STROKE   62A

An 82-year-old woman with atrial fibrillation comes to the emergency department with 1 hour of difficulty moving her right arm and leg. Her medical history includes a transient ischemic attack (TIA), hypertension, and diabetes mellitus. She had been taking warfarin but discontinued it 3 months ago after a fall and now takes no medications. On physical examination, she has weakness in and sensory neglect of her right upper and lower extremities and a global aphasia with deficits in comprehension and object naming. Complete blood count, platelets, and coagulation panel findings are normal. Noncontrast computed tomography (CT) of the brain shows no intracranial bleeding. Intravenous recombinant tissue plasminogen activator is administered.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Elderly patient; acute onset of aphasia, right-sided hemiplegia and neglect; presentation within 4.5 hours of symptom onset; risk factors of atrial fibrillation, hypertension, diabetes mellitus, and previous TIA; on no anticoagulant medication; no intracranial bleeding

How to think through: Stroke is the second leading cause of death in the United States and is a major cause of morbidity. What are the likely mechanisms of this patient’s stroke? (Atrial fibrillation leading to cardioembolic stroke or hypertension and diabetes leading to carotid atherosclerosis or intracranial small vessel disease and thrombotic stroke.) What is her CHADS2 score? (Using this decision aid, she receives 1 point each for hypertension, age older than 75 years, and diabetes plus 2 points for prior TIA for a total of 5 points; without anticoagulation, this confers a 6.9% risk of stroke per year.) Based on her examination, what vascular territory is involved? (Left middle cerebral artery.) How does one differentiate aphasia from dysarthria? (Repetition of simple words is intact in most cases of aphasia and demonstrates intelligible speech production.) What factors must be assessed before thrombolysis? (Absence of hemorrhage on noncontrast CT scan; stroke or head trauma in prior 3 months; recent major surgery or major bleeding; duration of symptoms >4.5 hours; blood pressure >185/110 mm Hg; international normalized ratio >1.7; platelets >100,000/mcL.) If the patient is in atrial fibrillation the day after her stroke, should cardioversion be considered? (No! Given her atrial fibrillation, recent stroke, and lack of anticoagulation, cardioversion could precipitate an embolic stroke.)

STROKE   62B

What are the essentials of diagnosis and general considerations regarding stroke?

Essentials of Diagnosis

Ischemic stroke is an occlusion of a major vessel leading to cerebral infarction.

Intracerebral hemorrhage is usually caused by hypertension and occurs suddenly.

With any stroke, the resulting deficit depends on the particular vessel involved and the extent of any collateral circulation.

General Considerations

Ischemic and hemorrhagic strokes cannot be distinguished solely by clinical features.

Brain imaging, usually starting with an immediate noncontrast head CT scan, is essential.

Ischemic stroke is often caused by thromboembolism from atrial fibrillation or flutter.

In elderly adults, cerebral amyloid angiopathy is a frequent cause of hemorrhage.

The risk of both ischemic and hemorrhagic stroke increases with age.

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