STROKE, 5TH MBBS, Integrated from Dr Eze L.I. & Adeleke’s Textbook, M4

Definition: Stroke = Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting 24 hours or longer or leading to death, with no apparent cause other than that of vascular origin. TIA (Transoent Ischemic Attack) = transient episode without acute infarction. Types Ischemic (85%) – thrombotic, embolic (cardioembolic or artery-to-artery), lacunar, watershed. Hemorrhagic (15%) – intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH). Risk Factors Non-modifiable: age, male sex, race (Black/Asian > White), family history. Modifiable: hypertension (#1), diabetes, AF, hyperlipidemia, smoking, alcohol, obesity, sedentary lifestyle, oral contraceptives, carotid stenosis, hypercoagulability. Pathophysiology Brain needs constant O2/glucose. CBF <16–18 mL/100g/min → infarction within 1 hour. Ischemic penumbra = salvageable tissue if reperfused early. Hemorrhagic stroke → mass effect, herniation, rapid death. Clinical Features (by artery) MCA (most common): contralateral weakness (face/arm > leg), sensory loss, homonymous hemianopia, aphasia (left), neglect (right). ACA: leg > arm weakness, abulia, primitive reflexes. PCA: homonymous hemianopia, cortical blindness, memory loss. Lacunar: pure motor, pure sensory, clumsy-hand dysarthria. Brainstem: lateral medullary (Wallenberg) = ipsilateral facial pain/temp loss + contralateral limb loss, dysphagia, Horner’s; locked-in syndrome; pseudobulbar palsy. Investigations Non-contrast CT brain (emergency) – hemorrhage seen immediately; ischemia takes hours to days. MRI, CTA/MRA, carotid doppler, ECG/echo, LP (if SAH suspected with negative CT). Blood: FBC, glucose, lipids, clotting profile, HbA1c, ESR, VDRL. Acute Management Ischemic Stroke Thrombolysis (alteplase 0.9 mg/kg, max 90 mg) within ≤4.5 hours if no contraindications (BP >185/110, platelets <100k, glucose <2.8 or >21.2, recent surgery/head trauma/MI, heparin use within 48h). Mechanical thrombectomy for large vessel occlusion. Antiplatelet: aspirin 325 mg within 24–48 hours (not within 24h of thrombolysis). Anticoagulation only if comorbid indication (AF, HF, valvular disease) – heparin, warfarin, NOACs. BP control: treat only if >220/120 mmHg (or >185/110 if thrombolysis candidate). ICP control: 30° head up, mannitol, hypertonic saline. Hemorrhagic Stroke Lower SBP to 160–170 mmHg (not too low). Reverse coagulopathy. Surgery for large bleeds, aneurysms, cerebellar hemorrhage. DVT prevention in ICH: intermittent pneumatic compression (IPC) + early mobilization. Pharmacological prophylaxis (heparin) is delayed until bleeding stability (usually after 24–48 hours if no active bleeding, but high caution). Complications Acute: cerebral edema, herniation, seizures, hemorrhagic transformation, aspiration pneumonia, SIADH, DVT/PE. Chronic: seizures, depression, UTI, pressure ulcers, joint stiffness. Rehabilitation Start early: physiotherapy, occupational therapy, speech therapy, psychotherapy. Secondary Prevention Lifestyle: smoking cessation, exercise, low-salt/low-fat diet. Antiplatelets (for non-cardioembolic ischemic stroke): aspirin, vasoprin, clopidogrel. Anticoagulants (for AF, valvular, cardioembolic): warfarin, LMWH (enoxaparin), NOACs (dabigatran, rivaroxaban, apixaban). Statins: atorvastatin, rosuvastatin (reduce recurrence irrespective of LDL). Antihypertensives.