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
- see specific type of stroke
- hemorrhagic stroke
- intracerebral hemorrhage (15%)
- subarachnoid hemorrhage (10%)
- ischemic stroke (75%)
- hemorrhagic stroke
- cryptogenic stroke[4]
- shared risk factors (hemorrhagic stroke & ischemic stroke)
- hypertension
- cocaine abuse
- tobacco abuse
- malignancies[46]
- lung cancer (RR=4.2)
- pancreatic cancer (RR=2.6)
- colorectal cancer (RR=2.5)
- breast cancer (RR=1.4)
- risk factors for severe stroke
* 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]
- incidence of stroke worldwide will increase by 50% by 2050 if action is not taken to reduce risk factors[69]
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
Table
| . 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
- onset, improvement or progression of symptoms, anatomic location of deficit, activity prior to onset, headache, nausea/vomiting, loss of consciousness, brisk neck movement, visual aura, scotoma, vertigo, seizure, trauma, confusion, dysarthria, incontinence, dysphagia, palpitations, prior TIAs or strokes, amaurosis fugax, HTN, diabetes, CAD, hyper- lipidemia, IVDA, cocaine, valvular heart disease, migraine, anticoagulants, oral contraceptives, tobacco, alcohol
Clinical manifestations
- focal or multifocal neurologic deficit evolving over second to minutes, persisting > 24 hours
- carotid or vertebrobasilar artery territories
- involvement of upper &/or lower extremity &/or face on opposite side, opposite visual field or eye onsame side
- motor dysfunction:
- dysarthria; weakness; clumsiness; pronator drift
- sensory: numbness; paresthesias
- blindness
- monocular blindness (same side)
- homonymous hemianopia (opposite visual field)
- carotid artery territory
- paresthesias of hand, arm & face (contralateral)
- hemiparesis more common with ischemic stroke
- weakness of hand, arm & face (contralateral)
- aphasia (dominant hemisphere)
- dysarthria
- unilateral neglect
- loss of vision (ipsilateral eye)
- carotid bruit
- lacunar TIAs
- hemibody sensory loss or paresthesias
- pure motor hemiparesis
- vertebrobasilar territory:
- carotid or vertebrobasilar artery territories
- nonfocal symptoms suggest increased intracranial pressure
- common with:
- hemorrhagic stroke
- major ischemic stroke with cerebral edema
- headache
- nausea & vomiting
- impaired consciousness
- elevated systolic blood pressure[15]
- common with:
Laboratory
- all patients[4]
- serum glucose
- electrolytes: serum K+ < 4.0 meq/L confers 2.5 fold increased risk of stroke in patients taking diuretics
- serum creatinine, BUN
- markers of myocardial infarction
- complete blood count (CBC)
- prothrombin time, INR, aPTT
- selected patients
- CSF analysis for xanthochromia if hemorrhagic stroke suspected[36]
Diagnostic procedures
- all patients
- selected patients
- echocardiography
- cerebral angiography
- determines localization & degree of carotid stenosis
- necessary prior to carotid endarterectomy
- identifies aneurysms & arteriovenous malformations (AVM)
- lumbar puncture
- CT negative for blood
- subarachnoid hemorrhage suspected
- CSF analysis for xanothochromia[36]
- electroencephalography (EEG) if seizures suspected[4]
Radiology
- all patients
- computed tomography (CT) of head
- obtained within 24 hours distinguishes hemorrhagic stroke from ischemic stroke[36]
- CT changes in ischemic stroke appear after 24 hours
- MRI[18][20] alternative to CT
- can detect early ischemic strokes not seen by CT
- can detect hemorrhagic strokes not seen on CT
- proposed standard of care[20]
- not as fast as CT
- patient in less monitored environment than CT[4]
- computed tomography (CT) of head
- selected patients
- carotid artery ultrasound (Doppler)
- chest X-ray (if lung disease suspected)[4]
Complications
- anxiety (27-40%) develop clinically significant anxiety[8]
- depression is common after stroke or TIA (14% at 1 year)[30]
- major depression with psychosis is a further complication
- cognitive impairment:[21]
- more common in hemorrhagic stroke than ischemic stroke
- more common with left hemisphere stroke, cortical stroke
- cognitive decline immediately after stroke & continued for at least 6-years thereafter[50]
- cognitive decline can occur both before & after a stroke[60]
- delirium occurs in 12% of patients admitted to stroke unit; associated with poor prognosis[28]
- residual focal neurologic deficits
- seizures early after stroke*
- more common with hemorrhagic stroke than ischemic stroke (15% vs 4%)[29]
- more common with cortical stroke than subcortical stroke (19% vs 10%)
- do not predict mortality or function at 6 months[29]
- risk of pneumonia is highest in the 1st week after stroke[68]
- PTSD in 25% of survivors within 1 year after stroke[34]
- fatigue after stroke due to depression, sleep apnea, heart failure[4]
- reemergence or recrudescence of stroke symptoms in the setting of an intercurrent illness[61]
- stroke often compromises well-being of family caregivers[48]
- spouses of stroke survivors have reduced health-related quality-of-life many years after stroke[51]
- 1/6 of patients will have another stroke within 5 years[9]
* among anticonvulsants used as monotherapy in poststroke epilepsy, lamotrigine is associated with the lowest risk for mortality, valproate the highest[66]
- disease interaction(s) of stroke with depression
- disease interaction(s) of stroke with urinary incontinence
- disease interaction(s) of stroke with ANCA-associated vasculitis
- disease interaction(s) of stroke with pneumonia
- disease interaction(s) of stroke with Alzheimer's disease
Differential diagnosis
- migraine headache (prodrome)
- head trauma - subdural hematoma
- seizure disorder with postictal hemiparesis
- arteritis
- multiple sclerosis (MS)
- central nervous system (CNS) infection
- intracranial mass lesion: brain tumor, brain abscess (evolution over hours to days)
- dementia (with subacute worsening of cognitive impairment)
- conversion disorder
- cardiac arrhythmia
- drug overdose
- hypertensive encephalopathy
- myasthenia gravis
- syncope
- systemic infection unmasking prior stroke-related deficit
- Bell's palsy
- facial droop with dysarthria may suggest stroke[56]
- paralysis of the forehead muscles suggests Bell's palsy
- most strokes that cause facial weakness have other neurologic signs, such as ipsilateral arm numbness or muscle weakness[56]
Management
- see ACLS algorithm for suspected stroke
- prehospital intravenous magnesium sulfate of no value[45]
- NIH stroke scale recommended during emergency evaluation[4]
- general
- nothing by mouth (NPO) for the 1st 24 hours
- provide supplemental oxygen
- supplemental oxygen in patients with normal SaO2 increases mortality[4]
- control excessively high blood pressure
- withhold antihypertensive treatment (2-7 days) if
- systolic blood pressure < 220 mm Hg and
- diastolic BP < 120 mm Hg[25]
- systolic blood pressure < 220 mm Hg and
- lower threshold (systolic blood pressure 180-200 mm Hg) recommended in patients with hemorrhagic stroke[26]
- target blood pressure is 160/90 mm Hg[4]
- initial goal is to lower systolic blood pressure by 25%
- aggressive control of blood pressure not indicated except in:
- labetolol nay be agent of choice
- negligible effect on intracranial pressure
- ARB not helpful[27]
- withhold antihypertensive treatment (2-7 days) if
- avoid hypotonic fluids (i.e. D5W) which may exacerbate cerebral edema
- avoid glucose containing solutions in diabetic patients
- serial neurologic examination
- DVT prophylaxis
- control of blood glucose; elevated blood glucose may induce increased intracranial pressure
- mechanical ventilation as needed for severe stroke
- early tracheostomy does not improve 6 month outcome[65]
- positioning, mobilization
- avoid mobilization within 24 hours[49]
- of no benefit, possibly harmful
- supine vs sitting up has no effect on disability or mortality after acute stroke[58]
- avoid mobilization within 24 hours[49]
- early physical therapy
- dysphagia screening[23][41]
- clinically assess swallowing before initiating diet
- beside swallowing evaluation with 97% sensitivity & -90% specificity for dysphagia[12]
- prophylactic antibiotics do not prevent pneumonia in post-stroke patients with dysphagia & may result in harm[53]
- patient education:
- expectations
- neurorehabilitation
- specific therapy under ischemic stroke & hemorrhagic stroke
- decompressive craniotomy or craniectomy for intracranial mass lesion effect
- stroke units (neurorehabilitation)
- proposed standard of care[20]
- neurorehabilitation begins when the patient is medically stable
- neurorehabilitation is provided in inpatient stroke units
- in-home or nursing home rehabilitation is generally reserved for patients requiring a slower pace of neurorehabilitation[12]
- inpatient care in a stroke unit associated with diminished mortality 1 year after stroke[54]
- telestroke systems of benefit for rural areas (see telehealth)
- cervical spinal cord stimulation for post-stroke upper extremity paresis investigational[67]
- follow-up:
- depression is common after stroke
- treatment of depression can improve recovery[5]
- nortriptyline is superior to fluoxetine[12]
- citalopram & trazodone have been shown beneficial[12][22]
- antidepressants may improve survival in patients with or without depression[17]
- anxiety is common after stroke (27-40%)[8]
- depression & anxiety often coexist (74%)
- treatment of anxiety may improve recovery
- relaxation theraoy is standard[63]
- deconditioning in common
- fatigue associated with lower extremity weakness[42]
- occupational therapy
- routine occupational therapy of no benefit[47]
- exercise of no benefit in subacute phase after stroke[63]
- caregiver training
- no benefit to training caregivers[35]
- risk factor modification*
- hypertension: systolic BP < 140 mm Hg noninferior to < 120 mm Hg[62]
- smoking
- diabetes
- alcohol abuse
- hypercholesterolemia
- dietary K+ may reduce risk of stroke in patient NOT taking diuretics[12]
- use of chlorthalidone vs HCTZ associated with lower cardiovascular morbidity & mortality[70]
- ACE inhibitor may reduce risk*
- combination of perindopril (Aceon) + indapamide (Lozol) found to reduced risk of recurrent stroke in patients with & without hypertension [7, 9]
- ramipril >= 10 mg/day reduced stroke risk 31% & fatal stroke risk 61%, with BP reduction of 3.8/2.8 mm Hg[11]
- screening for osteoporosis with bone mineral density suggested[59]
- wait at least 9 months after ischemic stroke prior to elective non-cardiac surgery[44]
- horse-riding & music-&-rhythm therapies may help improve function & perceived recovery in patients years after a stroke[57]
- depression is common after stroke
- prognosis
- degree of long-term cognitive impairment after stroke cannot be determined for at least 3 months[12]
- some patients with transient ischemic attack & minor stroke become disabled within 3 months, even without having a recurrent vascular event[32]
- predictors of disability include:
- baseline CT or CT angiography abnormalities
- symptoms at presentation
- female gender
- diabetes mellitus
- severity of initial neurologic deficit is the strongest predictor of long-term disability[4]
- predictors of disability include:
- ref[31] discusses reduction in early mortality by aggressive management vs severe long-term disability
- a first stroke relatively early in adulthood is associated with a higher mortality risk up to 20 years later[33] *
* Follow-up
More general terms
More specific terms
- brainstem infarction
- cerebellar infarction
- hemorrhagic stroke
- ischemic stroke
- silent brain infarct
- stroke, pre & postpartum (antenatal stroke)
- Weber-Gubler syndrome; hemiparesis alternans oculomotoria; superior alternating hemiplegia
Additional terms
- ACLS algorithm for suspected stroke
- hospice guidelines for determining prognosis, stroke & coma
- National Institutes of Health (NIH) Stroke Scale; (NIHSS score)
- neurorehabilitation
- reversible ischemic neurologic deficit (RIND)
- transient ischemic attack (TIA)
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 703
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1019-20
- ↑ Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.
- ↑ 5.0 5.1 Prescriber's Letter 7(9):53 2000
- ↑ Journal Watch 21(1):4, 2001 Bladin CF et al Seizures after stroke: a prospective multicenter study. Arch Neurol 57:1617, 2000 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11074794
- ↑ Prescriber's Letter 8(7):38 2001
- ↑ 8.0 8.1 8.2 UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001 & Sept 25-28 2002
- ↑ 9.0 9.1 Journal Watch 21(21):167, 2001 PROGRESS Collaborative Group, Lancet 358:1033, 2001
- ↑ 10.0 10.1 Journal Watch 21(22):178, 2001 Bernick C et al Silent MRI infarcts and the risk of future stroke: the cardiovascular health study. Neurology 57:1222, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11591840
- ↑ 11.0 11.1 Journal Watch 22(10):77, 2002 Bosch J et al Use of ramipril in preventing stroke: double blind randomised trial. BMJ 324:699, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11909785
Schrader J & Luders S Preventing stroke. BMJ 324:687, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11909769 - ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
Geriatrics Review Syllabus, American Geriatrics Society, 7th edition 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - ↑ Foley N, Teasell R, Salter K, Kruger E, Martino R. Dysphagia treatment post stroke: a systematic review of randomised controlled trials. Age Ageing. 2008 May;37(3):258-64. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18456790
- ↑ Journal Watch 22(19):149, 2002 Green DM et al, Serum potassium level and dietary potassium intake as risk factors for stroke. Neurology 59:314, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12177362
Levine SR & Coull BM, Potassium depletion as a risk factor for stroke: will a banana a day keep your stroke away? Neurology 59: 302, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12177360 - ↑ 15.0 15.1 Journal Watch 22(24):183, 2002 Ikeda M et al Using vital signs to diagnose impaired consciousness: cross sectional observational study. BMJ 325:800, 2002 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/12376438 <Internet> http://bmj.com/cgi/content/full/325/7368/800
- ↑ 16.0 16.1 Journal Watch 23(23):183, 2003 He K et al Dietary fat intake and risk of stroke in male US healthcare professionals: 14 year prospective cohort study. BMJ 327:777, 2003 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/14525873 <Internet> http://bmj.com/cgi/content/full/327/7418/777
- ↑ 17.0 17.1 Prescriber's Letter 10(12):68 2003
Jorge RE et al. Escitalopram and enhancement of cognitive recovery following stroke. Arch Gen Psychiatry 2010 Feb; 67:187. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20124118 - ↑ 18.0 18.1 Journal Watch 24(23):176, 2004 Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, Butman JA, Patronas N, Alger JR, Latour LL, Luby ML, Baird AE, Leary MC, Tremwel M, Ovbiagele B, Fredieu A, Suzuki S, Villablanca JP, Davis S, Dunn B, Todd JW, Ezzeddine MA, Haymore J, Lynch JK, Davis L, Warach S. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004 Oct 20;292(15):1823-30. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15494579
- ↑ 19.0 19.1 Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB, Wolf PA. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA. 2006 Dec 27;296(24):2939-46. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17190894
- ↑ 20.0 20.1 20.2 20.3 Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007 Jan 27;369(9558):293-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17258669
Candelise L, Gattinoni M, Bersano A, Micieli G, Sterzi R, Morabito A; PROSIT Study Group. Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet. 2007 Jan 27;369(9558):299-305. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17258670
Donnan GA, Dewey HM, Davis SM. MRI and stroke: why has it taken so long? Lancet. 2007 Jan 27;369(9558):252-4. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17258648 - ↑ 21.0 21.1 Nys GM et al, Cognitive disorders in acute stroke: Prevalence and clinical determinants. Cerebrovascular Disease 2007, 23:408 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17406110
- ↑ 22.0 22.1 Robinson RG et al, Escitalopram and problem-solving therapy for prevention of poststroke depression: A randomized controlled trial. JAMA 2008, 299:2391 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18505948
- ↑ 23.0 23.1 Turner-Lawrence DE et al A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med 2009 Sep; 54:344. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19362752
- ↑ Furie KL et al Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke. 2011;42:00-00 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20966421 <Internet> http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181f7d043v1
- ↑ 25.0 25.1 Adams HP et al Guidelines for the Early Management of Adults With Ischemic Stroke. Stroke. 2007;38:1655 http://stroke.ahajournals.org/cgi/content/abstract/38/5/1655
- ↑ 26.0 26.1 Morgenstern LB et al Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2010;41:2108 http://stroke.ahajournals.org/cgi/content/abstract/41/9/2108
- ↑ 27.0 27.1 Sandset EC et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): A randomised, placebo-controlled, double-blind trial. Lancet 2011 Feb 26; 377:741. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21316752
- ↑ 28.0 28.1 Oldenbeuving AW et al. Delirium in the acute phase after stroke: Incidence, risk factors, and outcome. Neurology 2011 Mar 15; 76:993. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21307355
- ↑ 29.0 29.1 29.2 Beghi E et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurology 2011 Nov 15; 77:1785 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21975208
De Herdt V et al. Early seizures in intracerebral hemorrhage: Incidence, associated factors, and outcome. Neurology 2011 Nov 15; 77:1794. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21975203 - ↑ 30.0 30.1 El Husseini N et al Depression and Antidepressant Use After Stroke and Transient Ischemic Attack Stroke March 29, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22461330 <Internet> http://stroke.ahajournals.org/content/early/2012/03/29/STROKEAHA.111.643130.abstract
- ↑ 31.0 31.1 Kelly AG et al. Early stroke mortality, patient preferences, and the withdrawal of care bias. Neurology 2012 Aug 28; 79:941 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22927679
- ↑ 32.0 32.1 Coutts SB et al What Causes Disability After Transient Ischemic Attack and Minor Stroke?: Results From the CT And MRI in the Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study Stroke. 2012; published online September 13 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22984013 <Internet> http://stroke.ahajournals.org/search?author1=Shelagh+B.+Coutts&sortspec=date&submit=Submit
- ↑ 33.0 33.1 Rutten-Jacobs LCA Long-term Mortality After Stroke Among Adults Aged 18 to 50 Years. JAMA. 2013;309(11):1136-1144 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23512060 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1669817
- ↑ 34.0 34.1 Edmondson D et al Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review. PLOS One. June 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23840467 <Internet> http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0066435
- ↑ 35.0 35.1 Forster A et al. A structured training programme for caregivers of inpatients after stroke (TRACS): A cluster randomised controlled trial and cost-effectiveness analysis. Lancet 2013 Sep 18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24054816
Hankey GJ. Training caregivers of disabled patients after stroke. Lancet 2013 Sep 18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24054814 - ↑ 36.0 36.1 36.2 36.3 The NNT: Hemorrhagic Stroke Diagnostics and Likelihood Ratios, Explained http://www.thennt.com/lr/hemorrhagic-stroke/
Runchey S, McGee S. Does this patient have a hemorrhagic stroke?: clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010 Jun 9;303(22):2280-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20530782 - ↑ 37.0 37.1 37.2 Feigin VL et al Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. The Lancet Global Health, Early Online Publication, 24 October 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24449944 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61953-4/abstract
Krishnamurthi RV et al Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. The Lancet Global Health, 1(5):e259-e281, November 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25104492 <Internet> http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(13)70089-5/abstract - ↑ Kumar S, Selim MH, Caplan LR. Medical complications after stroke. Lancet Neurol. 2010 Jan;9(1):105-18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20083041
- ↑ Swain S, Turner C, Tyrrell P et al Diagnosis and initial management of acute stroke and transient ischaemic attack: summary of NICE guidance. BMJ. 2008 Jul 24;337:a786. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18653633
- ↑ Bates B, Choi JY, Duncan PW et al Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary. Stroke. 2005 Sep;36(9):2049-56 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16120847
- ↑ 41.0 41.1 Westergren A. Detection of eating difficulties after stroke: a systematic review. Int Nurs Rev. 2006 Jun;53(2):143-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16650034
- ↑ 42.0 42.1 Lewis SJ, Barugh AJ, Greig CA et al Is fatigue after stroke associated with physical deconditioning? A cross-sectional study in ambulatory stroke survivors. Arch Phys Med Rehabil. 2011 Feb;92(2):295-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21272727
- ↑ 43.0 43.1 43.2 Koton S et al Stroke Incidence and Mortality Trends in US Communities, 1987 to 2011. JAMA. 2014;312(3):259-268 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25027141 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1887762
Sacco RL and Dong C Declining Stroke Incidence and Improving Survival in US Communities. Evidence for Success and Future Challenges. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25027138 JAMA. 2014;312(3):237-238 http://jama.jamanetwork.com/article.aspx?articleid=1887742 - ↑ 44.0 44.1 Jorgensen ME et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA 2014 Jul 16; 312:269. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25027142
- ↑ 45.0 45.1 Saver JL et al Prehospital Use of Magnesium Sulfate as Neuroprotection in Acute Stroke. N Engl J Med 2015; 372:528-536. February 5, 2015. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25651247 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1408827
- ↑ 46.0 46.1 Navi BB et al. Association between incident cancer and subsequent stroke. Ann Neurol 2015 Feb; 77:291 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25472885 <Internet> http://onlinelibrary.wiley.com/doi/10.1002/ana.24325/abstract
- ↑ 47.0 47.1 Sackley CM et al. An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): Cluster randomised controlled trial. BMJ 2015 Feb 5; 350:h468 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25657106 <Internet> http://www.bmj.com/content/350/bmj.h468
- ↑ 48.0 48.1 Haley WE et al. Long-term impact of stroke on family caregiver well-being: A population-based case-control study. Neurology 2015 Mar 31; 84:1323 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25740862
Cameron JI and Elliott TR. Studying long-term caregiver health outcomes with methodologic rigor. Neurology 2015 Mar 31; 84:1292 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25740867 - ↑ 49.0 49.1 The AVERT Trial Collaboration Group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): A randomised controlled trial. Lancet 2015 Apr 16; [e-pub] <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25892679 <Internet> http://www.jwatch.org/na37670/2015/05/14/early-mobilization-after-stroke-helpful-or-harmful
- ↑ 50.0 50.1 Levine DA, Galecki AT, Langa KM et al Trajectory of Cognitive Decline After Incident Stroke. JAMA. 2015;314(1):41-51. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26151265 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2382979
Gorelick PB, Nyenhuis D Stroke and Cognitive Decline. JAMA. 2015;314(1):29-30 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26151263 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2382955 - ↑ 51.0 51.1 Persson J et al Spouses of Stroke Survivors Report Reduced Health-Related Quality of Life Even in Long-Term Follow-Up. Results From Sahlgrenska Academy Study on Ischemic Stroke. Stroke. August 20, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26294675 <Internet> http://stroke.ahajournals.org/content/early/2015/08/20/STROKEAHA.115.009791.abstract
- ↑ Go AS, Mozaffarian D, Roger VL et al Heart disease and stroke statistics--2013 update: a report from the American Heart Circulation. 2013 Jan 1;127(1):e6-e245 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23239837
- ↑ 53.0 53.1 Kalra L et al. Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): A prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial. Lancet 2015 Sep 3; PMID: https://www.ncbi.nlm.nih.gov/pubmed/26343840
Meisel A and Smith CJ. Prevention of stroke-associated pneumonia: Where next? Lancet 2015 Sep 3 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26343837 - ↑ 54.0 54.1 Stroke Unit Trialists' Collaboration Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013 Sep 11;9:CD000197 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24026639
- ↑ Alqadri SL, Sreenivasan V, Qureshi AI. Acute hypertensive response management in patients with acute stroke. Curr Cardiol Rep. 2013 Dec;15(12):426. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24142579
- ↑ 56.0 56.1 56.2 Wilner AN Diagnostic Error in Patients With Neurologic Symptoms. Medscape. Oct 31, 2016 http://www.medscape.com/features/slideshow/diagnostic-errors/neurologic
- ↑ 57.0 57.1 Bunketorp-Kall L, Lundgren-Nilsson A, Samuelsson H et al Long-Term Improvements After Multimodal Rehabilitation in Late Phase After Stroke. A Randomized Controlled Trial. Stroke. June 15, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28619985 <Internet> http://stroke.ahajournals.org/content/early/2017/06/15/STROKEAHA.116.016433
- ↑ 58.0 58.1 Anderson CS, Arima H, Lavados P et al Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med 2017; 376:2437-2447. June 22, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28636854 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1615715
- ↑ 59.0 59.1 Kapoor E, Austin PC, Alibhai SMH et al Screening and Treatment for Osteoporosis After Stroke. Results From the Ontario Stroke Registry. Stroke. April 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31018778 https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.024685
- ↑ 60.0 60.1 Zheng F, Yan L, Zhong B, Yang Z, Xie W Progression of cognitive decline before and after incident stroke. Neurology 2019 May 24; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31127071 https://n.neurology.org/content/93/1/e20
- ↑ 61.0 61.1 NEJM Knowledge+ Question of the Week. Aug 13, 2019 https://knowledgeplus.nejm.org/question-of-week/1860/
Topcuoglu MA, Saka E, Silverman SB, Schwamm LH, Singhal AB. Recrudescence of deficits after stroke: clinical and imaging phenotype, triggers, and risk factors. JAMA Neurol 2017 Sep 1; 74:1048. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28783808 Free PMC Article - ↑ 62.0 62.1 Kitagawa K et al. Effect of standard vs intensive blood pressure control on the risk of recurrent stroke: A randomized clinical trial and meta-analysis. JAMA Neurol 2019 Nov; 76:1309. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31355878 https://jamanetwork.com/journals/jamaneurology/article-abstract/2738512
- ↑ 63.0 63.1 63.2 Nave AH et al. Physical Fitness Training in Patients with Subacute Stroke (PHYS-STROKE): Multicentre, randomised controlled, endpoint blinded trial. BMJ 2019 Sep 18; 366:l5101. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31533934 Free PMC Article https://www.bmj.com/content/366/bmj.l5101
- ↑ NINDS Stroke Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page
Post-stroke rehabilitation fact sheet https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Post-Stroke-Rehabilitation-Fact-Sheet - ↑ 65.0 65.1 Bosel J et al. Effect of early vs standard approach to tracheostomy on functional outcome at 6 months among patients with severe stroke receiving mechanical ventilation: The SETPOINT2 randomized clinical trial. JAMA 2022 May 17; 327:1899; [e-pub PMID: https://www.ncbi.nlm.nih.gov/pubmed/35506515 https://jamanetwork.com/journals/jama/fullarticle/2792016
- ↑ 66.0 66.1 Swift Yasgur B Lamotrigine Linked to Lowest Mortality Risk in Poststroke Epilepsy. Medscape. Jan 7, 2022 https://www.medscape.com/viewarticle/966285
- ↑ 67.0 67.1 Powell MP, Verma N, Sorensen E et al Epidural stimulation of the cervical spinal cord for post-stroke upper-limb paresis. Nature Medicine. 2023. Feb 20 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36807682 https://www.nature.com/articles/s41591-022-02202-6
- ↑ 68.0 68.1 Parr E, Ferdinand P, Roffe C. Management of Acute Stroke in the Older Person. Geriatrics (Basel). 2017 Aug 15;2(3):27. doi:http://dx.doi.org/ 10.3390/geriatrics2030027. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31011037 PMCID: PMC6371128 Free PMC article.
- ↑ 69.0 69.1 Feigin VL, Owolabi MO Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurology. 2023 Oct 6:S1474-4422(23)00277-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37827183 https://www.thelancet.com/commissions/global-burden-stroke
- ↑ 70.0 70.1 Ishani A, Hau C, Cushman WC, Leatherman SM et al Chlorthalidone vs Hydrochlorothiazide for Hypertension Treatment After Myocardial Infarction or Stroke: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2024 May 1;7(5):e2411081. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38743423 PMCID: PMC11094558 Free PMC article. Clinical Trial.
- ↑ 71.0 71.1 Reddin C, Canavan M, Hankey GJ et al Association of Vascular Risk With Severe vs Non-Severe Stroke: An Analysis of the INTERSTROKE Study. Neurology. 2024 Dec 10;103(11):e210087 PMID: https://www.ncbi.nlm.nih.gov/pubmed/39536279 https://www.neurology.org/doi/10.1212/WNL.0000000000210087
Patient information
stroke or cerebrovascular accident (CVA) patient information