Stroke

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Hemorrhagic stroke
Ischemic 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]

Overview

Causes

The following table lists causes for stroke.[1][2][3][4][5][6][7][8][9][10]

Cause
Disease Lethal causes Common causes Less common causes
Transient ischemic attack (TIA) Emboli from cardiac source (mostly secondary to AF) Arterial dissection
Ischemic stroke
Intracerebral hemorrhage ---
Subarachnoid hemorrhage

Rupture of an aneurysm

Rupture of an aneurysm

Subdural hemorrhage Rupture of bridging vessels Trauma (motor vehicle accidents, falls, and assaults)
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

Arteriovenous malformation

Intraventricular hemorrhage (IVH) ---

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 Symptoms Physical Examination Past medical history Diagnostic tests Other Findings
Headache ↓LOC Motor weakness Abnormal sensory Motor Deficit Sensory deficit Speech difficulty Gait abnormality Cranial nerves CT /MRI CSF Findings Gold standard test
Brain tumour[11] ✔ - - - ✔ ✔ ✔ - ✔ Weight loss, fatigue ✔ Cancer cells[12] MRI Cachexia, gradual progression of symptoms
Hemorrhagic stroke ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ - Hypertension ✔ - CT scan without contrast[13][14] Neck stiffness
Subdural hemorrhage ✔ ✔ ✔ ✔ ✔ - - - ✔ Trauma, fall ✔ Xanthochromia[15] CT scan without contrast[13][14] Confusion, dizziness, nausea, vomiting
Neurosyphilis[16][17] ✔ - ✔ ✔ ✔ ✔ - ✔ - STIs ✔ ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[18]

Blindness, confusion, depression,

Abnormal gait

Complex or atypical migraine ✔ - ✔ ✔ - - ✔ - - Family history of migraine - - Clinical assesment Presence of aura, nausea, vomiting
Hypertensive encephalopathy ✔ ✔ - - - - ✔ ✔ - Hypertension ✔ - Clinical assesment Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy - ✔ - - - ✔ ✔ ✔ ✔ History of alcohal abuse - - Clinical assesment and lab findings Ophthalmoplegia, confusion
CNS abscess ✔ ✔ - - ✔ ✔ ✔ - - History of drug abuse, endocarditis, immunosupression ✔ ↑ leukocytes, ↓ glucose and ↑ protien MRI is more sensitive and specific High grade fever, fatigue,nausea, vomiting
Drug toxicity - ✔ - ✔ ✔ ✔ - ✔ - - - - Drug screen test Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ History of emotional stress - - Diagnosis of exclusion Tremors, blindness, difficulty swallowing
Metabolic disturbances (electrolyte imbalance, hypoglycemia) - ✔ ✔ ✔ ✔ ✔ - - ✔ - - Hypoglycemia, hypo and hypernatremia, hypo and hyperkalemia Depends on the cause Confusion, seizures, palpitations, sweating, dizziness, low serum, glucose
Meningitis or encephalitis ✔ - - - - ✔ ✔ - - History of fever and malaise - ↑ Leukocytes,

↑ Protein

↓ Glucose

CSF analysis[19] Fever, neck

rigidity

Multiple sclerosis exacerbation - - ✔ ✔ - ✔ ✔ ✔ ✔ History of relapses and remissions ✔ ↑ CSF IgG levels

(monoclonal bands)

Clinical assesment and MRI [20] Blurry vision, urinary incontinence, fatigue
Seizure ✔ ✔ - - ✔ ✔ - - ✔ Previous history of seizures - Mass lesion Clinical assesment and EEG [21] Confusion, apathy, irritability,

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%.[22]
  • 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[22]
  • The incidence of new (610, 000) or recurrent stroke (185, 000) is estimated to be 795000 people annually or 250 cases per 100, 000.[22]
  • It is estimated that one incidence of stroke happens every 4 sec with death occuring every 4 min.[22]
  • About 87% of all strokes are ischemic strokes[23]
  • Stroke costs the United States an estimated $34 billion each year[23]

Worldwide

  • According to WHO, the incidence of stroke is estimated to be 15 million people annually, worldwide.[24].
  • Out of these, 5 million die and 5 million are left permanently disbaled.[24].

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. [23]
  • According to WHO, stroke also occurs in about 8% of children with sickle cell disease.[24].
  • In 2009, 34% of people hospitalized for stroke were younger than 65 years[23]
  • The incidence of stroke in people aged 18 to 50 years is estimated to be approximately 10%. [22]

The rate of decline in mortality rates of stroke in different age groups is as follows:[22]

  • >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.[23]
  • Hispanics’ risk for stroke falls between that of whites and blacks [23]

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.[23]

Diagnosis

References

  1. ↑ Kishimoto M, Arakawa KC (2003). "A patient with wegener granulomatosis and intraventricular hemorrhage". J Clin Rheumatol. 9 (6): 354–8. doi:10.1097/01.rhu.0000089967.51779.d7. PMID 17043443.
  2. ↑ Challa VR, Richards F, Davis CH (1981). "Intraventricular hemorrhage from pituitary apoplexy". Surg Neurol. 16 (5): 360–1. PMID 7336321.
  3. ↑ Flint AC, Roebken A, Singh V (2008). "Primary intraventricular hemorrhage: yield of diagnostic angiography and clinical outcome". Neurocrit Care. 8 (3): 330–6. doi:10.1007/s12028-008-9070-2. PMID 18320145.
  4. ↑ Fukutake T (2011). "Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL): from discovery to gene identification". J Stroke Cerebrovasc Dis. 20 (2): 85–93. doi:10.1016/j.jstrokecerebrovasdis.2010.11.008. PMID 21215656.
  5. ↑ Meretoja A, Strbian D, Putaala J, Curtze S, Haapaniemi E, Mustanoja S; et al. (2012). "SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage". Stroke. 43 (10): 2592–7. doi:10.1161/STROKEAHA.112.661603. PMID 22858729.
  6. ↑ Hart, Robert G., Bradley S. Boop, and David C. Anderson. "Oral anticoagulants and intracranial hemorrhage facts and hypotheses." Stroke 26.8 (1995): 1471-1477.
  7. ↑ Knudsen, Katherine A., et al. "Clinical diagnosis of cerebral amyloid angiopathy: validation of the Boston criteria." Neurology 56.4 (2001): 537-539.
  8. ↑ Lovelock, C. E., A. J. Molyneux, and P. M. Rothwell. "Change in incidence and aetiology of intracerebral haemorrhage in Oxfordshire, UK, between 1981 and 2006: a population-based study." The Lancet Neurology 6.6 (2007): 487-493.
  9. ↑ Rümke CL (1975). "Letter: Implications of the statement: No side effects were observed". N Engl J Med. 292 (7): 372–3. PMID 1117973.
  10. ↑ Hanley DF (2009). "Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage". Stroke. 40 (4): 1533–8. doi:10.1161/STROKEAHA.108.535419. PMC 2744212. PMID 19246695.
  11. ↑ Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
  12. ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  13. ↑ 13.0 13.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  14. ↑ 14.0 14.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  15. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  16. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  17. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  18. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  19. ↑ Carbonnelle E (2009). "[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]". Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.
  20. ↑ Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). "Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group". Arch Neurol. 51 (1): 61–6. PMID 8274111.
  21. ↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.
  22. ↑ 22.0 22.1 22.2 22.3 22.4 22.5 Writing Group Members. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ; et al. (2016). "Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association". Circulation. 133 (4): e38–360. doi:10.1161/CIR.0000000000000350. PMID 26673558.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 23.5 23.6 http://www.cdc.gov/stroke/facts.htm Accessed on November 3, 2016
  24. ↑ 24.0 24.1 24.2 Mackay, Judith, et al. The atlas of heart disease and stroke. World Health Organization, 2004 Accessed on November 3 2016

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