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Home Books Tintinalli's Emergency Medicine Manual, 7e

Chapter 141. Stroke, Transient Ischemic Attack, and Subarachnoid Hemorrhage

Steven Go

Stroke is defined as any disease process that interrupts blood flow to the brain. Ischemic strokes (87%) are more common than hemorrhagic intracerebral (10%) and a traumatic subarachnoid hemorrhage (SAH) (3%) (Table 141-1). A transient ischemic attack (TIA) is a transient neurologic deficit that typically lasts less than 1 to 2 hours, but duration can no longer be used to discriminate between TIA and stroke; they are best thought of as similar disease processes on a continuum.

Table 141-1 Stroke Classification
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Table 141-1 Stroke Classification

Stroke Type

Mechanism

Major Causes

Clinical Notes

Ischemic

Thrombotic

Narrowing of a damaged vascular lumen by an in situ process, usually clot formation

Atherosclerosis

Vasculitis

Arterial dissection

Polycythemia

Hypercoagulable state

Infection (human immunodeficiency virus infection, syphilis, trichinosis, tuberculosis, aspergillosis)

Symptoms often have gradual onset and may wax and wane.

Common cause of transient ischemic attack.

Embolic

Obstruction of a normal vascular lumen by intravascular material from a remote source

Valvular vegetations

Mural thrombi

Paradoxical emboli

Cardiac tumors (myxomas)

Arterial-arterial emboli from proximal source

Fat emboli

Particulate emboli (intravenous drug use)

Septic emboli

Typically sudden in onset.

Account for 20% of ischemic strokes.

Hypoperfusion

Low–blood flow state leading to hypoperfusion of the brain

Cardiac failure resulting in systemic hypotension

Diffuse injury pattern in watershed regions.

Symptoms may wax and wane with hemodynamic factors.

Hemorrhagic

Intracerebral

Intraparenchymal hemorrhage from previously weakened arterioles

Hypertension

Amyloidosis

Iatrogenic anticoagulation

Vascular malformations

Cocaine use

Intracranial pressure rise causes local neuronal damage.

Secondary vasoconstriction mediated by blood breakdown products or neuronal mechanisms (diaschisis) can cause remote perfusion changes.

Risks include advanced age, history of stroke, tobacco or alcohol use.

More common in Asians and blacks.

Nontraumatic subarachnoid

Hemorrhage into subarachnoid space

Berry aneurysm rupture

Vascular malformation rupture

May be preceded by a sentinel headache (“warning leak”).

Specific findings in stroke patients depend on regions of the brain that are compromised and the severity of the insult (Table 141-2). It is important to remember that stroke presentation can vary considerably from classically described syndromes.

Table 141-2 Symptoms of Stroke
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Table 141-2 Symptoms of Stroke

Traditional symptoms

Sudden numbness or weakness of face, arm, or leg—especially unilateral

Sudden confusion or aphasia

Sudden memory deficit or spatial orientation or perception difficulties

Sudden visual deficit or diplopia

Sudden dizziness, gait disturbance, or ataxia

Sudden severe headache with no known cause

Nontraditional symptoms

Loss of consciousness or syncope

Shortness of breath

Sudden pain in the face, chest, arms, or legs

Seizure

Falls or accidents

Sudden hiccups

Sudden nausea

Sudden fatigue

Sudden palpitations

Altered mental status

If the anterior cerebral artery is involved, the typical symptoms include contralateral leg weakness and sensory changes. A classic middle cerebral artery stroke presents with hemiparesis (arm > leg), facial plegia, and sensory loss. Weakness in the lower half of the face (variable) and ipsilateral gaze ...

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