A cerebrovascular accident (CVA) is an infarction or hemorrhage in the brain.
Stroke is the sudden onset of a focal neurologic deficit(s) resulting from either infarction or hemorrhage within the brain.
Two broad categories: ischemic (thrombotic or embolic; 87%) and hemorrhagic (13%)
Hemorrhage can be intracerebral or subarachnoid.
System(s) affected: neurologic; vascular
Synonym(s): CVA; cerebral infarct; brain attack
Related terms: transient ischemic attack (TIA), a transient episode of neurologic dysfunction due to focal ischemia without permanent infarction on imaging (see topic “Transient Ischemic Attack [TIA]”)
Cardiac abnormalities (congenital heart disease, paradoxical embolism, rheumatic fever, bacterial endocarditis)
Metabolic: homocystinuria, Fabry disease
Annual incidence in the United States is ˜795,000.
Prevalence in the United States: 550/100,000
Predominant age: Risk increases >45 years of age and is highest during the 7th and 8th decades.
Predominant sex: male > female at younger age, but higher incidence in women with age ≥75 years
ETIOLOGY AND PATHOPHYSIOLOGY
87% of stroke is ischemic, three main subtypes for etiology: thrombosis, embolism, and systemic hypoperfusion. Large vessel atherothrombotic strokes are commonly related to the origin of the internal carotid artery. Small vessel lacunar strokes are commonly due to lipohyalinotic occlusion. Embolic strokes are largely from a cardiac source (due to left atrial thrombus, atrial fibrillation, recent MI, valve disease, or mechanical valves) or ascending aortic atheromatous disease (>4 mm).
13% of stroke is hemorrhagic; most commonly due to HTN. Other causes include intracranial vascular malformations (cavernous angiomas, AVMs), cerebral amyloid angiopathy (lobar hemorrhages in elderly), and anticoagulation.
Other causes include fibromuscular dysplasia (rare), vasculitis, or drug use (cocaine, amphetamines).
Stroke is a polygenic multifactorial disease, with some clustering within families.
Uncontrollable: age, gender, race, family history/genetics, prior stroke or TIA
Metabolic: diabetes, dyslipidemia
Lifestyle: smoking, cocaine use, amphetamine use
Cardiovascular: hypertension, atrial fibrillation, valvular heart disease, endocarditis, recent MI, severe carotid artery stenosis, hypercoagulable states, and patent foramen ovale
Smoking cessation, regular exercise, weight control to maintain nonobese BMI and prevent type 2 diabetes, use alcohol in moderation, control BP, and manage hyperlipidemia; use of antiplatelet agent, such as aspirin, in high-risk persons; treatment of nonvalvular atrial fibrillation with dose-adjusted warfarin or dabigatran, apixaban, and rivaroxaban
COMMONLY ASSOCIATED CONDITIONS
Coronary artery disease is the major cause of death during the first 5 years after a stroke.
Secondary prevention of stroke with aggressive management of risk factors
Platelet inhibition using aspirin, clopidogrel, or aspirin plus extended-release dipyridamole (Aggrenox) based on physician and patient preference
Follow-up every 3 months for 1st year, then annually.
Patients with impaired swallowing should receive nasogastric or percutaneous endoscopic gastrostomy feedings to maintain nutrition and hydration.
National Stroke Association (800-STROKES or http://www.stroke.org)
Variable, depends on subtype and severity of stroke; NIH stroke scale may be used for prognosis.