Overview of Stroke

Initial symptoms of stroke occur suddenly. Symptoms depend on the location of infarction (see figure Areas of the brain by function Areas of the brain by function ).

Thus, symptoms can include numbness, weakness of limbs or face; aphasia; confusion; visual disturbances in one or both eyes (eg, transient monocular blindness); dizziness or loss of balance and coordination; and headache.

Neurologic deficits are used to determine the location of stroke (see table Selected Stroke Syndromes Selected Stroke Syndromes ). Anterior circulation stroke typically causes unilateral symptoms. Posterior circulation stroke can cause unilateral or bilateral deficits and is more likely to affect consciousness, especially when the basilar artery is involved.

Systemic or autonomic disturbances (eg, hypertension, fever) occasionally occur.

Other manifestations, rather than neurologic deficits, often suggest the type of stroke. For example,

Evaluation aims to establish the following:

Stroke is suspected in patients with any of the following:

Glucose is measured at bedside to rule out hypoglycemia.

If stroke is still suspected, immediate neuroimaging Diagnosis Ischemic stroke is sudden neurologic deficits that result from focal cerebral ischemia associated with permanent brain infarction (eg, positive results on diffusion-weighted MRI). Common causes... read more is required to differentiate hemorrhagic from ischemic stroke and to detect signs of increased intracranial pressure. CT is sensitive for intracranial blood but may be normal or show only subtle changes during the first hours of symptoms after anterior circulation ischemic stroke. CT also misses some small posterior circulation strokes. MRI is sensitive for intracranial blood and may detect signs of ischemic stroke missed by CT, but CT can usually be done more rapidly. If CT does not confirm clinically suspected stroke, diffusion-weighted MRI can usually detect ischemic stroke.

If consciousness is impaired and lateralizing signs are absent or equivocal, further tests Testing Coma is unresponsiveness from which the patient cannot be aroused and in which the patient's eyes remain closed. Impaired consciousness refers to similar, less severe disturbances of consciousness... read more to check for other causes are done.

After the stroke is identified as ischemic or hemorrhagic, tests are done to determine the cause. Patients are also evaluated for coexisting acute general disorders (eg, infection, dehydration, hypoxia, hyperglycemia, hypertension). Patients are asked about depression, which commonly occurs after stroke. A dysphagia team evaluates swallowing; sometimes a barium swallow study is necessary.

Stabilization may need to precede complete evaluation. Comatose or obtunded patients (eg, Glasgow Coma Score ≤ 8) may require airway support Overview of Mechanical Ventilation Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more . If increased intracranial pressure is suspected, intracranial pressure monitoring Intracranial Pressure (ICP) Monitoring Some monitoring of critical care patients depends on direct observation and physical examination and is intermittent, with the frequency depending on the patient’s illness. Other monitoring... read more and measures to reduce cerebral edema Increased intracranial pressure Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more may be necessary.

Specific acute treatments vary by type of stroke. They may include reperfusion Acute stroke treatment (eg, recombinant tissue plasminogen activator, thrombolysis, mechanical thrombectomy) for some ischemic strokes.

Providing supportive care, correcting coexisting abnormalities (eg, fever, hypoxia, dehydration, hyperglycemia, sometimes hypertension), and preventing and treating complications are vital during the acute phase and convalescence (see table Strategies to Prevent and Treat Stroke Complications Strategies to Prevent and Treat Stroke Complications ); these measures clearly improve clinical outcomes (1 Treatment reference Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more ). During convalescence, measures to prevent aspiration Prevention Aspiration pneumonitis and pneumonia are caused by inhaling toxic and/or irritant substances, most commonly large volumes of upper airway secretions or gastric contents, into the lungs. Chemical... read more , deep venous thrombosis Deep Venous Thrombosis (DVT) Prevention It is preferable and safer to prevent deep venous thrombosis (DVT) than to treat it, particularly in high-risk patients. DVT prophylaxis begins with risk assessment. Risk, along with other factors... read more , urinary tract infections Prevention Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more , pressure ulcers Pressure Injuries A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more , and undernutrition Undernutrition A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more may be necessary. Passive exercises, particularly of paralyzed limbs, and breathing exercises are started early to prevent contractures, atelectasis, and pneumonia.

After a stroke, most patients require rehabilitation Stroke Rehabilitation Rehabilitation after stroke aims to preserve or improve range of motion, muscle strength, bowel and bladder function, and functional and cognitive abilities. Specific programs are based on the... read more (occupational and physical therapy) to maximize functional recovery. Some need additional therapies (eg, speech therapy, feeding restrictions). For rehabilitation, an interdisciplinary approach is best.

Depression after stroke may require antidepressants; many patients benefit from counseling.

Modifying risk factors through lifestyle changes (eg, stopping cigarette smoking) and drug therapy (eg, for hypertension) can help delay or prevent subsequent strokes. Other stroke prevention strategies are chosen based on the patient's risk factors. For ischemic stroke prevention Long-term stroke treatment , strategies may include procedures (eg, carotid endarterectomy, stent placement), antiplatelet therapy, and anticoagulation.