hemorrhagic (intracerebral or subarachnoid) – 13%

EPIDEMIOLOGY

  • Incidence: ~795,000 strokes annually (U.S.)
  • Prevalence: 550/100,000
  • Age: Risk increases >45 yrs; highest in 7th/8th decades.
  • Sex: Males > females at younger ages; higher in women ≥75 yrs.

ETIOLOGY & PATHOPHYSIOLOGY

  • Ischemic stroke: Thrombosis, embolism, systemic hypoperfusion.
  • Hemorrhagic stroke: Most often due to hypertension.
  • Genetics: Polygenic, multifactorial.

RISK FACTORS

  • Uncontrollable: Age, gender, race, family history, prior stroke/TIA.
  • Modifiable:
  • Metabolic: diabetes, dyslipidemia
  • Lifestyle: smoking, alcohol, drugs, inactivity
  • Cardiovascular: HTN, atrial fibrillation, valvular heart disease, endocarditis, recent MI, carotid stenosis, hypercoagulable states, PFO

GENERAL PREVENTION

  • Smoking cessation, regular exercise, weight control (BMI <30)
  • Control BP, glucose, lipids
  • Antiplatelet therapy in high-risk patients
  • Anticoagulation for atrial fibrillation

COMMONLY ASSOCIATED CONDITIONS

  • Coronary artery disease (major cause of death in first 5 years post-stroke)

DIAGNOSIS

HISTORY

  • Time of symptom onset is critical
  • Symptoms: sudden arm/leg/face weakness, speech or swallowing difficulty, vertigo, vision changes, altered consciousness
  • Vomiting and severe headache suggest hemorrhage

PHYSICAL EXAM

  • ABCs: Airway, Breathing, Circulation
  • Vitals: Pulse, BP
  • Neuro Exam:
  • Anterior cerebral artery: Leg > face/arm motor/sensory deficit, gait apraxia
  • Middle cerebral artery:
    • Dominant: aphasia, face/arm > leg weakness, hemianopia
    • Non-dominant: neglect, hemianopia, similar weakness pattern
  • Posterior cerebral artery: hemianopia, visual hallucinations, sensory/motor deficits
  • Posterior circulation: diplopia, vertigo, ataxia, Horner syndrome, dysphagia
  • Predictive findings: Facial paresis, arm weakness/drift, abnormal speech

DIFFERENTIAL DIAGNOSIS

  • Complicated migraine, Todd paralysis, infection (meningitis, encephalitis), metabolic/toxic (hypoglycemia), tumor, trauma, other intracranial hemorrhage (epidural, subdural, SAH)

DIAGNOSTIC TESTS & INTERPRETATION

  • Labs: Glucose, ECG, CBC, electrolytes, troponin, PT/PTT/INR
  • Imaging: Emergent noncontrast head CT (within 20 min of ED arrival)
  • Multimodal CT/MRI improves diagnosis
  • MRI (DW) more sensitive for AIS/posterior lesions
  • Before IV tPA: Only noncontrast CT and glucose required unless contraindications
  • Echocardiogram: If suspect cardioembolic source

  • ECG monitoring: 30-day event monitor for cryptogenic stroke

  • Early CT findings of ischemia: Hyperdense MCA, loss of gray-white differentiation, sulcal effacement

TREATMENT

  • BP management:
  • Withhold antihypertensives unless SBP >220 or DBP >120 (goal: lower 15% in first 24 hr)
  • If thrombolysis planned: BP <185/110 before tPA
  • ICH: goal BP 160/90 or MAP 110
  • Thrombolysis:
  • IV tPA (alteplase) within 3 hours (up to 4.5 hr in select patients)
  • Dose: 0.9 mg/kg (max 90 mg), 10% bolus, rest over 60 min
  • Door-to-needle time <60 min
  • Monitor neuro status and BP closely
  • Discontinue if severe HA, angioedema, HTN, N/V develop

  • Obtain follow-up CT/MRI at 24 hr before antiplatelet/anticoagulation

  • Antiplatelet: Aspirin 160–300 mg/day within 24–48 hr after AIS

  • BP control options: Labetalol, nicardipine

  • Carotid endarterectomy: >70% ipsilateral stenosis, or 50–69% in selected patients

  • Endovascular thrombectomy: Effective up to 16–24 hours for eligible patients with large vessel occlusion

ISSUES FOR REFERRAL

  • Neurology follow-up 1 week after discharge

ADDITIONAL THERAPIES

  • DVT prophylaxis
  • Early PT/OT/speech therapy
  • Statin continuation
  • Deep brain stimulation and fluoxetine for motor recovery (if indicated)
  • Acupuncture may help neurologic function (limited evidence)

SURGERY/OTHER PROCEDURES

  • Ventricular drain for hydrocephalus
  • Decompressive surgery for major cerebellar infarction

ADMISSION, INPATIENT, NURSING CARE

  • Frequent neuro exams for 24 hr (monitor for cerebral edema)
  • Head elevation if ICP ↑; horizontal bed for ischemic stroke acute phase
  • Monitor cardiac rhythm 24 hr minimum
  • NPO until swallow evaluation; maintain O2 >94%, normal saline IV hydration
  • Treat hypo/hyperglycemia (target glucose 140–180 mg/dL)
  • Correct anticoagulant-induced ICH with vitamin K/FFP/PCC

ONGOING CARE

  • Aggressive risk factor management for secondary prevention (aspirin, clopidogrel, Aggrenox)
  • PT/OT/SLP as needed
  • Fall precautions, nutrition, and skin care

PATIENT EDUCATION

  • Refer to American Stroke Association: stroke.org

PROGNOSIS

  • Highly variable; NIHSS predicts prognosis

COMPLICATIONS

  • Acute: Brain herniation, hemorrhagic transformation, MI, CHF, dysphagia, aspiration, UTI, DVT, PE, malnutrition, pressure sores
  • Chronic: Falls, depression, dementia, contractures, OSA

ICD-10

  • I63.9: Cerebral infarction, unspecified
  • I61.9: Nontraumatic intracerebral hemorrhage, unspecified
  • I63.50: Cereb infarction due to unspecified occlusion/stenosis of unspecified cerebral artery

CLINICAL PEARLS

  • Unless hemorrhagic or thrombolysis, do not lower BP acutely.
  • IV tPA indicated within 4.5 hours for most ischemic strokes; earlier = better.
  • Noncontrast head CT is essential prior to thrombolysis.
  • Early recognition and treatment are critical to outcome.