stroke; cerebrovascular accident (CVA)

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Introduction

Cerebrovascular accident (CVA) or stroke is the rapid onset of a neurological deficit that persists for at least 24 hours.

Etiology

* may be likely cause in younger patients; unlikely to cause subsequent stroke in the absence of hypercoagulability[4]

Epidemiology

  • 4% of individuals (mean age 75 years) will suffer from stroke within 4 years[10]
  • 7% of individuals ((baseline age 45-64 years)) will suffer stroke within 24 years[43]
  • no association with dietary fat[16]
  • incidence of stroke is declining, but severity is not[19][43]
  • worldwide, death from stroke is declining, but incidence is increasing[37]
    • lower income countries account for the increase
    • incidence of stroke in high-income countries has declined
  • worldwide, children & adults < 65 years of age account for 1/3 of strokes[37]

Pathology

  • blockage of a blood vessel supplying or draining the brain (75%)
. elapsed time changes
6 hrs. no changes
8-48 hrs. swelling
> 48 hrs. soft, friable
2 weeks liquefaction
> 3 weeks cavitation (~1mL/3 months)

cell sensitivity to ischemia:

  • neurons > oligodendrocytes > astrocytes > microglia > blood vessels

brain region sensitivity to ischemia:

  • hippocampus (CA1) > extrapyramidal layer (3) of neocortex > cerebellar Purkinje cells > inferior olivary neurons > subthalamic nucleus

Microscopic pathology

. elapsed time changes
8 - 12 hrs. classic ischemic changes*
12 - 48 hrs. macrophages appear
48 hrs. macrophages become foamy
3rd day proliferating astrocytes, gemistocytes
7th day capillary wall thickening
> 30 days astrocytes only remaining (depends on size)

* classic ischemic changes: eosinophilic degeneration, glassy cytoplasm, loss of Nissl substance, hyperchromatic nuclei, neuronal shrinkage & increase in perineuronal space)

History

Clinical manifestations

Laboratory

Diagnostic procedures

Radiology

Complications

* among anticonvulsants used as monotherapy in poststroke epilepsy, lamotrigine is associated with the lowest risk for mortality, valproate the highest[66]

Differential diagnosis

Management

* 1/6 of patients will have another stroke within 5 years[9]

More general terms

More specific terms

Additional terms

References

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