377.1 🎓 醫孞生版

377.1.0.1 📌 䞀頁重點

377.1.0.1.1 Epidemiology
  • 2nd leading cause of death globally
  • Leading cause of long-term disability
  • ~ 85% ischemic, 15% hemorrhagic (ICH + SAH)
  • ↑ with age, male > female (women > men in older age)
377.1.0.1.2 Etiology (TOAST Classification)

377.1.1 1. Large-Artery Atherosclerosis (20-25%)

  • Carotid (extra/intracranial)
  • Vertebrobasilar
  • Symptomatic stenosis: > 50%
  • Mechanisms: artery-to-artery embolism, in-situ thrombosis, hemodynamic

377.1.2 2. Cardioembolic (20-30%)

  • Atrial fibrillation (most common)
  • Recent MI with LV thrombus
  • Mechanical valves
  • Cardiomyopathy
  • Endocarditis
  • PFO (paradoxical)
  • Cardiac tumors (myxoma)

377.1.3 3. Small-Vessel (Lacunar) (20-25%)

  • Penetrating arteries
  • Lipohyalinosis (chronic HTN, DM)
  • Classic syndromes:
    • Pure motor (posterior limb internal capsule)
    • Pure sensory (thalamus)
    • Sensorimotor
    • Ataxic hemiparesis
    • Dysarthria-clumsy hand

377.1.4 4. Other Determined Etiology (5%)

  • Dissection (young patients!)
  • Vasculitis (PACNS, GCA, infectious)
  • Hypercoagulable states
  • Hereditary (CADASIL, Fabry)
  • Drug use (cocaine, amphetamine)
  • Migraine-related
  • Reversible cerebral vasoconstriction syndrome (RCVS)

377.1.5 5. Cryptogenic (25-30%)

  • Unknown after workup
  • Many are embolic (ESUS)
377.1.5.0.1 Clinical Syndromes by Vascular Territory

377.1.6 Anterior Circulation

MCA: - Most common - Contralateral hemiparesis (face + arm > leg) - Hemisensory loss - Hemianopia - Aphasia (dominant) or neglect (non-dominant) - Gaze deviation toward lesion

ACA: - Contralateral leg > arm weakness - Cognitive/behavioral - Urinary incontinence

377.1.7 Posterior Circulation

PCA: - Contralateral homonymous hemianopia (macular sparing) - Memory (medial temporal) - Thalamic syndromes

Vertebrobasilar: - Cranial nerve deficits - Crossed signs - Ataxia - Vertigo, nausea - LOC (top of basilar) - Locked-in (ventral pons)

Cerebellar: - Ataxia - Dysmetria - Mass effect → obstructive hydrocephalus, herniation - 5 Ds: dizziness, diplopia, dysarthria, dysphagia, dystaxia

377.1.8 Lacunar Syndromes

  • Pure motor
  • Pure sensory
  • Sensorimotor
  • Ataxic hemiparesis
  • Dysarthria-clumsy hand
377.1.8.0.1 Acute Workup

377.1.9 Time is Brain

  • 1.9 million neurons die per minute of untreated ischemic stroke
  • Door-to-needle goal < 60 min (ideally < 45)
  • Door-to-groin (for thrombectomy) < 90-120 min

377.1.10 Initial Assessment

  • ABC, vital signs, glucose, time last known well
  • NIHSS (NIH Stroke Scale)
  • Quick neuro exam

377.1.11 Imaging

  • CT head non-contrast (rule out hemorrhage)
  • ASPECTS score for MCA (0-10, normal)
  • CTA head + neck (LVO assessment)
  • CT perfusion (penumbra for late window)
  • MRI DWI (definitive infarct, especially posterior fossa)

377.1.12 Labs

  • Glucose
  • Coagulation, platelets
  • CBC, electrolytes, renal, troponin
  • EKG (AF)
  • ABG

377.1.13 Other

  • Echocardiogram (TTE first, TEE for select)
  • Carotid Doppler / MRA / CTA
  • Holter or extended monitoring (occult AF)
  • Hypercoagulable workup (selected — young, recurrent, family history)
377.1.13.0.1 Acute Treatment

377.1.14 IV Thrombolysis

Alteplase (tPA) — historical standard: - Within 4.5 hours of symptom onset - 0.9 mg/kg IV (10% bolus, 90% over 60 min) - Inclusion: age ≥ 18, disabling deficit - Exclusion: hemorrhage, recent stroke/surgery/major bleed, INR > 1.7, BP > 185/110 (treat first), glucose < 50 or > 400

Tenecteplase (TNK) — emerging standard: - 0.25 mg/kg single IV bolus - Equivalent/non-inferior to alteplase - Easier administration - AcT, ATTEST, TWIST trials 2022-2023 - Increasingly adopted

377.1.15 Mechanical Thrombectomy

Standard Window (≀ 6 hours): - LVO (ICA, M1, possibly M2, basilar) - Significant deficit (NIHSS ≥ 6) - ASPECTS ≥ 6 - Premorbid mRS 0-1 - Number needed to treat ~ 2.6

Extended Window (6-24 hours): - DAWN (2018): 6-24 hr, clinical-imaging mismatch - DEFUSE-3 (2018): 6-16 hr, perfusion-imaging mismatch - MR-CLEAN-LATE (2023): 6-24 hr, less strict criteria - Selected by penumbra/mismatch

377.1.16 Basilar Artery Occlusion

  • Devastating outcome if untreated
  • BAOCHE, ATTENTION (2022) — thrombectomy beneficial extended window
  • IV thrombolysis if eligible
  • Earlier intervention better

377.1.17 Acute Blood Pressure

  • Pre-tPA: BP < 185/110
  • Post-tPA: BP < 180/105 × 24 hr
  • No tPA / thrombectomy: permissive (no clear target unless > 220/120)

377.1.18 Other Acute Care

  • Maintain euglycemia (140-180)
  • Normothermia
  • Aspiration precautions (NPO until swallow eval)
  • DVT prophylaxis (mechanical first, pharmacologic 24 hr post-tPA)
  • Statin initiation
  • Head of bed (HOB) — controversial; HEAD-POST suggests no difference

377.1.19 Hemicraniectomy (Malignant MCA)

  • Within 48 hr
  • Age < 60 best benefit
  • Bilateral pupil sparing
  • Saves lives, but disability
377.1.19.0.1 Secondary Prevention

377.1.20 Antiplatelet (Non-Cardioembolic)

  • Aspirin 50-325 mg/d — first-line
  • Clopidogrel 75 mg/d — alternative
  • Aspirin + ER dipyridamole — Aggrenox alternative
  • DAPT (short-term):
    • CHANCE/POINT: ASA + clopidogrel × 21 days for high-risk minor stroke/TIA
    • THALES: ASA + ticagrelor × 30 days
  • CYP2C19 LOF: alters clopidogrel response (consider testing or alternative)

377.1.21 Anticoagulation (Cardioembolic)

  • AF: DOACs preferred (apixaban, dabigatran, rivaroxaban, edoxaban)
  • Mechanical valve: warfarin only
  • Antiphospholipid syndrome: warfarin (TRAPS suggests caution with DOACs)

377.1.22 Statin

  • High-intensity statin (atorvastatin 80 mg or rosuvastatin 20-40 mg)
  • LDL target < 70 mg/dL (less is more, especially atherosclerotic)
  • SPARCL trial

377.1.23 BP Control

  • Target < 130/80 (most stroke patients)
  • ACEI/ARB / thiazide / CCB

377.1.24 Diabetes

  • A1c target individualized (< 7% typically)

377.1.25 Lifestyle

  • Smoking cessation
  • Mediterranean diet
  • Exercise
  • Weight loss

377.1.26 Carotid Intervention

  • Symptomatic stenosis 50-99%: CEA preferred for most
  • Asymptomatic stenosis 70-99%: CEA if life expectancy > 5 years, surgical risk < 3%
  • CAS (stenting) alternative — younger, high-risk for surgery
  • Best within 2 weeks of symptoms

377.1.27 PFO Closure

  • For cryptogenic stroke in young (< 60) with PFO + high-risk features (RoPE score)
  • RESPECT, REDUCE, CLOSE trials
  • Plus antiplatelet vs anticoagulation per individual

377.1.28 Atrial Fibrillation Detection

  • Extended monitoring after cryptogenic stroke
  • Implantable loop recorder if suspicion high
  • CRYSTAL-AF, STROKE-AF trials
377.1.28.0.1 Post-Stroke Care

377.1.29 Acute Hospitalization

  • Stroke unit care (reduces mortality)
  • Multidisciplinary team
  • Dysphagia screen before PO intake
  • DVT prevention
  • Bowel/bladder
  • Skin care
  • Early rehab consultation

377.1.30 Rehabilitation

  • Inpatient acute rehab
  • Outpatient
  • Physical, occupational, speech therapy
  • Cognitive
  • Robotic and AI-assisted emerging

377.1.31 Depression

  • Common (~ 30%)
  • SSRIs (sertraline, citalopram)

377.1.32 Long-Term

  • Risk factor management
  • Lifestyle
  • Adherence

377.1.32.1 🩺 床邊速查

  • TOAST classification: large-artery, cardioembolic, lacunar, other, cryptogenic
  • MCA: face + arm > leg, aphasia/neglect
  • ACA: leg > arm, cognitive
  • PCA: hemianopia
  • Vertebrobasilar: crossed signs
  • Acute Tx: alteplase or tenecteplase ≀ 4.5 hr; thrombectomy ≀ 6 hr (24 hr extended DAWN/DEFUSE-3)
  • Secondary prevention: antiplatelet + anticoagulation (AF) + high-intensity statin + BP + DM + lifestyle + carotid + PFO closure
  • Stroke unit + rehab improve outcomes