Home  ›  Usmle I Specialty Review and Study Guide a Series From Statpearls

Usmle I Specialty Review and Study Guide a Series From Statpearls

Written By Friday, April 22, 2022 Add Comment Edit

Summarytoggle arrow icon

Ischemic stroke is an acute neurological status caused by impaired cerebral blood period (east.g., vascular occlusion or systemic hypoperfusion). The most of import risk factors are chronic systemic hypertension and cardiovascular disease. Clinically, ischemic stroke is characterized by the acute onset of focal neurological deficits, which are dependent on the cerebral territory covered by the relevant vessel. If ischemic stroke is suspected, a noncontrast caput CT should immediately be performed to dominion out intracranial hemorrhage and blood glucose should be measured as it is a stroke mimic. Revascularization of the vessels affected in ischemic stroke, east.1000., via tissue plasminogen activator (tPA) or thrombectomy, can preserve brain tissue and ameliorate outcomes if given early. Further treatment consists of supportive care, neuroprotective measures, management of underlying causes, and secondary prevention with antiplatelet therapy and handling of modifiable risk factors (i.e., hypertension, atherosclerosis).

Recommendations in this commodity are primarily consistent with the 2019 American Centre Association (AHA) guidelines for the early direction of patients with astute ischemic stroke and the 2021 AHA guidelines for secondary stroke prevention. [1] [2]

Transient ischemic attack, intracerebral hemorrhage, and subarachnoid hemorrhage are covered in separate articles. See also "Overview of stroke."

  • Cerebral infarction due to bereft cognitive blood flow (hypoperfusion), which results in ischemia and neuronal injury
  • See "Overview of stroke" for related atmospheric condition.
  • Ischemic strokes business relationship for ∼ 85% of all strokes.
  • Risk factors for ischemic stroke
    • Nonmodifiable adventure factors [iii] [4] [5]
      • Age ≥ 65 years
      • Sex ♂ > ♀
      • African Americans, Native Americans, Alaska Natives, and Hispanics are at higher gamble.
      • Family history of cardiovascular or cerebrovascular disease
      • Genetic disorders (e.g., sickle cell affliction)
      • History of TIA
      • Migraine with aura
    • Modifiable hazard factors [3] [4]
      • Systemic hypertension
      • Hyperlipidemia
      • Diabetes mellitus
      • Atherosclerosis
      • Cardiovascular disease
      • Obesity
      • Coagulopathy , hyperhomocysteinemia
      • Heavy alcohol use
      • Tobacco employ
      • Recreational drug apply (east.g., cocaine tin cause cognitive vasospasm)
      • Oral contraceptive employ
      • Hormone replacement therapy

For both ischemic and hemorrhagic strokes, historic period is the most of import nonmodifiable risk factor and arterial hypertension is the most of import modifiable take chances factor!

References:[3] [four] [v]

Epidemiological data refers to the United states, unless otherwise specified.

  • Embolic strokes (∼ twenty% of all strokes)
    • Most commonly affect the center cerebral artery ( MCA )
    • Tin affect multiple cognitive vascular territories
    • Cardiac emboli
      • Atrial fibrillation
      • Atrial or ventricular thrombi
      • Rheumatic heart disease
      • Ventricular aneurysms
    • Atheroemboli
    • Infectious emboli: bacterial endocarditis
    • Paradoxical embolism : venous thromboembolism (especially due to deep vein thrombosis) in patients with correct-to-left cardiac shunt (due east.thou., persistent foramen ovale or atrial septal defect )
  • Thrombotic strokes (∼ twoscore%)
    • Big vessel atherosclerosis (∼ 20%)
      • Rupture of an atherosclerotic plaque and exposure of subendothelial collagen → formation of a thrombus
      • Thrombus formation most normally occurs at branch points in arteries (e.grand., ; internal carotid artery bifurcation or where the MCA branches from the circumvolve of Willis). .
    • Small vessel occlusion (e.k., lacunar infarct ) ( ∼ twenty% ) : see "Subtypes and variants" beneath.
  • Global cognitive ischemia
    • Systemic hypoperfusion
      • Shock or bilateral large artery atherosclerosis (e.g., of carotid arteries) → decreased effective oxygen delivery to the whole brain
      • Mutual during cardiac surgeries
      • Can consequence in watershed infarct (encounter "Subtypes and variants" beneath)
    • Hypoglycemia : Repeated episodes of hypoglycemia (e.g., due to insulinoma) increase the risk of cerebral ischemia.
    • Severe and/or chronic hypoxia : hypoxemia (e.thousand., due to respiratory arrest) → global tissue hypoxia in the brain
  • Other causes
    • Hypercoagulable states
    • Vasculitis (east.g., giant jail cell arteritis)
    • Arterial dissection (e.g., due to trauma or fibromuscular dysplasia)

References:[four] [half-dozen] [7] [8] [ix] [10] [eleven] [12] [xiii]

Patterns of necrosis in ischemic stroke [14]

Infarction of brain tissue is typically followed past liquefactive necrosis, in contrast to the coagulative necrosis seen later on infarction in other organs.

Selective neuronal necrosis

Pannecrosis

Histologic changes in the infarcted region [xiv] [fifteen]

To recall the areas near vulnerable to hypoxia: Vulnerable hipposouth Need PURe water (hippocampus, Northeocortex, PURkinje cells, and watershed areas).

References:[fourteen] [xv]

  • Sudden onset of focal neurological deficits (e.g., weakness/paralysis, paresthesias , aphasia , dysarthria )
  • Nonspecific symptoms (due east.g., impaired consciousness, nausea, vomiting, headache, seizures)
  • Symptoms depend on the location of the stroke (see "Stroke symptoms by affected vessel" and "Stroke symptoms past affected region")
  • Symptoms suggesting a specific etiology:
    • Aortic autopsy: chest hurting, hypotension, dyspnea
    • Endocarditis: fever, centre murmur
    • ICH/SAH: sudden, severe headache

Stroke should exist ruled out in patients presenting with first-time epileptic seizures and subsequent neurological deficits, every bit the seizure may have been caused by an astute cognitive pathology.

The differential diagnoses listed here are not exhaustive.

Primary survey

Clinical cess and management should occur simultaneously with the goals of stabilizing the patient, keeping the door-to-neuroimaging time to a minimum, and identifying candidates for reperfusion therapy equally soon every bit possible. [1] [xvi] [17]

  • Airway management: Secure airway if airway protective reflexes are impaired, due east.m., due to depressed level of consciousness or bulbar dysfunction.
  • Respiratory support
    • Provide oxygen therapy to keep SpO2 > 94%.
    • Consider mechanical ventilation for respiratory failure.
  • Hemodynamic back up: Encounter "Blood pressure management in ischemic stroke."
  • Rapid focused neurological assessment
    • Decide the time of symptom onset or, if this is unknown, the time the patient was last seen well or at neurological baseline.
    • Place take chances factors for ischemic stroke and adventure factors for hemorrhagic stroke.
    • Minimum neurological examination
      • GCS score
      • Pupillary examination
      • Identification of lateralizing signs, due east.g., hemiparesis, facial droop, pronator drift
      • Screening for signs of cerebral herniation
    • Focused neurological examination
      • Attempt to localize lesion by identifying stroke symptoms by affected vessel.
      • Perform severity assessment: e.one thousand., NIHSS
  • Critical management steps [1] [18]
    • Check POC glucose and treat immediately if < threescore mg/dL or > 400 mg/dL to dominion out stroke mimic.
    • Arrange emergency neuroimaging, e.g., noncontrast CT caput, to rule out intracranial hemorrhage.
    • Care for eligible patients with reperfusion therapy for acute ischemic stroke (e.thou., IV thrombolytics , mechanical thrombectomy)
    • Initiate neuroprotective measures and supportive care for ischemic stroke.
    • Kickoff ICP direction if needed: Avoid steroids, hypothermia, and barbiturates.
  • Consults and disposition
    • Consult neurology immediately if astute ischemic stroke identified.
    • Consult neurosurgery for whatever hemorrhagic transformation or if in that location are indications for ventriculostomy or decompressive craniectomy: e.one thousand., cerebral edema with refractory ↑ ICP, large cerebellar infarction with obstructing hydrocephalus.
    • Acknowledge the patient to a dedicated stroke unit (or ICU) for at least 24 hours (accommodate interfacility transfer if necessary).
  • Side by side steps: See "Diagnostics of ischemic stroke" and "Treatment of ischemic stroke."

Only POC glucose and noncontrast neuroimaging (e.g., CT caput or MR brain) are required prior to thrombolytic therapy. Do not delay treatment to complete the residuum of the diagnostic evaluation. A archetype clinical presentation without evidence of a stroke mimic or intracranial haemorrhage on initial neuroimaging is typically enough to diagnose acute ischemic stroke in time-limited settings. [1]

Malignant infarctions in the MCA territory or large PICA infarctions may crave surgical intervention before edema reaches its maximum extent to forbid encephalon herniation. [ane]

Blood force per unit area direction in acute ischemic stroke [1]

  • Provide immediate hemodynamic back up for hypotension and hypovolemia (see "Neurogenic stupor").
  • Treatment of hypertension in patients not undergoing reperfusion therapy
    • BP < 220/120 mm Hg
      • Permissive hypertension: Moderate hypertension is tolerated inside the showtime 48–72 hours with the goal of maintaining cerebral perfusion.
      • Before BP reduction is indicated in patients with certain comorbidities, e.g., concomitant heart failure or aortic dissection, and after thrombolysis.
    • BP ≥ 220/120 mm Hg: Conscientious BP reduction, e.g., by ∼ 15% within the first 24 hours of stroke onset may exist considered.
  • Patients undergoing reperfusion therapy: Reduce BP to < 185/110 mmHg beforehand and keep BP < 180/105 mm Hg for the first 24 hours afterwards handling.
  • Recommended agents: labetalol , clevidipine , or nicardipine
  • Once the patient is neurologically stable, commencement (or restart) oral antihypertensive therapy if BP > 140/xc mm Hg.

The following scales can be calculated at initial presentation to guide treatment decisions and approximate prognosis, or repeated to monitor progression and response to therapy during access, rehabilitation, and follow-up. They are also used as result measures in clinical trials.

National Institutes of Health Stroke Scale (NIHSS) [19]

The NIHSS is weighted towards anterior circulation strokes and underestimates stroke severity in the posterior circulation . [twenty]

Diagnostic arroyo [two] [28] [29] [xxx]

Obtain noncontrast neuroimaging as soon as possible.

The decision to obtain avant-garde imaging should not filibuster the assistants of thrombolytic therapy in advisable candidates. [ane]

All patients with a suspected ischemic stroke should receive an initial ECG and cardiac monitoring.

Consider these in select patients, east.chiliad., to identify the underlying cause, appraise the chance of recurrence, and evaluate comorbidities or complications.

Noncontrast CT head [29] [xxx] [37] [38] [39]

  • Indication: all patients with a suspected acute stroke to rule out intracerebral hemorrhage and potential stroke mimics (e.k., tumors) and detect early signs of stroke [1]
  • Stroke protocols: can be paired with CTA head and cervix in some centers.
  • Findings: may be normal or prove evolving ischemic changes over time [28] [xl]
    • < 2 hours after event
      • Unremarkably, no signs of infarction are visible.
      • In a large avenue apoplexy, there may be hyperdense occluded vessels (e.k., hyperdense MCA sign , which indicates an acute thromboembolic occlusion of the MCA ).
    • < 6 hours after the event : in some cases, early on signs of cytotoxic edema
    • 12–24 hours after outcome ; : Hypodense parenchyma starts becoming more clearly demarcated.
    • iii–v days after issue : maximum extent of edema and mass effect [41]
    • 2–three weeks after event: Infarcted region appears isodense. [42]
    • Chronic infarcts appear hypodense (isodense to cerebral spinal fluid) and well-demarcated, with negative mass event.

Infarctions in the cerebellum and brainstem may exist harder to detect with noncontrast head CT than infarctions in other regions. [43]

MRI brain [1] [37] [44]

  • Indications
    • If readily bachelor, brain MRI may be performed instead of noncontrast caput CT. [45]
    • Unclear time of onset or wake-up stroke: to determine eligibility for thrombolysis
    • Signs or symptoms of a posterior circulation infarct
  • Stroke protocols: includes T1-weighted, T2-weighted, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI).
  • Findings: The appearance of early on ischemic lesions depends on the time and imaging sequence [xxx] [46]
    • Early astute (< vi hours later event)
      • Arterial enhancement or a hyperdense media sign may be visible.
      • DWI: Ischemic lesion appears hyperintense within a few minutes (most sensitive modality).
    • Late acute (6–24 hours after outcome)
    • Chronic infarcts can evidence variable bespeak intensity.
    • Typical signal patterns can advise an underlying etiology [47]
      • Cardioembolic: multiple lesions in different vascular territories
      • Large avenue atherosclerosis: scattered lesions in one vascular territory

DWI-FLAIR mismatch indicates hyperacute ischemic stroke that occurred within the past half dozen hours. [46]

Neurovascular studies [ane] [2] [thirteen]

In potential candidates for mechanical thrombectomy, perform CTA immediately following noncontrast CT. If indicated, thrombolysis can be performed simultaneously. [one]

If indicated, practise not delay CTA to look for creatinine or TSH levels , as the chance of iodine-induced hyperthyroidism and contrast-induced nephropathy is relatively low, especially in patients with no known history of thyroid or renal abnormalities. [35] [39] [52] [53]

Therapeutic approach [1]

  • Care for all eligible patients with reperfusion therapy for astute ischemic stroke inside recommended time frames.
  • Continue supportive care for ischemic stroke including neuroprotective measures.
  • Initiate secondary prevention of recurrent ischemic stroke.
    • Start antiplatelet treatment with aspirin or clopidogrel inside 24–48 hours afterwards symptom onset.
    • Treat underlying conditions: e.g., atrial fibrillation, carotid artery stenosis
    • Reduce modifiable run a risk factors: e.chiliad., smoking, hypertension, hyperlipidemia, diabetes
  • Monitor and treat whatsoever complications.
  • Provide early rehabilitation and mobilization.

General principles [1]

Time is brain! Reperfusion therapy should not be delayed. All the same, intracranial hemorrhage is a contraindication for reperfusion therapy and must be ruled out first.

Intravenous thrombolysis [1]

Inclusion and exclusion criteria for thrombolysis are not strict and handling decisions should be fabricated in consultation with a neurologist taking into business relationship multiple private patient factors.

  • Agents: intravenous recombinant tissue plasminogen activator ( tPA )
    • Alteplase
    • OR tenecteplase [i] [54]
  • Inclusion criteria
    • No bear witness of stroke mimic or intracranial hemorrhage
    • Astute disabling neurological symptoms
    • Fourth dimension from onset of symptoms or concluding seen normal (or at baseline)

If a patient is unable to consent to treatment (e.m., contradistinct mental condition, aphasia) and a legal representative is not immediately nowadays, IV alteplase can nonetheless exist administered in eligible patients with disabling stroke symptoms. [ane]

Practice not wait on coagulation parameters before administering tPA in patients with no known history of coagulopathy or thrombocytopenia. Discontinue handling if platelets are < 100,000/mm3 , INR > 1.vii or PT is abnormally elevated. [1]

Exclusion criteria for thrombolysis in astute ischemic stroke [1]

Accented contraindications

Relative contraindications

Preexisting conditions
  • Recent ischemic stroke or severe caput trauma (≤ 3 months ago)
  • Recent intracranial or intraspinal surgery (≤ 3 months agone)
  • History of intracranial hemorrhage
  • GI malignancy or contempo GI bleed (≤ 21 days ago)
  • Intraaxial intracranial neoplasm
  • Contempo major surgery or trauma (not including head) (< 14 days ago)
  • History of bleeding diathesis or coagulopathy
  • Current malignancy
  • History of cerebral microbleeding
  • History of GI bleeding (> 21 days agone) or genitourinary bleeding
  • Known left atrial or ventricular thrombus
  • Pregnancy or early on postpartum period (< 14 days after commitment)
  • Recent arterial puncture (< vii days ago)
Acute findings
  • Astute intracranial or subarachnoid hemorrhage [1]
  • Acute bleeding diathesis
    • INR > i.vii , PT > xv sec, or aPTT > 40 sec
    • Depression platelet count : < 100,000/mm3
    • Anticoagulation with direct thrombin inhibitors or straight gene Xa inhibitors
    • Recent handling dose of LMWH (< 24 hours)
  • Agile internal bleeding [55]
  • Acute infective endocarditis
  • Acute aortic arch dissection
  • Nondisabling minor stroke (NIHSS < 5)
  • Large areas of marked hypodensity on CT
  • Severe uncontrolled hypertension (BP > 185/110 mm Hg) [55]
  • Very astringent stroke (NIHSS > 25) > iii hours afterward effect
  • Acute pericarditis
  • Intracranial weather condition that may increase bleeding risk

Some conditions commonly misconceived as contraindications for thrombolysis therapy include antiplatelet therapy, terminate-stage renal affliction, and concurrent MI. In patients with preexisting disability or dementia, treatment decisions should exist based on prestroke functionality and quality of life. [ane]

Severe hypo- or hyperglycemia (glucose < 50 mg/dL or > 400 mg/dL) and astringent hypertension > 185/110 mm Hg should be treated earlier tPA assistants. [1]

Complications of Iv thrombolytic therapy [1]

Additional measures after thrombolysis

Mechanical thrombectomy [1]

  • Description: concrete retrieval or aspiration of the occluding thrombus via the femoral avenue using a stent retriever and/or an aspiration catheter
  • Inclusion criteria [1]
    • Historic period ≥ 18 years
    • Acute big artery occlusion ; causing a stroke: due east.k., proximal artery occlusion in anterior cerebral circulation (M1) or occlusion of the internal carotid artery
    • Disabling stroke symptoms (NIHSS ≥ 6)
    • Limited afflicted area on CT (Alberta Stroke Program Early CT Score ≥ vi)
    • Previously independent in ADLs (prestroke modified Rankin scale (mRS) ≤ 1)
    • Patients with symptom onset within the past 6 hours or selected patients with symptom onset between vi and 24 hours ago

Patients who are eligible for tPA should receive thrombolysis immediately, while mechanical thrombectomy is being considered. If indicated, mechanical thrombectomy should be performed without delay to appraise the response to thrombolysis. [1]

Follow standard measures, including the following specific targets for acute ischemic stroke: [one]

Further therapeutic goals consist of identifying and treating risk factors and underlying conditions to prevent recurrent stroke. [1] [32]

Antiplatelet therapy [1] [2] [32]

  • Starting within first 24–48 hours after symptom onset
    • Aspirin
    • OR Clopidogrel
    • Dual antiplatelet therapy (DAPT): Consider starting 21 day course in patients with pocket-size stroke symptoms (e.g., NIHSS ≤ three–5), Aspirin AND clopidogrel [22]
  • Long-term antiplatelet therapy
    • Indicated in patients with noncardioembolic stroke to reduce the chance of recurrence.
    • Choose an agent based on individual risk factors, eastward.g., aspirin , clopidogrel , or combination therapy. [57] [58]
    • Consult neurology for indication in patients with cardioembolic stroke and pregnant atherosclerosis. [ane]

Await at least 24 hours earlier initiating antiplatelet treatment later on thrombolysis.

Management of underlying causes [1] [2] [32]

  • Large vessel affliction
  • Cardioembolic sources
    • Atrial fibrillation or atrial flutter: anticoagulation with warfarin or straight oral anticoagulant is indicated regardless of frequency or persistence .
    • Patient foramen ovale: Initiate antiplatelet therapy and refer to neurologist and cardiologist to consider PFO closure.
    • LV thrombus or cardiomyopathy with left atrial thrombus: anticoagulation for 3 months
    • Valvular centre disease and/or prosthetic valve
      • Valvular AF: anticoagulation with warfarin
      • Mechanical valve (mitral) and stroke prior to surgery: aspirin PLUS warfarin
      • Other valvular diseases without another indication for anticoagulation: antiplatelet therapy typically preferred.
  • Hypercoagulable states: see thrombophilia therapy.

Treatment of modifiable risk factors [2]

  • ASCVD: Run into also "Secondary prevention of ASCVD"
    • Diet and exercise
      • A heart-healthy diet is preferred over a low-fat nutrition.
      • Patients who can exercise
        • Moderate intensity: minimum 10 minutes 4 times/week
        • Loftier intensity: minimum 20 minutes 2 times/calendar week
      • Patients who cannot do: Refer to physical therapy and rehabilitation.
    • Hypertension
    • Diabetes mellitus ; : glycemic control with antihyperglycemics every bit needed to maintain HbA1c < 7% (See "Handling" in "Diabetes mellitus")
    • Hyperlipidemia ; : Initiate statin therapy (See too "Treatment" in "Lipid disorders").
    • Smoking: Offering counseling on smoking cessation.
    • Obesity: Weight loss is recommended.
      • Screen BMI of all patients
      • Provide directed counseling on weight and diet changes and referral to comprehensive weight loss plan.
  • Others
    • Substance use
      • Alcohol consumption: Eliminate OR reduce to ≤ 2 drinks/24-hour interval for men and ≤ i drink/twenty-four hours for women
      • Provide counseling on substance use disorders and rehabilitation referrals for the following:
        • Patients using CNS stimulants
        • Patients with infectious endocarditis due to 4 substance use.
    • Obstructive sleep apnea (OSA): Consider screening in patients with risk factors for OSA, and CPAP therapy for established OSA.

The single about important treatable take a chance factor for secondary stroke prevention is hypertension.

Initial evaluation

  • Perform primary survey
  • Determine the time of onset of symptoms and appraise severity with NIHSS.
  • Call for immediate neurology consult or activate stroke squad.
  • Establish IV access
  • Continuous cardiac monitoring
  • Start supplemental O2 to keep SpOtwo > 94%
  • Obtain POC glucose and treat immediately if < 60 mg/dL or > 400 mg/dL.
  • Society immediate head CT (without contrast)
  • Stabilize patient prior to neuroimaging as needed
    • Intubation and mechanical ventilation for airway protection or respiratory failure
    • Blood force per unit area management for acute ischemic stroke for daze or hypertensive emergency
    • Begin ICP direction for cerebral herniation syndromes
  • Consider further imaging (due east.chiliad., MRI or CTA with or without perfusion protocol) without delaying reperfusion therapy.
  • Evaluate inclusion and exclusion criteria for thrombolysis in consultation with neurology.
  • If thrombolysis is indicated:
    • Lower claret force per unit area to < 185/110 mm Hg.
    • Administrate thrombolytic therapy (per neurologist).
  • Evaluate indications for mechanical thrombectomy in discussions with stroke specialists.

After stabilization

  • Admit preferentially to stroke unit (medicine or neurology) or ICU for outset 24 hours.
  • Continue blood force per unit area management and other neuroprotective measures (e.1000., euglycemia, normothermia)
  • Perform serial neurological assessments
  • Identify and care for the underlying cause: ECG, laboratory studies, neurovascular studies
  • Ensure supportive care: e.k., NPO and dysphagia screening, VTE prophylaxis, physical and occupational therapy
  • Identify and treat any complications (eastward.g., seizures, neurogenic fever)
  • Commencement secondary stroke prevention measures (e.grand., antiplatelet therapy, statins)
  • Obtain 24-hour follow-upwards imaging, if indicated (post thrombolysis)

We listing the most important complications. The choice is not exhaustive.

Lacunar infarct [9] [61]

  • Definition: noncortical infarcts characterized past the absence of cortical signs (e.k., no aphasia, hemianopsia, agnosia, apraxia)
  • Etiology
    • Most mutual: chronic hypertensive vasculopathy → lipohyalinosis of the small vessels → apoplexy of modest, penetrating arteries (e.g., lenticulostriate artery ) ; → lacunar stroke resulting in specific lacunar syndromes (see " Lacunar syndromes ")
    • Less common
      • Cardioembolic result
      • Microatheroma formation
      • Microbleed (rare)
  • Run a risk factors
    • Hypertension
    • Diabetes mellitus
  • Clinical features
    • Astute transient focal neurological symptoms that often have a stuttering course
    • Symptoms depend on the affected territory.
      • See "Lacunar syndromes."
      • Unremarkably affected areas
        • Internal capsule, corona radiata
        • Pons
        • Basal ganglia (striatum, putamen, globus pallidus, thalamus, caudate)
  • Diagnosis: diffusion-weighted MRI
  • Pathology: results in a pale infarction at the periphery of the cortex
  • Treatment: same as for other ischemic strokes (see "Handling")

Infarction of the posterior limb of the internal capsule is the most common type of lacunar stroke and may manifest clinically with pure motor stroke , pure sensory stroke (rare), sensorimotor stroke , dysarthria-impuissant hand syndrome , and/or ataxic hemiparesis .

Interested in the newest medical research, distilled downward to just 1 minute? Sign up for the I-Minute Telegram in "Tips and links" below.

  1. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Direction of Patients With Astute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Clan/American Stroke Clan. Stroke. 2019; 50 (12). doi: ten.1161/str.0000000000000211 . | Open in Read past QxMD
  2. Kleindorfer Do, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Assault: A Guideline From the American Heart Association/American Stroke Clan. Stroke. 2021 . doi: 10.1161/str.0000000000000375 . | Open up in Read past QxMD
  3. Stroke Facts. https://www.cdc.gov/stroke/facts.htm. Updated: December 30, 2016. Accessed: March 28, 2017.
  4. Caplan LR, Kasner SE, Dashe JF. Etiology, Nomenclature, and Epidemiology of Stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://world wide web.uptodate.com/contents/etiology-classification-and-epidemiology-of-stroke.Concluding updated: March 14, 2017. Accessed: March 28, 2017.
  5. Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: a systematic review. Stroke. 2009; 40 (four). doi: 10.1161/STROKEAHA.108.540781 . | Open up in Read by QxMD
  6. Kasper DL, Fauci Every bit, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Educational activity ; 2015
  7. Agabegi SS, Agabegi ED. Step-Upwardly To Medicine. Wolters Kluwer Health ; 2015
  8. Le T, Bhushan V, Skelley Northward. Get-go Aid for the USMLE Step 2 CK. McGraw-Hill Teaching ; 2012
  9. Oliveira Filho J. Lacunar infarcts. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/lacunar-infarcts.Final updated: March ix, 2017. Accessed: March 28, 2017.
  10. Furie KL, Rost NS. Overview of secondary prevention of ischemic stroke. In: Postal service TW, ed. UpToDate. Waltham, MA: UpToDate. http://world wide web.uptodate.com/contents/overview-of-secondary-prevention-of-ischemic-stroke.Last updated: September 1, 2016. Accessed: March 28, 2017.
  11. Oliveira Filho J, Mullen MT. Initial assessment and management of acute stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke.Terminal updated: Baronial 15, 2016. Accessed: March 29, 2017.
  12. Yew KS, Cheng EM. Diagnosis of Astute Stroke. Am Fam Doc. 2015; 91 (8): p.528-536.
  13. EC J, JL S, Jr AH, et al.. Guidelines for the Early Direction of Patients With Acute Ischemic Stroke. Stroke. 2013; 44 (3): p.870-947. doi: 10.1161/STR.0b013e318284056a . | Open up in Read by QxMD
  14. De Lucas EM, Sánchez East, Gutiérrez A, et al. CT Protocol for Acute Stroke: Tips and Tricks for General Radiologists. RadioGraphics. 2008; 28 (half-dozen): p.1673-1687. doi: x.1148/rg.286085502 . | Open up in Read by QxMD
  15. Tomandl BF, Klotz E, Handschu R, et al. Comprehensive Imaging of Ischemic Stroke with Multisection CT. RadioGraphics. 2003; 23 (iii): p.565-592. doi: 10.1148/rg.233025036 . | Open up in Read by QxMD
  16. Srinivasan A, Goyal Grand, Azri FA, Lum C. State-of-the-Fine art Imaging of Acute Stroke. RadioGraphics. 2006; 26 : p.S75-S95. doi: 10.1148/rg.26si065501 . | Open in Read by QxMD
  17. Mayer SA, Viarasilpa T, Panyavachiraporn N, et al. CTA-for-All. Stroke. 2020; 51 (1): p.331-334. doi: ten.1161/strokeaha.119.027356 . | Open in Read by QxMD
  18. Kernan WN, Ovbiagele B, Black HR et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Assail. Stroke. 2014; 45 (7): p.2160-2236. doi: 10.1161/STR.0000000000000024 . | Open in Read by QxMD
  19. Morris JG, Duffis EJ, Fisher M. Cardiac Workup of Ischemic Stroke. Stroke. 2009; 40 (viii): p.2893-2898. doi: ten.1161/strokeaha.109.551226 . | Open in Read by QxMD
  20. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic assail: a scientific statement for healthcare professionals from the American Centre Clan/American Stroke Clan Stroke Council; Quango on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Quango on Peripheral Vascular Affliction.. Stroke. 2009; 40 (6): p.2276-93. doi: x.1161/STROKEAHA.108.192218 . | Open in Read past QxMD
  21. Davenport M, Wang C, Asch D. ACR Manual on Contrast Media. American College of Radiology ; 2021
  22. Back-scratch NS, Davenport R, Pavord S, et al. The use of viscoelastic haemostatic assays in the management of major haemorrhage. Br J Haematol. 2018; 182 (half-dozen): p.789-806. doi: 10.1111/bjh.15524 . | Open in Read by QxMD
  23. Venkataraman P, Lui F. Lacunar Syndromes. StatPearls. 2018 .
  24. Standring Southward. Grayness's Anatomy: The Anatomical Footing of Clinical Practice. Elsevier Health Sciences ; 2016
  25. Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the Main Prevention of Stroke. Stroke. 2014; 45 (12): p.3754-3832. doi: 10.1161/str.0000000000000046 . | Open in Read by QxMD
  26. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. J Am Coll Cardiol. 2019; 74 (10): p.e177-e232. doi: 10.1016/j.jacc.2019.03.010 . | Open in Read past QxMD
  27. Goljan EF. Rapid Review Pathology. Elsevier Saunders ; 2018
  28. Mena H, Cadavid D, Rushing EJ. Human cognitive infarct: a proposed histopathologic nomenclature based on 137 cases. Acta Neuropathol. 2004; 108 (half dozen): p.524-530. doi: 10.1007/s00401-004-0918-z . | Open in Read past QxMD
  29. Brott T, Adams HP, Olinger CP, et al. Measurements of acute cognitive infarction: a clinical test scale.. Stroke. 1989; 20 (seven): p.864-870. doi: x.1161/01.str.20.7.864 . | Open in Read by QxMD
  30. Adams HP, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome later stroke: A report of the Trial of Org 10172 in Acute Stroke Handling (TOAST). Neurology. 1999; 53 (1): p.126-126. doi: 10.1212/wnl.53.one.126 . | Open in Read past QxMD
  31. Shah S, Luby Grand, Poole K, et al. Screening with MRI for Accurate and Rapid Stroke Treatment: SMART. Neurology. 2015; 84 (24): p.2438-2444. doi: 10.1212/wnl.0000000000001678 . | Open in Read by QxMD
  32. Prasad Chiliad, Siemieniuk R, Hao Q, et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic set on and pocket-size ischaemic stroke: a clinical practice guideline. BMJ. 2018; 363 : p.k5130. doi: x.1136/bmj.k5130 . | Open in Read past QxMD
  33. Hackam DG, Spence JD. Antiplatelet Therapy in Ischemic Stroke and Transient Ischemic Attack. Stroke. 2019; 50 (iii): p.773-778. doi: ten.1161/strokeaha.118.023954 . | Open up in Read past QxMD
  34. Lansberg MG, O'Donnell MJ, Khatri P, et al. Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 (2): p.e601S-e636S. doi: 10.1378/chest.11-2302 . | Open in Read by QxMD
  35. Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke. 2016; 47 (6). doi: ten.1161/str.0000000000000098 . | Open up in Read past QxMD
  36. NIH Stroke Scale. https://world wide web.stroke.nih.gov/resources/calibration.htm. . Accessed: September 15, 2020.
  37. Meyer BC, Lyden PD. The Modified National Institutes of Health Stroke Scale: its Time has Come. International Journal of Stroke. 2009; four (four): p.267-273. doi: 10.1111/j.1747-4949.2009.00294.x . | Open up in Read by QxMD
  38. Fischer U, Baumgartner A, Arnold K, et al. What Is a Minor Stroke?. Stroke. 2010; 41 (4): p.661-666. doi: x.1161/strokeaha.109.572883 . | Open in Read by QxMD
  39. Haydel MJ, Garmel GM. Appendix A Clinical conclusion rules and guidelines. In: 5. Mahadevan S, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. Cambridge University Printing ; 2012.
  40. Frankel MR, Morgenstern LB, Kwiatkowski T, et al. Predicting prognosis afterward stroke: A placebo group analysis from the National Found of Neurological Disorders and Stroke rt-PA Stroke Trial. Neurology. 2000; 55 (7): p.952-959. doi: 10.1212/wnl.55.7.952 . | Open in Read by QxMD
  41. Wouters A, Nysten C, Thijs V, Lemmens R. Prediction of Issue in Patients With Astute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 h. Frontiers in Neurology. 2018; 9 . doi: x.3389/fneur.2018.00308 . | Open in Read by QxMD
  42. Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients.. Stroke. 1988; 19 (5): p.604-607. doi: 10.1161/01.str.19.5.604 . | Open in Read by QxMD
  43. Fearon P, McArthur KS, Garrity M, et al. Prestroke Modified Rankin Stroke Scale Has Moderate Interobserver Reliability and Validity in an Acute Stroke Setting. Stroke. 2012; 43 (12): p.3184-3188. doi: x.1161/strokeaha.112.670422 . | Open up in Read past QxMD
  44. Catanese L, Tarsia J, Fisher Thousand. Acute Ischemic Stroke Therapy Overview. Circ Res. 2017; 120 (3): p.541-558. doi: 10.1161/circresaha.116.309278 . | Open in Read by QxMD
  45. González RG, Hirsch JA, Lev MH, Schaefer PW, Schwamm LH. Acute Ischemic Stroke. Springer Scientific discipline & Business Media ; 2010
  46. Potter CA, Vagal AS, Goyal M, Nunez DB, Leslie-Mazwi TM, Lev MH. CT for Handling Pick in Acute Ischemic Stroke: A Code Stroke Primer. RadioGraphics. 2019; 39 (half dozen): p.1717-1738. doi: ten.1148/rg.2019190142 . | Open in Read by QxMD
  47. Geyer JD, Gomez CR. Stroke. Lippincott Williams & Wilkins ; 2009 : p. 263
  48. Dostovic Z, Dostovic East, Smajlovic D, Avdic O. Brain Edema Afterwards Ischaemic Stroke. Medical Archives. 2016; 70 (5): p.339. doi: 10.5455/medarh.2016.70.339-341 . | Open in Read by QxMD
  49. Wardlaw JM. RADIOLOGY OF STROKE. Journal of Neurology, Neurosurgery & Psychiatry. 2001; 70 (90001): p.7i-11. doi: 10.1136/jnnp.70.suppl_1.i7 . | Open in Read past QxMD
  50. Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting astute posterior fossa infarct.. J Emerg Med. 2012; 42 (5): p.559-65. doi: ten.1016/j.jemermed.2011.05.101 . | Open up in Read past QxMD
  51. Mandell J. Core Radiology. Cambridge University Press ; 2013
  52. Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. The Lancet. 2007; 369 (9558): p.293-298. doi: ten.1016/s0140-6736(07)60151-2 . | Open in Read by QxMD
  53. Allen LM, Hasso AN, Handwerker J, Farid H. Sequence-specific MR Imaging Findings That Are Useful in Dating Ischemic Stroke. RadioGraphics. 2012; 32 (five): p.1285-1297. doi: x.1148/rg.325115760 . | Open up in Read by QxMD
  54. Kang D-Due west, Chalela JA, Ezzeddine MA, Warach South. Association of Ischemic Lesion Patterns on Early Diffusion-Weighted Imaging With TOAST Stroke Subtypes. Arch Neurol. 2003; 60 (12): p.1730. doi: 10.1001/archneur.60.12.1730 . | Open in Read past QxMD
  55. Copen WA, Schaefer PW, Wu O. MR Perfusion Imaging in Acute Ischemic Stroke. Neuroimaging Clin N Am. 2011; 21 (2): p.259-283. doi: 10.1016/j.nic.2011.02.007 . | Open in Read past QxMD
  56. Vagal A, Wintermark Thou, Nael K, et al. Automated CT perfusion imaging for acute ischemic stroke. Neurology. 2019 : p.10.1212/WNL.0000000000008481. doi: 10.1212/wnl.0000000000008481 . | Open up in Read by QxMD
  57. Mazya MV, Ahmed N, Azevedo E, et al. Impact of Transcranial Doppler Ultrasound on Logistics and Outcomes in Stroke Thrombolysis. Stroke. 2018; 49 (vii): p.1695-1700. doi: 10.1161/strokeaha.118.021485 . | Open in Read by QxMD
  58. Latchaw RE, Alberts MJ, Lev MH, et al. Recommendations for Imaging of Astute Ischemic Stroke. Stroke. 2009; 40 (11): p.3646-3678. doi: x.1161/strokeaha.108.192616 . | Open in Read by QxMD
  59. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Direction of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016; 26 (10): p.1343-1421. doi: x.1089/thy.2016.0229 . | Open in Read by QxMD
  60. Brinjikji West, Demchuk AM, Murad MH, et al. Neurons Over Nephrons. Stroke. 2017; 48 (7): p.1862-1868. doi: 10.1161/strokeaha.117.016771 . | Open up in Read past QxMD
  61. Burgos AM, Saver JL. Evidence that Tenecteplase Is Noninferior to Alteplase for Astute Ischemic Stroke. Stroke. 2019; 50 (8): p.2156-2162. doi: 10.1161/strokeaha.119.025080 . | Open in Read by QxMD
  62. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke. 2016; 47 (ii): p.581-641. doi: x.1161/str.0000000000000086 . | Open up in Read past QxMD
  63. Cucchiara BL, Messé SR. Antiplatelet therapy for secondary prevention of stroke. In: Mail service TW, ed. UpToDate. Waltham, MA: UpToDate. https://world wide web.uptodate.com/contents/antiplatelet-therapy-for-secondary-prevention-of-stroke.Concluding updated: July 25, 2016. Accessed: February 20, 2017.
  64. Schur PH, Kaplan AA. Treatment of antiphospholipid syndrome. In: Mail TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/handling-of-antiphospholipid-syndrome.Terminal updated: February 23, 2017. Accessed: Apr 3, 2017.
  65. Louis R Caplan. Overview of the Evaluation of Stroke. In: Mail TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-the-evaluation-of-stroke?search=overview%20of%20the%20evaluation%20of%20stroke&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.Final updated: February 14, 2019. Accessed: Apr i, 2019.
  66. Warren J Manning, Daniel East singer, Gregory YH Lip. Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. In: Postal service TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism?source=autocomplete&alphabetize=0~4&search=atrial%20fibrillation:.Terminal updated: July 24, 2018. Accessed: April 1, 2019.
  67. Sorensen AG, Ay H. Transient ischemic attack: definition, diagnosis, and run a risk stratification.. Neuroimaging Clin N Am. 2011; 21 (2): p.303-13, x. doi: 10.1016/j.nic.2011.01.013 . | Open in Read by QxMD
  68. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Breast. 2016; 149 (two): p.315-352. doi: 10.1016/j.chest.2015.11.026 . | Open in Read by QxMD
  69. Porth C, Matfin G. Pathophysiology. Lippincott Williams & Wilkins ; 2009
  70. Harbison J, Hossain O, Jenkinson D, Davis J, Louw SJ, Ford GA. Diagnostic Accurateness of Stroke Referrals From Primary Care, Emergency Room Physicians, and Ambulance Staff Using the Face Arm Spoken language Test. Stroke. 2003; 34 (1): p.71-76. doi: 10.1161/01.str.0000044170.46643.5e . | Open in Read past QxMD
  71. Smith EE, Kent DM, Bulsara KR, et al. Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early on Management of Patients With Acute Ischemic Stroke. Stroke. 2018; 49 (3). doi: 10.1161/str.0000000000000160 . | Open in Read by QxMD
  72. NIHSS MD Calc. https://www.mdcalc.com/nih-stroke-scale-score-nihss. . Accessed: March ii, 2020.
  73. Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med. 2018; 379 (vii): p.611-622. doi: 10.1056/nejmoa1804355 . | Open in Read by QxMD
  74. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch betwixt Arrears and Infarct. N Engl J Med. 2018; 378 (1): p.xi-21. doi: 10.1056/nejmoa1706442 . | Open up in Read by QxMD
  75. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. North Engl J Med. 2018; 378 (viii): p.708-718. doi: 10.1056/nejmoa1713973 . | Open up in Read past QxMD
  76. Hirai T, Korogi Y, Ono Thousand, et al. Prospective evaluation of suspected stenoocclusive disease of the intracranial artery: combined MR angiography and CT angiography compared with digital subtraction angiography.. AJNR Am J Neuroradiol. 2002; 23 (i): p.93-101.
  77. Bash S, Villablanca JP, Jahan R, et al. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography.. AJNR Am J Neuroradiol. 2005; 26 (5): p.1012-21.
  78. Goyal M, Demchuk AM, Menon BK, et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Engl J Med. 2015; 372 (eleven): p.1019-1030. doi: x.1056/nejmoa1414905 . | Open in Read by QxMD
  79. Jovin TG, Chamorro A, Cobo Due east, et al. Thrombectomy within 8 Hours subsequently Symptom Onset in Ischemic Stroke. N Engl J Med. 2015; 372 (24): p.2296-2306. doi: ten.1056/nejmoa1503780 . | Open in Read by QxMD
  80. Saver JL, Goyal M, Bonafe A, et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Lone in Stroke. N Engl J Med. 2015; 372 (24): p.2285-2295. doi: 10.1056/nejmoa1415061 . | Open in Read by QxMD
  81. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. Due north Engl J Med. 2015; 372 (eleven): p.1009-1018. doi: 10.1056/nejmoa1414792 . | Open in Read by QxMD
  82. Berkhemer OA, Fransen PSS, Beumer D, et al. A Randomized Trial of Intraarterial Treatment for Astute Ischemic Stroke. N Engl J Med. 2015; 372 (1): p.11-twenty. doi: 10.1056/nejmoa1411587 . | Open in Read by QxMD
  83. Kasner SE. Clinical interpretation and employ of stroke scales. The Lancet Neurology. 2006; 5 (7): p.603-612. doi: 10.1016/s1474-4422(06)70495-one . | Open up in Read past QxMD
  84. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. The Lancet. 2000; 355 (9216): p.1670-1674. doi: 10.1016/s0140-6736(00)02237-half dozen . | Open up in Read by QxMD
  85. Thomalla Yard, Cheng B, Ebinger Chiliad, et al. DWI-FLAIR mismatch for the identification of patients with astute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational written report. The Lancet Neurology. 2011; ten (xi): p.978-986. doi: 10.1016/s1474-4422(xi)70192-two . | Open in Read by QxMD
  86. Johnston SC, Easton JD, Farrant 1000, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Run a risk TIA. N Engl J Med. 2018; 379 (3): p.215-225. doi: 10.1056/nejmoa1800410 . | Open in Read by QxMD
  87. Parker Due south, Ali Y. Irresolute contraindications for t-PA in acute stroke: review of twenty years since NINDS.. Curr Cardiol Rep. 2015; 17 (10): p.81. doi: 10.1007/s11886-015-0633-5 . | Open in Read by QxMD
  88. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to 4 rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015; v (3): p.110-121. doi: 10.1177/1941874415578532 . | Open up in Read by QxMD

dolanbose1950.blogspot.com

Source: https://www.amboss.com/us/knowledge/Ischemic_stroke

0 Response to "Usmle I Specialty Review and Study Guide a Series From Statpearls"

Post a Comment

Subscribe to: Post Comments (Atom)

Iklan Atas Artikel

Iklan Tengah Artikel 1

Iklan Tengah Artikel 2

Iklan Bawah Artikel