th180 judd

8/18/2019 TH180 Judd

1/181

Stroke In The Young AdultStroke In The Young Adult

8/18/2019 TH180 Judd

2/181

8/18/2019 TH180 Judd

3/181

What Is A Stroke ?What Is A Stroke ?

A stroke occurs when blood flow to A stroke occurs when blood flow to

the brain is interrupted by a blockedthe brain is interrupted by a blocked

or a ruptured blood vessel.or a ruptured blood vessel.

A brain attack. A brain attack.

8/18/2019 TH180 Judd

4/181

StrokeStroke

Acute stroke is typicallyAcute stroke is typicallycharacterized by the sudden onset ofcharacterized by the sudden onset ofa focal neurologic deficit, thougha focal neurologic deficit, thoughsome patients have a stepwise orsome patients have a stepwise orgradual progression of symptoms.gradual progression of symptoms.

8/18/2019 TH180 Judd

5/181

StrokeStroke

Common deficits include:Common deficits include: Dysphasia (difficulty swallowingDysphasia (difficulty swallowing

Dysarthria (difficulty speakingDysarthria (difficulty speaking !emianopia (difficulty with sight!emianopia (difficulty with sight "eakness"eakness

8/18/2019 TH180 Judd

6/181

Stroke Common DeficitsStroke Common Deficits

Ata#iaAta#ia $ensory loss$ensory loss

%eglect%eglect Consciousness is generally normalConsciousness is generally normal

but maybe impairedbut maybe impaired

8/18/2019 TH180 Judd

7/181

Stroke Warning SignsStroke Warning Signs

$udden weakness or numbness of the$udden weakness or numbness of theface, arm or leg, especially on one sideface, arm or leg, especially on one sideof the bodyof the body

$udden confusion, trouble speaking or$udden confusion, trouble speaking orunderstandingunderstanding

$udden trouble seeing in one or both$udden trouble seeing in one or botheyeseyes

8/18/2019 TH180 Judd

8/181


$udden trouble walking, dizziness,$udden trouble walking, dizziness,loss of balance or coordinationloss of balance or coordination

$udden, severe headaches with no$udden, severe headaches with noknown cause (for hemorrhagicknown cause (for hemorrhagicstrokestroke

8/18/2019 TH180 Judd

9/181


Acute loss of focal cerebral functionAcute loss of focal cerebral function& Abrupt onsetAbrupt onset& $ymptoms occur in all affected areas at$ymptoms occur in all affected areas at

the same timethe same time& $ymptoms resolve gradually$ymptoms resolve gradually& $ymptoms are 'negative $ymptoms are 'negative

8/18/2019 TH180 Judd

10/181

Nature of SymptomsNature of Symptoms )ositive symptoms indicate active discharge)ositive symptoms indicate active discharge

from central nervous system neurons. *ypicalfrom central nervous system neurons. *ypicalpositive symptoms can be visual (e.g., brightpositive symptoms can be visual (e.g., brightlines, shapes, ob+ects, auditory (e.g.,lines, shapes, ob+ects, auditory (e.g.,tinnitus, noises, music, somatosensory (e.g.,tinnitus, noises, music, somatosensory (e.g.,

burning, pain, paresthesias, or motor (e.g.,burning, pain, paresthesias, or motor (e.g., +erking or repetitive rhythmic movements. +erking or repetitive rhythmic movements.

%egative symptoms indicate an absence or%egative symptoms indicate an absence orloss of function, such as loss of vision,loss of function, such as loss of vision,hearing, feeling, or ability to move a part ofhearing, feeling, or ability to move a part ofthe body.the body.

8/18/2019 TH180 Judd

11/181

Annual Incidence of Ischemic Annual Incidence of Ischemic

StrokeStroke n young adults (-/0 years has beenn young adults (-/0 years has been

estimated at appro#imately 1/-- perestimated at appro#imately 1/-- per-22,222 in Caucasians, 11.3 per -22,222-22,222 in Caucasians, 11.3 per -22,222

in African Americansin African Americans -24-22,222 in a 5ayo Clinic study of-24-22,222 in a 5ayo Clinic study of

women ages - to 16women ages - to 16

About 1/-17 of cerebral infarcts occur inAbout 1/-17 of cerebral infarcts occur inyoung adult patients, with a higheryoung adult patients, with a higherfre8uency between 9- and 0 yearsfre8uency between 9- and 0 years

8/18/2019 TH180 Judd

12/181

Annual Incidence of Ischemic Annual Incidence of Ischemic

StrokeStroke $troke ranks second after ischemic$troke ranks second after ischemic

heart disease as a cause of lostheart disease as a cause of lostdisabilityad+usted lifeyears in highdisabilityad+usted lifeyears in highincome countriesincome countries

8/18/2019 TH180 Judd

13/181

Mortality of StrokesMortality of Strokes

5ortality in the first month after stroke5ortality in the first month after strokehas been reported to range from 1.7 inhas been reported to range from 1.7 inpatients with lacunar infarcts to ;37 inpatients with lacunar infarcts to ;37 in

patients with spaceoccupying hemisphericpatients with spaceoccupying hemisphericinfarction.infarction. Lacunar strokeLacunar stroke oror lacunar infarctlacunar infarct

((LACILACI is a type of stroke that results is a type of stroke that resultsfrom occlusion of one of the penetratingfrom occlusion of one of the penetratingarteries that provides blood to the brain

8/18/2019 TH180 Judd

14/181

StrokeStroke

Stroke in young adults is surprisinglyStroke in young adults is surprisingly

common.common.

The differential diagnosis forThe differential diagnosis for

potential etiologies is broader than potential etiologies is broader than

that for older adultsthat for older adults..

8/18/2019 TH180 Judd

15/181

StrokeStroke

n children and young adults=n children and young adults= Congenital and ac8uired heartCongenital and ac8uired heart

problems,problems, !ematologic conditions,!ematologic conditions, >asculopathies,>asculopathies,

5etabolic disorders,5etabolic disorders, Drug ingestionDrug ingestion

are more common.are more common.

8/18/2019 TH180 Judd

16/181

Causes of StrokeCauses of Stroke

*he largest series studies of young*he largest series studies of youngadults with ischemic stroke citeadults with ischemic stroke citeundetermined as the most fre8uentundetermined as the most fre8uentetiology (up to 97 of patientsetiology (up to 97 of patients

schemic stroke is much moreschemic stroke is much morecommon than hemorrhagiccommon than hemorrhagic

8/18/2019 TH180 Judd

17/181


?p to 07 of strokes in young adults?p to 07 of strokes in young adultsare due to spontaneous intracerebralare due to spontaneous intracerebralhemorrhage.hemorrhage.

>ascular malformations, aneurysms,>ascular malformations, aneurysms,hypertension, and illicit drug use arehypertension, and illicit drug use arethe main causes.the main causes.

8/18/2019 TH180 Judd

18/181

Causes of Ischemic Stroke in Young

Adults !ur Neurol "##$%&$'"(")"(*

8/18/2019 TH180 Judd

19/181

Cardio+ascular ,isk -actors inCardio+ascular ,isk -actors in

"$" Young .atients / 0n1"$" Young .atients / 0n15a+or cardiovascular risk factors 9 (6@5a+or cardiovascular risk factors 9 (6@

Arterial hypertension 11 (6Arterial hypertension 11 (6 Diabetes mellitus 3 (1-Diabetes mellitus 3 (1- !ypercholesterolemia -; (0@!ypercholesterolemia -; (0@ Atherosclerosis (-0Atherosclerosis (-0

Causes of schemic $troke in oung AdultsCauses of schemic $troke in oung AdultsBur %eurol 122;=;:1-1/1-3Bur %eurol 122;=;:1-1/1-3

8/18/2019 TH180 Judd

20/181

Cardio+ascular ,isk -actors inCardio+ascular ,isk -actors in

"$" Young .atients / 0n1"$" Young .atients / 0n1

5inor cardiovascular risk factors @95inor cardiovascular risk factors @9(-;1(-;1

Cigarette smoking 06 (-99Cigarette smoking 06 (-99 ral contraceptives -3 (-;ral contraceptives -3 (-; !igh alcohol intake 9- (30!igh alcohol intake 9- (30

Causes of schemic $troke in oungCauses of schemic $troke in oungAdults Bur %eurol 122;=;:1-1/1-3Adults Bur %eurol 122;=;:1-1/1-3

8/18/2019 TH180 Judd

21/181

.re+ention of Stroke.re+ention of Stroke

Control high blood pressureControl high blood pressure )revent heart disease)revent heart disease

$top cigarette smoking$top cigarette smoking ecognize signs of *Aecognize signs of *A educe blood cholesterol levelseduce blood cholesterol levels

8/18/2019 TH180 Judd

22/181

Stroke ,isk -actors That Can 2eStroke ,isk -actors That Can 2e

TreatedTreated !ypertension4!igh Elood )ressure!ypertension4!igh Elood )ressure

!eart Disease!eart Disease

Cigarette $mokingCigarette $moking

*ransient schemic Attacks*ransient schemic Attacks

8/18/2019 TH180 Judd

23/181

Stroke ,isk -actors That Can 2eStroke ,isk -actors That Can 2e

TreatedTreated DiabetesDiabetes

Blevated Elood Cholesterol4FipidsBlevated Elood Cholesterol4Fipids

Asymptomatic Carotid EruitsAsymptomatic Carotid Eruits

8/18/2019 TH180 Judd

24/181

Stroke ,isk -actorsStroke ,isk -actors

That Cannot 2e TreatedThat Cannot 2e Treated AgeAge GenderGender

aceace )rior stroke)rior stroke Hamily historyHamily history

8/18/2019 TH180 Judd

25/181

Stroke ,isk -actors 3ess Well4Stroke ,isk -actors 3ess Well4

DocumentedDocumented Geographical FocationGeographical Focation

$ocioeconomic Hactors$ocioeconomic Hactors

B#cessive Alcohol ntakeB#cessive Alcohol ntake

Certain Iinds of Drug AbuseCertain Iinds of Drug Abuse

8/18/2019 TH180 Judd

26/181

What Are the Types of Stroke ?What Are the Types of Stroke ?

schemic $troke (Elockageschemic $troke (Elockage&& Caused by a blockage in bloodCaused by a blockage in blood

vessels in brainvessels in brain!emorrhagic $troke (Eleeding!emorrhagic $troke (Eleeding

&& Caused by ruptured or leaking bloodCaused by ruptured or leaking blood

vessels in brainvessels in brain

8/18/2019 TH180 Judd

27/181

Stroke 2ackgroundStroke 2ackground

& nade8uate blood flownade8uate blood flow Ischemic strokeIschemic stroke

& HocalHocal / thrombotic or embolic occlusion of/ thrombotic or embolic occlusion of

ma+or arteryma+or artery& GlobalGlobal / inade8uate cerebral perfusion/ inade8uate cerebral perfusion

& !emorrhage!emorrhage ParenchymalParenchymal / into brain tissue/ into brain tissue SubarachnoidSubarachnoid / surrounding subarachnoid/ surrounding subarachnoid

spacespace

8/18/2019 TH180 Judd

28/181

8/18/2019 TH180 Judd

29/181


$ome of the most common causes of$ome of the most common causes ofischemia in the youngischemia in the young

Cardioembolism (12/97,Cardioembolism (12/97,

Dissection of e#tracranial arteries (@/Dissection of e#tracranial arteries (@/17,17,

5igraine with aura (-/1275igraine with aura (-/127

Drugs (-27Drugs (-27 !ypercoagulable states (/-27!ypercoagulable states (/-27 )remature atherosclerosis (1217)remature atherosclerosis (1217

8/18/2019 TH180 Judd

30/181

Ischemic StrokeIschemic Stroke

n patients younger than years,n patients younger than years,only about -27 of strokes areonly about -27 of strokes arecaused by largevesselcaused by largevessel

atherosclerotic disease.atherosclerotic disease.

8/18/2019 TH180 Judd

31/181

What Are the Causes of IschemicWhat Are the Causes of Ischemic

Stroke?Stroke?Farge vessel diseaseFarge vessel disease

)remature atherosclerosis)remature atherosclerosis Dissection (spontaneous or traumaticDissection (spontaneous or traumatic nherited metabolic diseases (homocystinuria, HabryJs, pseudo#anthomanherited metabolic diseases (homocystinuria, HabryJs, pseudo#anthoma

elasticum, 5BFA$ syndromeelasticum, 5BFA$ syndrome Hibromuscular dysplasiaHibromuscular dysplasia

nfection (bacterial, fungal, tuberculosis, syphilis, Fymenfection (bacterial, fungal, tuberculosis, syphilis, Fyme >asculitis (collagen vascular diseases K systemic lupus erythematosus,>asculitis (collagen vascular diseases K systemic lupus erythematosus,rheumatoid arthritis, $+LgrenJs syndrome, polyarteritis nodosa= *akayasuJsrheumatoid arthritis, $+LgrenJs syndrome, polyarteritis nodosa= *akayasuJsdisease, "egenerJs syndrome, cryoglobulinemia, sarcoidosis, inflammatorydisease, "egenerJs syndrome, cryoglobulinemia, sarcoidosis, inflammatorybowel disease, isolated central nervous system angiitisbowel disease, isolated central nervous system angiitis

5oyamoya disease: (Mapanese, Npuff of cigar smokeN is an inherited5oyamoya disease: (Mapanese, Npuff of cigar smokeN is an inheriteddisease in which certain arteries in the brain are constricteddisease in which certain arteries in the brain are constricted

adiationadiation *o#ic (illicit drugs K cocaine, heroin, phencyclidine= therapeutic drugs K F*o#ic (illicit drugs K cocaine, heroin, phencyclidine= therapeutic drugs K Fasparaginase, cytosine arabinoside, ephedra, phenylephrineasparaginase, cytosine arabinoside, ephedra, phenylephrine

8/18/2019 TH180 Judd

32/181


Stroke?Stroke? Cardiac disease (includingCardiac disease (including

congenital, rheumatic valve disease,congenital, rheumatic valve disease,mitral valve prolapse, patentmitral valve prolapse, patent

foramen ovale, endocarditis, atrialforamen ovale, endocarditis, atrialmy#oma, arrhythmias, cardiacmy#oma, arrhythmias, cardiacsurgerysurgery

8/18/2019 TH180 Judd

33/181


Stroke?Stroke?

$mall vessel disease$mall vessel disease >asculopathy (infectious,>asculopathy (infectious,

noninfectious, microangiopathynoninfectious, microangiopathy ndependent predictors ofndependent predictors of

arteriopathy are sickle cell diseasearteriopathy are sickle cell diseaseand recent upper respiratoryand recent upper respiratoryinfection.infection.

8/18/2019 TH180 Judd

34/181

8/18/2019 TH180 Judd

35/181

5ematologic Disorders5ematologic Disorders

5any hematologic disorders are5any hematologic disorders areassociated with ischemic stroke.associated with ischemic stroke.

*he disorders most likely to cause*he disorders most likely to causeischemic stroke in patients youngerischemic stroke in patients youngerthan 0 years are:than 0 years are:

Antiphospholipid antibody syndromeAntiphospholipid antibody syndrome $ickle cell anemia$ickle cell anemia !eparin induced thrombocytopenia!eparin induced thrombocytopenia

8/18/2019 TH180 Judd

36/181

A.S A.S

Antiphospholipid syndromeAntiphospholipid syndrome (A)$ or A)F$ or(A)$ or A)F$ orantiphospholipid antibody syndromeantiphospholipid antibody syndrome is ais adisorder of coagulation that causes blood clotsdisorder of coagulation that causes blood clots(thrombosis in both arteries and veins as well as(thrombosis in both arteries and veins as well as

pregnancyrelated complications such aspregnancyrelated complications such asmiscarriage, stillbirth, preterm delivery, or severemiscarriage, stillbirth, preterm delivery, or severepreeclampsia. *he syndrome occurs due to thepreeclampsia. *he syndrome occurs due to theautoimmune production of antibodies againstautoimmune production of antibodies againstphospholipid (a)F, a cell membrane substance.phospholipid (a)F, a cell membrane substance.

n particular, the disease is characterized byn particular, the disease is characterized byantibodies against cardiolipin (anticardiolipinantibodies against cardiolipin (anticardiolipinantibodies and O1 glycoprotein.antibodies and O1 glycoprotein.

8/18/2019 TH180 Judd

37/181

5ematologic disorders5ematologic disorders

5ost of the common hereditary5ost of the common hereditaryhypercoagulable disorders, such ashypercoagulable disorders, such asfactor > Feiden4activated protein Cfactor > Feiden4activated protein C

resistance, the prothrombin generesistance, the prothrombin genemutation (G121-2A, antithrombinmutation (G121-2A, antithrombin deficiency, protein C deficiency, deficiency, protein C deficiency,and protein $ deficiency, typicallyand protein $ deficiency, typically

cause venous thrombosis much morecause venous thrombosis much moreoften than they cause arterialoften than they cause arterialthrombosis.thrombosis.

8/18/2019 TH180 Judd

38/181


Stroke?Stroke?

5igraine: especially with aura5igraine: especially with aura

8/18/2019 TH180 Judd

39/181

!m6olism'

Cardiogenic 0atrial fi6rillation7mural throm6us7 my8oma7

+al+ular +egetations1

Artery4to4artery-at Air

.arado8ical 0em6oli of+enous origin passing through

a patent foramen o+ale1

8/18/2019 TH180 Judd

40/181

Cardiogenic !m6olismCardiogenic !m6olism

5a+or risk factors:5a+or risk factors: AnticoagulationAnticoagulationndicatedndicated& Atrial fibrillationAtrial fibrillation

& 5itral stenosis5itral stenosis& )rosthetic cardiac valve)rosthetic cardiac valve& ecent 5ecent 5& *hrombus in F> or FA appendage*hrombus in F> or FA appendage

& Atrial my#omaAtrial my#oma& nfective endocarditis (%o anticoagulationnfective endocarditis (%o anticoagulation& Dilated cardiomyopathyDilated cardiomyopathy

8/18/2019 TH180 Judd

41/181


5inor risk factors:5inor risk factors: Eest treatment unclearEest treatment unclear& )athologic 5itral valve prolapse (17 of)athologic 5itral valve prolapse (17 of

populationpopulation

& 5itral annular calcification5itral annular calcification& )atent foramen ovale (17 2f population)atent foramen ovale (17 2f population& Atrial septal aneurysmAtrial septal aneurysm& Calcific aortic stenosisCalcific aortic stenosis

& F> regional wall motion abnormalityF> regional wall motion abnormality& Aortic arch atheromatous pla8uesAortic arch atheromatous pla8ues& $pontaneous echocardiographic contrast$pontaneous echocardiographic contrast

8/18/2019 TH180 Judd

42/181


nefifth to onethird of strokes innefifth to onethird of strokes inthe young may be caused bythe young may be caused bycardioembolic phenomena.cardioembolic phenomena.

8/18/2019 TH180 Judd

43/181

Cardiogenic !m6olismCardiogenic !m6olism Paradoxical embolizationParadoxical embolization

from the right heart to the left isfrom the right heart to the left isbelieved to occur via a patentbelieved to occur via a patentforamen ovale or atrial septalforamen ovale or atrial septaldefect (which can be found ondefect (which can be found onautopsy in up to one fourth of allautopsy in up to one fourth of allpeople.people.

AtherosclerosisAtherosclerosis of theof theaorta or carotid arteriesaorta or carotid arteriescan be a source of bothcan be a source of bothatheroemboli andatheroemboli andthromboembolithromboemboli

8/18/2019 TH180 Judd

44/181


Left atrial thrombiLeft atrial thrombiaccount for nearly halfaccount for nearly halfof cardiacof cardiacthromboemboli. *hethromboemboli. *he

most common cause ismost common cause isatrial fibrillation= otheratrial fibrillation= othercauses are dilatedcauses are dilatedcardiomyoapthy,cardiomyoapthy,mitral valve stenosis,mitral valve stenosis,

and someand somehypercoagulablehypercoagulablestates.states.

Left L ft t i

8/18/2019 TH180 Judd

45/181

Rightatrium

Left

atrium

Valsalva

Right atrium

Left atrium

Figure 1 !ransesophageal "chocardiograms of aFigure 1 !ransesophageal "chocardiograms of a

Patent Foramen #$alePatent Foramen #$ale

n )anel A, a transesophageal echocardiogram in then )anel A, a transesophageal echocardiogram in thelongitudinal plane shows a separation between thelongitudinal plane shows a separation between theprimum septum (arrowhead and the secundum septumprimum septum (arrowhead and the secundum septumK a finding consistent with the presence of patentK a finding consistent with the presence of patentforamen ovale.foramen ovale.)anel E shows a transesophageal echocardiogram, also in)anel E shows a transesophageal echocardiogram, also inthe longitudinal plane, obtained during the in+ection ofthe longitudinal plane, obtained during the in+ection ofagitatedsaline contrast material through an antecubitalagitatedsaline contrast material through an antecubitalvein with use of the >alsalva maneuver. *here isvein with use of the >alsalva maneuver. *here iscomplete opacification of the right atrium, and passage ofcomplete opacification of the right atrium, and passage of

a cloud of bubbles between the primum and secunduma cloud of bubbles between the primum and secundumsepta into the left atrium is visible.septa into the left atrium is visible.

8/18/2019 TH180 Judd

46/181

,A

3A

Figure % *ransesophageal echocardiogram showing a thrombus (arrows

passing from right atrium (A to left atrium (FA through a patent foramenovale.

Left

8/18/2019 TH180 Judd

47/181

Right

atrium

Left

atrium

Right

ventricle

Leftventricle

Right

atrium

Left

atrium

Figure % !ransesophageal "chocardiograms of an Atrial SeptalFigure % !ransesophageal "chocardiograms of an Atrial Septal

AneurysmAneurysm

n )anel A, a transesophageal echocardiogram (in the horizontal planen )anel A, a transesophageal echocardiogram (in the horizontal planeshows an atrial septal aneurysm protruding into the right atrium (arrow.shows an atrial septal aneurysm protruding into the right atrium (arrow.Atrial septal aneurysm is defined as either sustained bowing of a -mmAtrial septal aneurysm is defined as either sustained bowing of a -mm

segment of interatrial septal membrane in the fossa ovalis of at least -- mmsegment of interatrial septal membrane in the fossa ovalis of at least -- mm(or at least - mm by a more conservative definition beyond the plane of(or at least - mm by a more conservative definition beyond the plane ofthe interatrial septum or as phasic e#cursion to either side totaling the samethe interatrial septum or as phasic e#cursion to either side totaling the samedistance.distance.)anel E shows a transesophageal echocardiogram showing the same atrial)anel E shows a transesophageal echocardiogram showing the same atrialseptal aneurysm (arrow viewed in the longitudinal plane.septal aneurysm (arrow viewed in the longitudinal plane.

8/18/2019 TH180 Judd

48/181

.-9.-9

Figure & Percutaneous Closure of a Patent ForamenFigure & Percutaneous Closure of a Patent Foramen#$ale#$ale

"ith use of a femoral approach, a transvenous sheath is"ith use of a femoral approach, a transvenous sheath isadvanced across the foramen into the left atrium, where aadvanced across the foramen into the left atrium, where afolded disk is e#panded and pulled back, apposing thefolded disk is e#panded and pulled back, apposing theprimum and secundum septa closed. *his step is followedprimum and secundum septa closed. *his step is followedby deployment of a rightsided disk, at which time the twoby deployment of a rightsided disk, at which time the twodisk device is released. Clopidogrel and aspirin aredisk device is released. Clopidogrel and aspirin arerecommended for a period of three months to preventrecommended for a period of three months to preventthrombus formation on the device, with aspirin therapythrombus formation on the device, with aspirin therapycontinued for an additional three months, whencontinued for an additional three months, whenendothelialization is complete. Antibiotic prophyla#is for si#endothelialization is complete. Antibiotic prophyla#is for si#

months is recommended. Complete late closure of themonths is recommended. Complete late closure of theforamen has been reported in 32 to 6 percent of patients.foramen has been reported in 32 to 6 percent of patients.

8/18/2019 TH180 Judd

49/181

8/18/2019 TH180 Judd

50/181

8/18/2019 TH180 Judd

51/181

Cocaine A6useCocaine A6use

Another important cause of ischemic stroke is theAnother important cause of ischemic stroke is theuse of sympathomimetic drugs such as cocaineuse of sympathomimetic drugs such as cocaineamphetamines, ephedra, or phenylephrine. *heamphetamines, ephedra, or phenylephrine. *hestrongest association is with cocaine, which hasstrongest association is with cocaine, which has

been seen in case series to cause cerebralbeen seen in case series to cause cerebralvasoconstriction in a dosedependent manner.vasoconstriction in a dosedependent manner.>asoconstriction is also related to a longer>asoconstriction is also related to a longerduration of cocaine use. $everal casecontrolduration of cocaine use. $everal casecontrolstudies have found that the risk of stroke is 0. tostudies have found that the risk of stroke is 0. to

@. times higher in drug abusers than in controls,@. times higher in drug abusers than in controls,and that use of catecholamines or cocaine aloneand that use of catecholamines or cocaine alonewas associated with a significantly increased riskwas associated with a significantly increased riskof stroke.of stroke.

8/18/2019 TH180 Judd

52/181

What Are the Causes ofWhat Are the Causes of

5emorrhagic Stroke?5emorrhagic Stroke?

ccurs when a weakened bloodccurs when a weakened bloodvessel rupturesvessel ruptures

&& Aneurysms: Eallooning of aAneurysms: Eallooning of aweakened region of a blood vesselweakened region of a blood vessel

&& Arteriovenous 5alformations (A>5s:Arteriovenous 5alformations (A>5s:Cluster of abnormal blood vesselsCluster of abnormal blood vessels

8/18/2019 TH180 Judd

53/181

Arterio+enous Malformations Arterio+enous Malformations

Cerebral A>5s are most commonlyCerebral A>5s are most commonlydiscovered in young adults aged 1202discovered in young adults aged 1202years.years.

*hese lesions are usually detected in*hese lesions are usually detected in

patients as the result of a seizure orpatients as the result of a seizure orhemorrhage.hemorrhage. A>5s hemorrhage at a rate of 07 perA>5s hemorrhage at a rate of 07 per

year.year.

Appro#imately half of these hemorrhagesAppro#imately half of these hemorrhageswill carry significant morbidity or mortality.will carry significant morbidity or mortality.

8/18/2019 TH180 Judd

54/181

HEMORRHAGICHEMORRHAGIC

Arteriovenous malformationArteriovenous malformation %eoplasm (primary central nervous%eoplasm (primary central nervous

system, metastatic, leukemiasystem, metastatic, leukemia

!ematologic (sicklecell disease,!ematologic (sicklecell disease,neoplasm, thrombocytopenianeoplasm, thrombocytopenia

5oyamoya disease5oyamoya disease

Drug use (warfarin, amphetamines,Drug use (warfarin, amphetamines,cocaine, phenypropanolaminecocaine, phenypropanolamine atrogenic (periproceduralatrogenic (periprocedural

8/18/2019 TH180 Judd

55/181

MoyamoyaMoyamoya

5oyamoya syndrome is characterized by progressive5oyamoya syndrome is characterized by progressivestenosis of the internal carotid arteries and formation ofstenosis of the internal carotid arteries and formation ofcollateral vessels that give a Npuff of smokeN appearance oncollateral vessels that give a Npuff of smokeN appearance onangiography.angiography.

5oyamoya disease occurs mainly in Mapanese and other5oyamoya disease occurs mainly in Mapanese and otherAsian populations and may have a genetic basis.Asian populations and may have a genetic basis.

$econdary moyamoya syndrome is seen in association with$econdary moyamoya syndrome is seen in association withneurofibromatosis, Down syndrome, "illiams syndrome,neurofibromatosis, Down syndrome, "illiams syndrome,sickle cell disease, and as a se8uela of cranial irradiation.sickle cell disease, and as a se8uela of cranial irradiation.ntracranial hemorrhage is common in young adults.ntracranial hemorrhage is common in young adults.

Dissection K Arterial dissection is the most commonDissection K Arterial dissection is the most commonvascular abnormality in some young adult seriesvascular abnormality in some young adult series

8/18/2019 TH180 Judd

56/181

Intracerebral 'emorrhageIntracerebral 'emorrhage

(iffuse ) subarachnoid hemorrhage(iffuse ) subarachnoid hemorrhage

Focal ) intraparenchymalFocal ) intraparenchymal

Accounts for %*+ of all strokesAccounts for %*+ of all strokes

Acute rise in intracranial pressureAcute rise in intracranial pressurefrom arterial rupture fre,uentlyfrom arterial rupture fre,uently

results in loss of consciousness atresults in loss of consciousness at

outsetoutset

Some patients die from herniationSome patients die from herniation

fC f S

8/18/2019 TH180 Judd

57/181

Causes of SpontaneousCauses of Spontaneous


-IC'.-IC'. Intraparenchymal hemorrhageIntraparenchymal hemorrhage

& *rauma*rauma& !ypertension!ypertension& Amyloid angiopathyAmyloid angiopathy

& Arteriovenous malformationArteriovenous malformation& Eleeding diathesis (anticoagulants,Eleeding diathesis (anticoagulants,thrombolyticsthrombolytics

& Drugs (amphetamines, cocaineDrugs (amphetamines, cocaine

fC f S t

8/18/2019 TH180 Judd

58/181



-IC'.-IC'. Cervical arterial dissection causes upCervical arterial dissection causes upto 127 of strokes in patientsto 127 of strokes in patientsyounger than 0 years.younger than 0 years.

Dissections usually involve theDissections usually involve thee#tracranial portion of the vessel,e#tracranial portion of the vessel,and involve the internal carotidand involve the internal carotid

arteries at least three times as oftenarteries at least three times as oftenas the vertebral arteries.as the vertebral arteries.

C f SC f S t

8/18/2019 TH180 Judd

59/181



-IC'.-IC'. n many cases the dissection is precededn many cases the dissection is precededby mild neck trauma, which may be asby mild neck trauma, which may be asminor as a vigorous cough or turning ofminor as a vigorous cough or turning of

the head.the head. *ypical features of dissection include: %eck*ypical features of dissection include: %eckpain, headache, and !orner syndrome,pain, headache, and !orner syndrome,followed minutes to hours later byfollowed minutes to hours later by

symptoms of ocular or cerebral ischemia,symptoms of ocular or cerebral ischemia,usually a transient ischemic attack ratherusually a transient ischemic attack ratherthan a stroke.than a stroke.

C f SC f S t

8/18/2019 TH180 Judd

60/181



-IC'.-IC'.nherited disorders that arenherited disorders that areassociated with increased risk ofassociated with increased risk ofcervical arterial dissection include:cervical arterial dissection include:

BhlersDanlos syndrome type >BhlersDanlos syndrome type > 5arfan syndrome5arfan syndrome Autosomal dominant polycysticAutosomal dominant polycystic

kidney diseasekidney disease steogenesis imperfecta type steogenesis imperfecta type Hibromuscular dysplasiaHibromuscular dysplasia

(i i 0 t(i i 0 t

8/18/2019 TH180 Judd

61/181

(iagnosis/ 0anagement/(iagnosis/ 0anagement/

and Prognosis of IC'and Prognosis of IC' C! diagnostic test of choiceC! diagnostic test of choice

& !yperintense area with mass effect and!yperintense area with mass effect andlater hypointense surrounding edemalater hypointense surrounding edema

0I less sensiti$e in early stages0I less sensiti$e in early stages

8/18/2019 TH180 Judd

62/181

8/18/2019 TH180 Judd

63/181

Subarachnoid 'emorrhageSubarachnoid 'emorrhage

Aneurysms can rupture any time but moreAneurysms can rupture any time but morecommon during strenuous acti$itycommon during strenuous acti$ity

0ost common manifestation is headache0ost common manifestation is headache

& ' 'worst headache of my life worst headache of my life 2eck pain and rigidity2eck pain and rigidity Loss of consciousness and $omiting commonLoss of consciousness and $omiting common Seen on C! in 34+ of cases ) location maySeen on C! in 34+ of cases ) location may

suggest site of rupturesuggest site of rupture

2ormal C! does not rule out so do lumbar2ormal C! does not rule out so do lumbarpuncturepuncture / #anthochromia (develops after @/ #anthochromia (develops after @hourshours

C f S tC f S t

8/18/2019 TH180 Judd

64/181



-IC'.-IC'. Subarachnoid hemorrhageSubarachnoid hemorrhage

& Congenital saccular aneurysm (37Congenital saccular aneurysm (37& ?nknown (-7?nknown (-7

Wh t . t f th 2 iWh t . t f th 2 i

8/18/2019 TH180 Judd

65/181

What .arts of the 2rainWhat .arts of the 2rain

Are Affected 6y Stroke? Are Affected 6y Stroke?

i ht -2 d i t.ight -2on dominant.

8/18/2019 TH180 Judd

66/181

ight -2on5dominant.ight -2on5dominant.

'emisphere Stroke6'emisphere Stroke6

Common PatternCommon Pattern 2eglect of left $isual field2eglect of left $isual field "xtinction of left5sided stimuli"xtinction of left5sided stimuli Left hemiparesisLeft hemiparesis Left5sided sensory lossLeft5sided sensory loss Left $isual field defectLeft $isual field defect Poor left con7ugate gazePoor left con7ugate gaze (ysarthria(ysarthria Spatial disorientationSpatial disorientation

8/18/2019 TH180 Judd

67/181

Left -(ominant.Left -(ominant.

'emisphere Stroke6'emisphere Stroke6Common PatternCommon Pattern

AphasiaAphasia ight hemiparesisight hemiparesis ight5sided sensory lossight5sided sensory loss ight $isual field defectight $isual field defect Poor right con7ugate gazePoor right con7ugate gaze (ysarthria(ysarthria (ifficulty reading/ 8riting/ or(ifficulty reading/ 8riting/ or

calculatingcalculating

8/18/2019 TH180 Judd

68/181

Erain $tem 4 Cerebellum 4Erain $tem 4 Cerebellum 4

)osterior !emisphere $troke:)osterior !emisphere $troke:

Common )atternCommon )attern 0otor or sensory loss in all four limbs0otor or sensory loss in all four limbs

Crossed signsCrossed signs

Limb or gait ataxiaLimb or gait ataxia (ysarthria(ysarthria

(yscon7ugate gaze(yscon7ugate gaze

2ystagmus2ystagmus AmnesiaAmnesia

9ilateral $isual field defects9ilateral $isual field defects

8/18/2019 TH180 Judd

69/181

Small SubcorticalSmall Subcortical

'emisphere or 9rain Stem'emisphere or 9rain Stem

Stroke6 Common PatternStroke6 Common Pattern Pure 0otorPure 0otor

& "eakness of face and limbs on one side of the"eakness of face and limbs on one side of the

body without abnormalities of higher brainbody without abnormalities of higher brainfunction, sensation, or visionfunction, sensation, or vision

Pure SensoryPure Sensory

& Decreased sensation of face and limbs on oneDecreased sensation of face and limbs on oneside of the body without abnormalities ofside of the body without abnormalities ofhigher brain function, motor function, or visionhigher brain function, motor function, or vision

8/18/2019 TH180 Judd

70/181

& %eurologic B#am%eurologic B#am& Carotid EruitsCarotid Eruits& Cardiac B#amCardiac B#am

& )eripheral )ulses)eripheral )ulses& DermatologicDermatologic& phthalmologicphthalmologic

.hysical !8am.hysical !8am

8/18/2019 TH180 Judd

71/181

DermatologicDermatologic

$plinter hemorrhages and needle$plinter hemorrhages and needletracks (endocarditistracks (endocarditis

Panthoma (hyperlipidemiaPanthoma (hyperlipidemia CafQaulait spotsCafQaulait spots %eurofibromas (neurofibromatosis%eurofibromas (neurofibromatosis

)urpura (coagulopathy)urpura (coagulopathy Capillary angiomata (cavernousCapillary angiomata (cavernousmalformationmalformation

8/18/2019 TH180 Judd

72/181

8/18/2019 TH180 Judd

73/181

9pthalmlogic9pthalmlogic

Corneal arcus (hypercholesterolemiaCorneal arcus (hypercholesterolemia Corneal opacity (HabryJs diseaseCorneal opacity (HabryJs disease Fisch nodulesFisch nodules ptic atrophy (neurofibromatosisptic atrophy (neurofibromatosis

Fens sublu#ation (5arfanJs syndrome,Fens sublu#ation (5arfanJs syndrome,homocystinuriahomocystinuria etinal perivasculitis (sicklecell disease, syphilis,etinal perivasculitis (sicklecell disease, syphilis,

connective tissue diseases, inflammatory bowelconnective tissue diseases, inflammatory boweldiseasedisease

cclusions (embolicclusions (emboli Angioma (cavernous malformationAngioma (cavernous malformation !amartoma (tuberous sclerosis.!amartoma (tuberous sclerosis.

8/18/2019 TH180 Judd

74/181

optic atrophy in tuberous sclerosis

lens dislocation in marfan syndrome

Corneal arcusCorneal arcus

Diagnostic Testing for PatientsDiagnostic Testing for Patients

8/18/2019 TH180 Judd

75/181


ith !tro"eith !tro"e9asic stroke e$aluation9asic stroke e$aluation

Cranial computed tomography (C*Cranial computed tomography (C* Carotid ultrasonography S transcranial DopplerCarotid ultrasonography S transcranial Doppler *ransthoracic echocardiography*ransthoracic echocardiography BIG monitoringBIG monitoring outine blood studies (complete blood count withoutine blood studies (complete blood count with

differential and platelet count, prothrombin timedifferential and platelet count, prothrombin time(international normalized ratio, activated partial(international normalized ratio, activated partial

thromboplastin time, glucose, chemistries,thromboplastin time, glucose, chemistries,serology for syphilis, and an erythrocyteserology for syphilis, and an erythrocytesedimentation ratesedimentation rate


8/18/2019 TH180 Judd

76/181


ith !tro"eith !tro"eComprehensi$e stroke e$aluationComprehensi$e stroke e$aluation

Cranial magnetic resonance imaging (5Cranial magnetic resonance imaging (5 maging of the intracranial arteries (5, C*, or catheter angiographymaging of the intracranial arteries (5, C*, or catheter angiography of the brainof the brain maging of the e#tracranial arteries (5, C*, or catheter angiographymaging of the e#tracranial arteries (5, C*, or catheter angiography of the neckof the neck

*ransesophageal echocardiography (*BB*ransesophageal echocardiography (*BB )rolonged BIG monitoring with !olter or event loop recorder)rolonged BIG monitoring with !olter or event loop recorder ?rine to#icology screen (often productive?rine to#icology screen (often productive ?rine pregnancy test?rine pregnancy test Elood testing for a hypercoagulable state anticardiolipin antibodies, lupusElood testing for a hypercoagulable state anticardiolipin antibodies, lupus

anticoagulants, protein $, protein C, activated protein C resistance,anticoagulants, protein $, protein C, activated protein C resistance,antithrombin is re8uested in patients without a firmly identified causeantithrombin is re8uested in patients without a firmly identified causeof stroke or if the patient or family members have a history of thromboses.of stroke or if the patient or family members have a history of thromboses.t is advantageous to send such a profile prior to initiating anticoagulation,t is advantageous to send such a profile prior to initiating anticoagulation,as heparin can alter interpretation of some of those assays.as heparin can alter interpretation of some of those assays.

n select cases, blood testing for rare genetic causes of stroke (CADA$F,n select cases, blood testing for rare genetic causes of stroke (CADA$F,Habry disease, 5BFA$Habry disease, 5BFA$

5o: Are Strokes Treated?5o: Are Strokes Treated?

8/18/2019 TH180 Judd

77/181

5o: Are Strokes Treated?5o: Are Strokes Treated?

schemic $trokeschemic $troke&& Clot-busters e.g., t-PAClot-busters e.g., t-PA&& Anticoagulants warfarin, aspirin Anticoagulants warfarin, aspirin Carotid !ndarterectomy Carotid !ndarterectomy

Angioplasty"Stents Angioplasty"Stents

8/18/2019 TH180 Judd

78/181

Treatment of StrokesTreatment of Strokes

& Antiplatelet therapy remains treatmentAntiplatelet therapy remains treatmentof choice to prevent recurrentof choice to prevent recurrentthromboembolism in ma+ority ofthromboembolism in ma+ority of

patientspatients

& Anticoagulation may be appropriateAnticoagulation may be appropriate Atrial fibrillationAtrial fibrillation ecent 5ecent 5 $uspected propagation of thrombus or$uspected propagation of thrombus orstroke in evolutionstroke in evolution

8/18/2019 TH180 Judd

79/181

f

8/18/2019 TH180 Judd

80/181

3imitations of Imaging3imitations of Imaging

C* will miss a minority of acuteC* will miss a minority of acutebleedsbleeds

5 with D" (diffusion weighted5 with D" (diffusion weighted

imaging, 8uite sensitive for acuteimaging, 8uite sensitive for acutestroke, has an occasional falsestroke, has an occasional falsenegative result (-; out of ;31negative result (-; out of ;31patients in a recent studypatients in a recent study

5AJs resolution is not yet on par5AJs resolution is not yet on parwith conventional angiography.with conventional angiography.

Th 6 l i .A

8/18/2019 TH180 Judd

81/181

Throm6olysis t4.AThrom6olysis t4.A

& :uidelines for treatment6:uidelines for treatment6 )resent within 9 hours of onset of clearly)resent within 9 hours of onset of clearly

defined stroke / fre8uency of symptomaticdefined stroke / fre8uency of symptomatichemorrhage most likely increases after thishemorrhage most likely increases after this

timetime C* scan shows no evidence ofC* scan shows no evidence ofintracranial hemorrhageintracranial hemorrhage

& %o anticoagulants or antiplatelet agents%o anticoagulants or antiplatelet agentsgiven for 10 hoursgiven for 10 hours& Avoid E) values T -34--2Avoid E) values T -34--2

; id li N t t T t

8/18/2019 TH180 Judd

82/181

;uidelines Not to Treat;uidelines Not to Treat

)revious stroke or serious head)revious stroke or serious headtrauma in preceding 9 monthstrauma in preceding 9 months

!istory of intracranial hemorrhage!istory of intracranial hemorrhage

epeated systolic E)Js T -3 mm !gepeated systolic E)Js T -3 mm !gor diastolic E)Js T --2 mm !gor diastolic E)Js T --2 mm !g

;; id li N t t T t

8/18/2019 TH180 Judd

83/181

;uidelines Not to Treat;uidelines Not to Treat

e8uires aggressive treatment toe8uires aggressive treatment toreduce E) to specified limitsreduce E) to specified limits

*aking anticoagulants or propensity to*aking anticoagulants or propensity to

hemorrhagehemorrhage ecent invasive surgical procedureecent invasive surgical procedure apidly improving neurological deficitapidly improving neurological deficitor minor symptomsor minor symptoms

5 A S k T d5 A St k T t d

8/18/2019 TH180 Judd

84/181

5o: Are Strokes Treated5o: Are Strokes Treated

!emorrhagic $troke!emorrhagic $troke Surgical #nterventionSurgical #ntervention

!ndovascular Procedures, e.g.,!ndovascular Procedures, e.g.,

$coils% $coils%

8/18/2019 TH180 Judd

85/181

Wh t I th I t f St k ?Wh t I th I t f St k ?

8/18/2019 TH180 Judd

86/181

What Is the Impact of Stroke?What Is the Impact of Stroke?

$troke is the third leading cause of$troke is the third leading cause ofdeath in the ?nited $tatesdeath in the ?nited $tates

&& &n average, someone suffers a&n average, someone suffers astroke every '( secondsstroke every '( seconds

&& About )*+,((( Americans suffer a About )*+,((( Americans suffer astroke each year stroke each year

&& About every ' minutes, someone About every ' minutes, someonedies of a strokedies of a stroke

Wh t I th I t f St k ?Wh t I th I t f St k ?

8/18/2019 TH180 Judd

87/181

What Is the Impact of Stroke?What Is the Impact of Stroke?

$troke is a leading cause of serious,$troke is a leading cause of serious,long term disabilitylong term disability

About @.0 million Americans areAbout @.0 million Americans are

stroke survivorsstroke survivors Americans will pay about U;9.;Americans will pay about U;9.;

billion in 12-2 for strokerelatedbillion in 12-2 for strokerelated

medical costs and lost productivitymedical costs and lost productivitylongtermlongterm

, h 6ilit ti, h 6ilit ti

8/18/2019 TH180 Judd

88/181

,eha6ilitation,eha6ilitation

After suffering a stroke, itJsAfter suffering a stroke, itJsimportant to begin a rehabilitationimportant to begin a rehabilitationprogram as soon as possible.program as soon as possible.

*ypes of rehabilitation programs:*ypes of rehabilitation programs: !ospital programs!ospital programs B#tended care facilitiesB#tended care facilities utpatient programsutpatient programs !omebased programs!omebased programs

, h 6ilit ti S i li t, h 6ilit ti S i li t

8/18/2019 TH180 Judd

89/181

,eha6ilitation Specialists,eha6ilitation Specialists

)rovider)rovider ehabilitation specialistehabilitation specialist )hysical therapist)hysical therapist $peech therapist$peech therapist ccupational therapistccupational therapist

)hysiatrist)hysiatrist )sychiatrist)sychiatrist

- il , l ti hi- il , l ti hi

8/18/2019 TH180 Judd

90/181

-amily ,elationships-amily ,elationships

verall, -9 studies reported conse8uences ofverall, -9 studies reported conse8uences ofstroke for family relationships and in thosestroke for family relationships and in thosestudies, 7 to 07 of the samples e#periencedstudies, 7 to 07 of the samples e#periencedfamily problems.family problems.

%ine studies reported marital problems after%ine studies reported marital problems afterstroke, including separation or divorce.stroke, including separation or divorce. $i# of these reported that marital problems were$i# of these reported that marital problems were

a direct conse8uence of the stroke.a direct conse8uence of the stroke. ne study reported that 7 of the sample hadne study reported that 7 of the sample had

e#perienced deterioration in the spousale#perienced deterioration in the spousalrelationship, whereas another found that 937 ofrelationship, whereas another found that 937 ofcouples had e#perienced conflict since the stroke.couples had e#perienced conflict since the stroke.

S l , l ti hiS l , l ti hi

8/18/2019 TH180 Judd

91/181

Se8ual ,elationshipsSe8ual ,elationships

*en studies investigated the impact*en studies investigated the impactof stroke on se#ual relationships,of stroke on se#ual relationships,reporting problems in participantsJreporting problems in participantsJ

se#ual relationships or fre8uency ofse#ual relationships or fre8uency ofse#ual activities.se#ual activities. )revalence of deterioration in se#ual)revalence of deterioration in se#ual

relationships reported in 3 studiesrelationships reported in 3 studiesranged from 7 to ;@7.ranged from 7 to ;@7.

S i l A ti itiS i l A ti iti

8/18/2019 TH180 Judd

92/181

Social Acti+itiesSocial Acti+ities

%ine studies reported conse8uences%ine studies reported conse8uencesof stroke on social or leisureof stroke on social or leisureactivities with 0 of these reportingactivities with 0 of these reporting

deterioration or decrease in thesedeterioration or decrease in theseactivities.activities. Hive studies 8uantified reportedHive studies 8uantified reported

decrease in leisure activities rangingdecrease in leisure activities rangingfrom -7 to ;67.from -7 to ;67.

8/18/2019 TH180 Judd

93/181

8/18/2019 TH180 Judd

94/181

8/18/2019 TH180 Judd

95/181

8/18/2019 TH180 Judd

96/181

8/18/2019 TH180 Judd

97/181

8/18/2019 TH180 Judd

98/181

8/18/2019 TH180 Judd

99/181

8/18/2019 TH180 Judd

100/181

8/18/2019 TH180 Judd

101/181

8/18/2019 TH180 Judd

102/181

8/18/2019 TH180 Judd

103/181

8/18/2019 TH180 Judd

104/181

8/18/2019 TH180 Judd

105/181

8/18/2019 TH180 Judd

106/181

!tro"e Chameleons!tro"e Chameleons

8/18/2019 TH180 Judd

107/181

$trokes with atypical presentations that take on$trokes with atypical presentations that take onthe appearance of other disease process may bethe appearance of other disease process may betermed stroke chameleons, for like thetermed stroke chameleons, for like thechameleon, these disguised strokes may changechameleon, these disguised strokes may changeand evolve with time.and evolve with time.

*he provider is left with the daunting problem of*he provider is left with the daunting problem ofdiscovering the unusual manifestation of andiscovering the unusual manifestation of anuncommon clinical process.uncommon clinical process.

*he presence of historical risk factors for*he presence of historical risk factors for

cerebrovascular disease and the abrupt onset ofcerebrovascular disease and the abrupt onset ofsymptoms may be the best clues available to thesymptoms may be the best clues available to theprovider to detect these unusual strokeprovider to detect these unusual strokesyndromes.syndromes.

8/18/2019 TH180 Judd

108/181


8/18/2019 TH180 Judd

109/181


Atherosclerosis (leading to thromboembolism orAtherosclerosis (leading to thromboembolism orlocal occlusion and cardioembolism are thelocal occlusion and cardioembolism are theleading causes of brain ischemia.leading causes of brain ischemia.

?nusual causes should be considered, especially if?nusual causes should be considered, especially ifpatients are younger (e.g., below 2 years of agepatients are younger (e.g., below 2 years of ageand have no apparent cardiovascular risk factors.and have no apparent cardiovascular risk factors.

$ome clinical clues that suggest alternative$ome clinical clues that suggest alternativediagnoses are ptosis and miosis contralateral todiagnoses are ptosis and miosis contralateral tothe deficit (carotidartery dissection, fever and athe deficit (carotidartery dissection, fever and a

cardiac murmur (infective endocarditis, andcardiac murmur (infective endocarditis, andheadache and an elevated erythrocyteheadache and an elevated erythrocytesedimentation rate.sedimentation rate.

DifferentialDifferential

8/18/2019 TH180 Judd

110/181

DiagnosisDiagnosis

$eizures and migraine auras$eizures and migraine aurascharacteristically (but not always begincharacteristically (but not always beginwith positive symptoms, while *Aswith positive symptoms, while *Asinvariably are characterized by negativeinvariably are characterized by negative

symptoms.symptoms. $eizures occasionally cause paralytic$eizures occasionally cause paralyticattacks but, on close observation, thereattacks but, on close observation, thereare usually features of the history andare usually features of the history andphysical e#amination that suggest thephysical e#amination that suggest the

presence of a seizure disorder such aspresence of a seizure disorder such asminor twitching of a finger or toe or aminor twitching of a finger or toe or atingling sensation in the affected limb.tingling sensation in the affected limb.

Differential Diagnosis of StrokeDifferential Diagnosis of Stroke

8/18/2019 TH180 Judd

111/181


ntracranial mass: *umor, $ubduralntracranial mass: *umor, $ubduralhematomahematoma

$eizure with persistent neurological$eizure with persistent neurological

signssigns 5igraine with persistent neurological5igraine with persistent neurological

signssigns 5etabolic5etabolic


8/18/2019 TH180 Judd

112/181


!yperglycemia (nonketotic!yperglycemia (nonketotichyperosmolar comahyperosmolar coma

!ypoglycemia!ypoglycemia )ostcardiac arrest ischemia)ostcardiac arrest ischemia Drug4narcotic overdoseDrug4narcotic overdose

HocalHocalsymptomsymptomss

%onfocal%onfocalsymptomssymptoms

8/18/2019 TH180 Judd

113/181

CommonCommondisordersdisorders

$eizures$eizures VVVV VVVV

*As*As VVVVVVVV occasionallyoccasionally

5igraine5igraine VVVVVVVV VVVVVVVV

$yncope$yncope 22 22

Fess commonFess commondisordersdisorders

>estibulopathy>estibulopathy VVVV VVVV

5etabolic5etabolic VV VVVVVV

N*umor attacksNN*umor attacksN VVVVVV VV

5ultiple5ultiplesclerosissclerosis VVVVVVVV 22

)sychiatric)sychiatric VVVV VVVV%erves and%erves andnerve rootnerve root VVVVVVVV 22

*ransient global*ransient globalamnesiaamnesia VVVVVVVV 22

DifferentialDifferential

8/18/2019 TH180 Judd

114/181

Diagnosis of Transient NeurologicalDiagnosis of Transient Neurological

DiseasesDiseases *A*A $eizure$eizure 5igraine with aura5igraine with aura $yncope$yncope

!ypoglycemia!ypoglycemia

5ypoglycemia5ypoglycemia

8/18/2019 TH180 Judd

115/181

5ypoglycemia5ypoglycemia

*hat transient hypoglycemia may produce a stroke like picture*hat transient hypoglycemia may produce a stroke like picturewith hemiplegia and aphasia has been known for years.with hemiplegia and aphasia has been known for years. *hese patients may be drowsy but are often alert and do not show*hese patients may be drowsy but are often alert and do not show

the more common response to hypoglycemia of confusion,the more common response to hypoglycemia of confusion,diminished level of consciousness, or coma.diminished level of consciousness, or coma.

Aphasia may make the history of diabetes more difficult toAphasia may make the history of diabetes more difficult todiscover.discover.

$yndrome has also been reported in alcoholics with hypoglycemia.$yndrome has also been reported in alcoholics with hypoglycemia. *he pathogenesis of this focal C%$ dysfunction is unclear.*he pathogenesis of this focal C%$ dysfunction is unclear. !ypoglycemia is generally defined as a blood glucose level of less!ypoglycemia is generally defined as a blood glucose level of less

than 0 mg4dl in these studies.than 0 mg4dl in these studies. *he wide use of bedside rapid laboratory testing for glucose now*he wide use of bedside rapid laboratory testing for glucose now

makes this easily detectable and treatable.makes this easily detectable and treatable. *he hemiplegia may resolve immediately with the administration*he hemiplegia may resolve immediately with the administrationof intravenous glucose but resolution over a hours is alsoof intravenous glucose but resolution over a hours is also

reported.reported.

Mass 3esionsMass 3esions

8/18/2019 TH180 Judd

116/181

Mass 3esionsMass 3esions

$ubdural hematoma, cerebral abscess, primary C%$$ubdural hematoma, cerebral abscess, primary C%$tumors, and metastatic tumors are among the clinicaltumors, and metastatic tumors are among the clinicalconditions simulating stroke in the studies cited above.conditions simulating stroke in the studies cited above.

*he typical clinical presentation of a slowly increasing mass*he typical clinical presentation of a slowly increasing massis a progressive syndrome= an abrupt onset of symptoms ofis a progressive syndrome= an abrupt onset of symptoms ofthese masses seems counterintuitive.these masses seems counterintuitive.

A review of patients with brain tumors presenting to an BDA review of patients with brain tumors presenting to an BDshowed that @7 of patients had symptoms that were of lessshowed that @7 of patients had symptoms that were of lessthan one dayJs duration= it was thought that these patientsthan one dayJs duration= it was thought that these patientswith brief symptom duration might reflect a subpopulationwith brief symptom duration might reflect a subpopulationwho suffer acute deterioration from hemorrhage into thewho suffer acute deterioration from hemorrhage into thetumor or who develop obstructive hydrocephalus.tumor or who develop obstructive hydrocephalus.

$econdary effects of mass or edema on cerebral vasculature$econdary effects of mass or edema on cerebral vasculaturehave been identified as possible causes of abrupt onset ofhave been identified as possible causes of abrupt onset ofseizures as well.seizures as well.

Chronic subdural hematoma has been fre8uently reportedChronic subdural hematoma has been fre8uently reportedas a cause of stroke and *Alike symptoms.as a cause of stroke and *Alike symptoms.

Functional HemiparesisFunctional Hemiparesis

8/18/2019 TH180 Judd

117/181

Functional HemiparesisFunctional Hemiparesis

Fittle is written about a factitious or feigned stroke yetFittle is written about a factitious or feigned stroke yetseveral studies discover rare patients initially thought toseveral studies discover rare patients initially thought tohave cerebrovascular disease but later determined to havehave cerebrovascular disease but later determined to havea functional cause of the hemiparesis or other strokea functional cause of the hemiparesis or other strokesyndrome.syndrome.

Conversion disorder is the most commonly assignedConversion disorder is the most commonly assigned

psychiatric disorder.psychiatric disorder. ne study of emergency department presentations ofne study of emergency department presentations ofconversion disorder noted that symptoms of paresis,conversion disorder noted that symptoms of paresis,paralysis, or movement disorders were common and were aparalysis, or movement disorders were common and were apresentation in almost 927 of patients.presentation in almost 927 of patients.

*hey noted significant comorbidity in this population, often*hey noted significant comorbidity in this population, often

other psychiatric disorders, and emphasized thatother psychiatric disorders, and emphasized thatconversion disorder is a diagnosis of e#clusion.conversion disorder is a diagnosis of e#clusion. )atients often undergo multiple diagnostic tests before the)atients often undergo multiple diagnostic tests before the

diagnosis is assigned.diagnosis is assigned.

Sei

8/18/2019 TH180 Judd

118/181

Sei

8/18/2019 TH180 Judd

119/181

Sei

8/18/2019 TH180 Judd

120/181

Sei

8/18/2019 TH180 Judd

121/181

Sei

8/18/2019 TH180 Judd

122/181

Sei

8/18/2019 TH180 Judd

123/181

-ocal Sei

8/18/2019 TH180 Judd

124/181

What is a TIAWhat is a TIA

& Acute loss of focal cerebral functionAcute loss of focal cerebral function& $ymptoms last less than 10 hours$ymptoms last less than 10 hours& Due to inade8uate blood supplyDue to inade8uate blood supply

*hrombosis*hrombosis BmbolismBmbolism

Transient Ischemic Attacks 0TIAs1Transient Ischemic Attacks 0TIAs1

8/18/2019 TH180 Judd

125/181

Transient Ischemic Attacks 0TIAs10 1

"arning strokes that can happen before a ma+or"arning strokes that can happen before a ma+orstrokestroke

ccur when blood flow through a brain artery isccur when blood flow through a brain artery is

blocked or reduced for a short timeblocked or reduced for a short time $ymptoms are temporary (W10 hours but similar$ymptoms are temporary (W10 hours but similar

to those of a full fledged stroketo those of a full fledged stroke

A person who has a *A is 6. times more likelyA person who has a *A is 6. times more likelyto have a stroketo have a stroke

TIA ,isk -actors=!pidemiologyTIA ,isk -actors=!pidemiology

8/18/2019 TH180 Judd

126/181

TIA ,isk -actors=!pidemiologyTIA ,isk -actors=!pidemiology

922,222 *As per year in ?$922,222 *As per year in ?$ year stroke risk after *A 167year stroke risk after *A 167

& 09.7 in 1 years with T;27 carotid stenosis09.7 in 1 years with T;27 carotid stenosis

treated medicallytreated medically 5any stroke patients have had a *A5any stroke patients have had a *A

& 17 27 in large artery atherothrombotic17 27 in large artery atherothromboticstrokesstrokes

& --7 927 in cardioembolic strokes--7 927 in cardioembolic strokes& --7 to -07 in lacunar strokes--7 to -07 in lacunar strokes

,isk -actors for a TIA,isk -actors for a TIA

8/18/2019 TH180 Judd

127/181

,isk -actors for a TIA

isk factors are the same as strokeisk factors are the same as stroke& ncreasing agencreasing age& $e#$e#& Hamily history 4 aceHamily history 4 ace

& )rior stroke 4 *A)rior stroke 4 *A& !ypertension!ypertension& DiabetesDiabetes& !eart disease!eart disease& Carotid artery 4 )eripheral artery diseaseCarotid artery 4 )eripheral artery disease& besitybesity& !igh cholesterol!igh cholesterol& )hysical inactivity)hysical inactivity

TIA SymptomsTIA Symptoms

8/18/2019 TH180 Judd

128/181

TIA Symptomsy p

$ymptoms last less than 10 hours$ymptoms last less than 10 hours& 5ost last less than one hour5ost last less than one hour& Fess than -2 percent T @ hoursFess than -2 percent T @ hours

& Amaurosis fuga# up to five minutesAmaurosis fuga# up to five minutes((Amaurosis fugaxAmaurosis fugax is loss of vision inis loss of vision inone eye due to a temporary lackone eye due to a temporary lackof blood flow to the retina. $ymptomsof blood flow to the retina. $ymptomsinclude the sudden loss of vision in oneinclude the sudden loss of vision in oneeye.eye.

TIA DemographyTIA Demography

8/18/2019 TH180 Judd

129/181

TIA Demographyg p y

lder patientslder patients $troke risk factors present$troke risk factors present 5enTwomen5enTwomen

TIA .resentationTIA .resentation

8/18/2019 TH180 Judd

130/181

Acute loss of focal cerebral functionAcute loss of focal cerebral function& Abrupt onsetAbrupt onset& $ymptoms occur in all affected areas at$ymptoms occur in all affected areas at

the same timethe same time& $ymptoms resolve gradually$ymptoms resolve gradually& $ymptoms are 'negative $ymptoms are 'negative


8/18/2019 TH180 Judd

131/181

Acute loss of focal cerebral functionAcute loss of focal cerebral function& 5otor symptoms5otor symptoms

"eakness or clumsiness on one side"eakness or clumsiness on one side

Difficulty swallowingDifficulty swallowing

& $peech disturbances$peech disturbances ?nderstanding or e#pressing spoken?nderstanding or e#pressing spoken

languagelanguage

eading or writingeading or writing $lurred speech$lurred speech CalculationsCalculations


8/18/2019 TH180 Judd

132/181

Acute loss of focal cerebral functionAcute loss of focal cerebral function& $ensory symptoms$ensory symptoms

Altered feeling on one sideAltered feeling on one side

Foss of vision on one sideFoss of vision on one side Foss of vision in left or right visual fieldFoss of vision in left or right visual field Eilateral blindnessEilateral blindness Double visionDouble vision

>ertigo>ertigo


8/18/2019 TH180 Judd

133/181

%onfocal $ymptoms (%ot *A%onfocal $ymptoms (%ot *A& Generalized weakness or numbnessGeneralized weakness or numbness& Haintness or syncopeHaintness or syncope

& ncontinencencontinence& solated symptoms (symptomssolated symptoms (symptoms

occurring aloneoccurring alone

>ertigo or loss of balance>ertigo or loss of balance $lurred speech or difficulty swallowing$lurred speech or difficulty swallowing Double visionDouble vision


8/18/2019 TH180 Judd

134/181

%onfocal $ymptoms (%ot *A%onfocal $ymptoms (%ot *A& ConfusionConfusion

DisorientationDisorientation

mpaired attention4concentrationmpaired attention4concentration

Diminution of all mental activityDiminution of all mental activity Distinguish fromDistinguish from

& solated language or visualspatial perceptionsolated language or visualspatial perceptionproblems (may be *Aproblems (may be *A

& solated memory problems (transient globalsolated memory problems (transient globalamnesiaamnesia

TIATIA

8/18/2019 TH180 Judd

135/181

& $ignificant risk factor for recurrent$ignificant risk factor for recurrentstroke, with average 7 risk per yearstroke, with average 7 risk per year& )rophylactic antiplatelet therapy shown)rophylactic antiplatelet therapy shown

to prevent secondary effectsto prevent secondary effects AspirinAspirin *iclopidine: thrombotic stroke*iclopidine: thrombotic strokereductionreduction

Clopidogrel: reduce events associatedClopidogrel: reduce events associatedwith atherosclerosis that includewith atherosclerosis that includestrokes, 5, )>Dstrokes, 5, )>D

TIATIA

8/18/2019 TH180 Judd

136/181

& *reat with warfarin if significant risk for*reat with warfarin if significant risk forcardiogenic thromboembolismcardiogenic thromboembolism

& !ospital admission for newonset and!ospital admission for newonset andrecurrent *AJs unless confident inrecurrent *AJs unless confident indiagnosis of etiologydiagnosis of etiology

& Angiography / treat medically orAngiography / treat medically orsurgicallysurgically

TIATIA

8/18/2019 TH180 Judd

137/181

?sually minutes, mostly W- hour?sually minutes, mostly W- hour $pells during days, weeks, months=$pells during days, weeks, months=

not usually yearsnot usually years

8/18/2019 TH180 Judd

138/181

Migraine DemographyMigraine Demography

8/18/2019 TH180 Judd

139/181

g g p yg g y

ounger ageounger age "omenTmen (0:-"omenTmen (0:- -2127 of the population-2127 of the population *he risk of migraine with aura and*he risk of migraine with aura and

transient ischemic attacks (*AJs istransient ischemic attacks (*AJs isgreater than 1 fold.greater than 1 fold.

-49 have migraine with aura-49 have migraine with aura

Migraine :ith AuraMigraine :ith Aura

8/18/2019 TH180 Judd

140/181

g

5igraine with aura5igraine with aura& )ositive symptoms)ositive symptoms& $pread over minutes$pread over minutes& >isual disturbances>isual disturbances

& $omatosensory or motor disturbance$omatosensory or motor disturbance& !eadache within - hour!eadache within - hour

5igraine with aura is associated with a5igraine with aura is associated with atwofold risk of ischemic stroke. *his risk istwofold risk of ischemic stroke. *his risk is

higher in women, age W 0, smokers, andhigher in women, age W 0, smokers, andwomen who used oral contraceptives.women who used oral contraceptives.

E5M1226=996:b96-0, 5igraine and cardiovascular diseaseE5M1226=996:b96-0, 5igraine and cardiovascular disease


8/18/2019 TH180 Judd

141/181

g

Aura without !eadacheAura without !eadache& 637 >isual symptoms637 >isual symptoms& 927 with other symptoms927 with other symptoms

1@7 sensory1@7 sensory -@7 aphasia-@7 aphasia @7 dysarthria@7 dysarthria -27 weakness-27 weakness

& 5ean age 03.; (vs. @1.-5ean age 03.; (vs. @1.-& Hewer cardiovascular risk factorsHewer cardiovascular risk factors

Migraine CNS TimingMigraine CNS Timing

8/18/2019 TH180 Judd

142/181

g g

?sually 12 to 92 minutes?sually 12 to 92 minutes $poradic attacks during years$poradic attacks during years


8/18/2019 TH180 Judd

143/181

Migraine Associated SymptomsMigraine Associated Symptoms

8/18/2019 TH180 Judd

144/181

!eadache after attack, nausea,!eadache after attack, nausea,vomiting, photophobia, phonophobiavomiting, photophobia, phonophobia(usually G or autonomic nervous(usually G or autonomic nervous

systemsystem

8/18/2019 TH180 Judd

145/181

MigraineMigraine

8/18/2019 TH180 Judd

146/181

5ost migraine auras resolve in 12 to 925ost migraine auras resolve in 12 to 92minutes and seldom last more than oneminutes and seldom last more than onehour.hour.*ypical auras may involve any of the*ypical auras may involve any of the

following manifestations:following manifestations: >isual disturbances ( the most common>isual disturbances ( the most common

type of auratype of aura $ensory symptoms$ensory symptoms 5otor weakness5otor weakness $peech disturbances$peech disturbances

8/18/2019 TH180 Judd

147/181

Syncope DemographySyncope Demography

8/18/2019 TH180 Judd

148/181

Any age, often youngerAny age, often younger "omenTmen"omenTmen

Syncope TimingSyncope Timing

8/18/2019 TH180 Judd

149/181

?sually a few seconds?sually a few seconds $poradic attacks during years$poradic attacks during years

Syncope Associated SymptomsSyncope Associated Symptoms

8/18/2019 TH180 Judd

150/181

$weating, pallor, nausea$weating, pallor, nausea

Most Common Types of SyncopeMost Common Types of Syncope

8/18/2019 TH180 Judd

151/181

%eurocardiogenic (vasovagal syncope%eurocardiogenic (vasovagal syncope $ituational syncope (during or$ituational syncope (during or

immediately after urination,immediately after urination,

defecation, cough, or swallowingdefecation, cough, or swallowing rthostatic syncope (associated withrthostatic syncope (associated with

orthostatic hypotensionorthostatic hypotension

$yncope related to cardiac ischemia or$yncope related to cardiac ischemia orcardiac arrhythmiacardiac arrhythmia

(ifferential diagnosis of transient neurologic symptoms(ifferential diagnosis of transient neurologic symptoms

$eizures$eizures *As*As 0igraine0igraine $yncope$yncope

DemographyDemography Any age, oftenAny age, oftenyoungeryounger

lder patientslder patients ounger ageounger age Any age, oftenAny age, oftenyoungeryounger

$troke risk factors$troke risk factors "omenTmen"omenTmen "omenTmen"omenTmen

8/18/2019 TH180 Judd

152/181

$troke risk factorspresentpresent

"omen men "omen men

5enTwomen5enTwomen Central nervousCentral nervoussystem symptomssystem symptoms

)ositive symptoms:)ositive symptoms:limb +erking, headlimb +erking, headturning, loss ofturning, loss ofconsciousnessconsciousness

%egative symptoms:%egative symptoms:numbness, visualnumbness, visualloss, paralysis, ata#ialoss, paralysis, ata#ia

Hirst positiveHirst positivesymptoms, thensymptoms, thennegative in samenegative in samemodality: scintillatingmodality: scintillatingscotomas andscotomas andparasthesias mostparasthesias mostcommon= secondcommon= second

sensory modality issensory modality isinvolved after firstinvolved after firstclearsclears

Fightheaded, dimFightheaded, dimvision, noisesvision, noisesdistant, decreaseddistant, decreasedalertnessalertness

%egative symptoms%egative symptomsmay develop, remainmay develop, remainpostictally, andpostictally, andpersistpersist

All sensoryAll sensorymodalities affectedmodalities affectedsimultaneouslysimultaneously

*ransient loss of*ransient loss ofconsciousnessconsciousness

*iming*iming 12 to 32 seconds12 to 32 seconds ?sually minutes,?sually minutes,mostly W- hourmostly W- hour

?sually 12 to 92?sually 12 to 92minutesminutes

?sually a few?sually a fewsecondsseconds

Absence, atonicAbsence, atonicseizures andseizures andmyoclonic +erks aremyoclonic +erks are

shortershorter

$pells during days,$pells during days,weeks, months= notweeks, months= notusually yearsusually years

$poradic attacks$poradic attacksduring yearsduring years

$poradic attacks$poradic attacksduring yearsduring years

)ostictal depression)ostictal depression

$pells occur during$pells occur duringyearsyears

Transient ;lo6al AmnesiaTransient ;lo6al Amnesia

8/18/2019 TH180 Judd

153/181

& $udden disorder of memory$udden disorder of memory& Antegrade and often retrogradeAntegrade and often retrograde& ecurrence 97 per yearecurrence 97 per year

& Btiology unclearBtiology unclear 5igraine5igraine Bpilepsy (;7 within - yearBpilepsy (;7 within - year ?nknown?nknown

Transient ;lo6al AmnesiaTransient ;lo6al Amnesia

8/18/2019 TH180 Judd

154/181

& %o difference in vascular risk factors%o difference in vascular risk factorscompared with general populationcompared with general population& Hewer risk factors when compared withHewer risk factors when compared with

*A patients*A patients& )rognosis significantly better than *A)rognosis significantly better than *A

Structural intracranial lesionStructural intracranial lesion

8/18/2019 TH180 Judd

155/181

& *umor*umor )artial seizures)artial seizures >ascular steal>ascular steal !emorrhage!emorrhage >essel compression by tumor>essel compression by tumor

Intracranial hemorrhageIntracranial hemorrhage

8/18/2019 TH180 Judd

156/181

& C! rare to confuse with *AC! rare to confuse with *A& $ubdural hematoma$ubdural hematoma

!eadache!eadache Hluctuation of symptomsHluctuation of symptoms 5ental status changes5ental status changes

Multiple sclerosisMultiple sclerosis

8/18/2019 TH180 Judd

157/181

& ?sually subacute but can be acute?sually subacute but can be acute ptic neuritisptic neuritis Fimb ata#iaFimb ata#ia

& Age and risk factorsAge and risk factors& $igns more pronounced than symptoms$igns more pronounced than symptoms

3a6yrinthine Disorders3a6yrinthine Disorders

8/18/2019 TH180 Judd

158/181

& Central vs. )eripheral vertigoCentral vs. )eripheral vertigo& 5QniYre

8/18/2019 TH180 Judd

159/181

5etabolic perturbations, such as5etabolic perturbations, such ashypoglycemia, can be associated with focalhypoglycemia, can be associated with focalneurologic deficits.neurologic deficits.

5ultiple sclerosis occasionally can cause5ultiple sclerosis occasionally can cause

paro#ysmal attacks, particularly of ata#iaparo#ysmal attacks, particularly of ata#iaand dysarthria.and dysarthria. Erain tumors can occasionally result inErain tumors can occasionally result in

transient neurologic symptoms= thetransient neurologic symptoms= themechanism in these cases is thought tomechanism in these cases is thought to

involve mechanical changes that result ininvolve mechanical changes that result inpressure on structures ad+acent to thepressure on structures ad+acent to thetumor.tumor.

9thers in the Differential Diagnosis9thers in the Differential Diagnosis

8/18/2019 TH180 Judd

160/181

$ubdural hematomas may cause attacks of$ubdural hematomas may cause attacks oftransient neurologic dysfunction, again due totransient neurologic dysfunction, again due tomechanical changes that result in pressure onmechanical changes that result in pressure onstructures ad+acent to the hematoma.structures ad+acent to the hematoma.

Cerebral amyloid angiopathy, better known as aCerebral amyloid angiopathy, better known as a

cause of intracerebral hemorrhage, may alsocause of intracerebral hemorrhage, may alsocause transient neurologic symptoms. Affectedcause transient neurologic symptoms. Affectedpatients complain of recurrent, brief (minutes,patients complain of recurrent, brief (minutes,often stereotyped spells of weakness, numbness,often stereotyped spells of weakness, numbness,paresthesias, or other cortical symptoms that canparesthesias, or other cortical symptoms that canspread smoothly over contiguous body parts.spread smoothly over contiguous body parts.

8/18/2019 TH180 Judd

161/181

8/18/2019 TH180 Judd

162/181

8/18/2019 TH180 Judd

163/181

8/18/2019 TH180 Judd

164/181

8/18/2019 TH180 Judd

165/181

Case "Case "

8/18/2019 TH180 Judd

166/181

"hen 11yearold 5s. I$ began"hen 11yearold 5s. I$ begane#periencing left arm weakness, shee#periencing left arm weakness, shewent to a clinic only to be told thatwent to a clinic only to be told that

nothing was seriously wrong. Eutnothing was seriously wrong. Eutwhen her symptoms persisted, so didwhen her symptoms persisted, so didshe. $he was finally referred to theshe. $he was finally referred to the5edical Center, where neurologists5edical Center, where neurologistsconfirmed that her symptoms wereconfirmed that her symptoms werethe result of a stroke.the result of a stroke.

Case "Case "

8/18/2019 TH180 Judd

167/181

Hurther testing in the CoagulationHurther testing in the CoagulationFaboratory revealed activated proteinFaboratory revealed activated proteinC resistance, the result of aC resistance, the result of a

heterozygous mutation in factor >heterozygous mutation in factor >Feiden, as well as a homozygousFeiden, as well as a homozygousmutation in the methylenemutation in the methylenetetrahydrofolate reductase gene,tetrahydrofolate reductase gene,responsible for elevated homocystineresponsible for elevated homocystine

Case "Case "

8/18/2019 TH180 Judd

168/181

Although she had had only one clinical stroke,Although she had had only one clinical stroke,multiple other strokes were evident by imagingmultiple other strokes were evident by imagingstudies. Hactors contributing to herstudies. Hactors contributing to herhypercoagulable state included: -. the methylenehypercoagulable state included: -. the methylenetetrahydrofolate reductase deficiency, whichtetrahydrofolate reductase deficiency, which

elevated her homocystine level, 1. theelevated her homocystine level, 1. theheterozygous state for factor > Feiden, causingheterozygous state for factor > Feiden, causingactivated protein C resistance, 9. oralactivated protein C resistance, 9. oralcontraceptives, 0. smoking, and . hypertension.contraceptives, 0. smoking, and . hypertension.$he is doing well, without recurrence, on aspirin,$he is doing well, without recurrence, on aspirin,

and antihypertensive medicines, having stoppedand antihypertensive medicines, having stoppedsmoking and birth control pills.smoking and birth control pills.

Case Case

8/18/2019 TH180 Judd

169/181

n another case, a 12yearold femalen another case, a 12yearold femalecollege student was sent to the 5edicalcollege student was sent to the 5edicalCenter after a brain scan showed what herCenter after a brain scan showed what herphysicians thought to be a brain tumor.physicians thought to be a brain tumor.%eurosurgeons 8uickly realized there was%eurosurgeons 8uickly realized there wasno tumor, and that the young woman hadno tumor, and that the young woman hadsuffered a stroke. After thrombosis ofsuffered a stroke. After thrombosis ofintracranial venous sinuses was diagnosedintracranial venous sinuses was diagnosedshe was treated with heparin, and thenshe was treated with heparin, and then

"arfarin. epeat imaging revealed"arfarin. epeat imaging revealedrecanalization of the previouslyrecanalization of the previouslythrombosed sinuses.thrombosed sinuses.

8/18/2019 TH180 Judd

170/181

Case Case

8/18/2019 TH180 Judd

171/181

nvestigation in the $pecial Coagulationnvestigation in the $pecial CoagulationFaboratory revealed deficiency ofFaboratory revealed deficiency ofantithrombin , on two separateantithrombin , on two separateoccasions, several weeks apart. *hisoccasions, several weeks apart. *his

patient suffered a venous infarctionpatient suffered a venous infarctionsecondary to a hypercoagulable statesecondary to a hypercoagulable stateinduced by inherited antithrombin induced by inherited antithrombin deficiency, probably e#acerbated by use ofdeficiency, probably e#acerbated by use of

oral contraceptives. "ith anticoagulationoral contraceptives. "ith anticoagulationand careful monitoring, her prognosis isand careful monitoring, her prognosis isgood.good.

Case @Case @

8/18/2019 TH180 Judd

172/181

A %;5year5old man has sudden 8eakness of the leftA %;5year5old man has sudden 8eakness of the leftarm and leg and slurred speecharm and leg and slurred speech "xcept for untreated hypertension/ his medical"xcept for untreated hypertension/ his medical

history is unremarkablehistory is unremarkable 'e is a current smoker'e is a current smoker #n arri$al at the emergency department 1 hour 14#n arri$al at the emergency department 1 hour 14

minutes after the onset of symptoms/ he reports nominutes after the onset of symptoms/ he reports noheadache or $omitingheadache or $omiting 'is blood pressure is 1;*

8/18/2019 TH180 Judd

173/181

!e had sudden leftsided!e had sudden leftsidedhemiparesis, strongly suggestive of ahemiparesis, strongly suggestive of a

right hemisphere stroke.right hemisphere stroke.

SummarySummary

8/18/2019 TH180 Judd

174/181

*hese are not isolated cases. Hre8uently*hese are not isolated cases. Hre8uentlyyoung patients, even teenagers, who haveyoung patients, even teenagers, who havesuffered stroke are misdiagnosed. *houghsuffered stroke are misdiagnosed. *houghthey may have presented with classicthey may have presented with classic

symptoms dizziness, severe headache,symptoms dizziness, severe headache,weakness in a limb, or unilateral loss ofweakness in a limb, or unilateral loss ofsensation, for e#ample they often havesensation, for e#ample they often havebeen misdiagnosed by their provider, mostbeen misdiagnosed by their provider, mostlikely because they do not fit the profile oflikely because they do not fit the profile ofthe NtypicalN stroke patient.the NtypicalN stroke patient.

SummarySummary

8/18/2019 TH180 Judd

175/181

5isdiagnosis has included patients5isdiagnosis has included patientsbeing told they had vertigo,being told they had vertigo,migraine, alcohol into#ication ormigraine, alcohol into#ication or

other conditions. *hey wereother conditions. *hey weredischarged from clinic and laterdischarged from clinic and laterdiscovered to have suffered a stroke.discovered to have suffered a stroke.

SummarySummary

8/18/2019 TH180 Judd

176/181

*he second important point is that the*he second important point is that thecauses of stroke in young people are muchcauses of stroke in young people are muchmore diverse, and less likely to be themore diverse, and less likely to be theones that commonly cause stroke in olderones that commonly cause stroke in older

people, such as atherosclerosis of brainpeople, such as atherosclerosis of brainsupplying vessels and emboli from cardiacsupplying vessels and emboli from cardiacdisorders related to coronary arterydisorders related to coronary arterydisease. "ithout the right resources,disease. "ithout the right resources,

providers may be at a loss to pinpoint theproviders may be at a loss to pinpoint thecause in order to treat it and preventcause in order to treat it and prevent

th180 judd

Documents