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Stroke for the American Board of Psychiatry & Neurology (ABPN) Exam

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Overview of Stroke
  • Types:
    • Ischemic Stroke: Caused by an obstruction within a blood vessel supplying the brain (85% of strokes).
    • Hemorrhagic Stroke: Result of bleeding into or around the brain (15% of strokes).
Ischemic Stroke
  • Common Causes:
    • Thrombosis due to atherosclerosis.
    • Cardiac embolism from atrial fibrillation or post-myocardial structural abnormalities.
  • Rare Causes:
    • Dissection of cervical arteries: Can be spontaneous or traumatic.
    • Vasculitis: Including CNS vasculitis or secondary to systemic diseases like lupus or temporal arteritis.
    • Hypercoagulable states: Protein C and S deficiencies, antiphospholipid syndrome, Factor V Leiden mutation.
    • Infectious causes: Septic emboli, directly infective endarteritis (e.g., as seen in meningitis or syphilis).
    • Migrainous strokes: Particularly in women with migraine with aura.
    • Drug-induced strokes: Cocaine or other sympathomimetic drugs causing vasospasm or cardiovascular complications.
    • Genetic disorders: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy), MELAS (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes).
Clinical Presentation
  • Symptoms by Vascular Territories:
    • Anterior Cerebral Artery: Contralateral leg weakness, cognitive and behavioral disturbances.
    • Middle Cerebral Artery: Contralateral face and arm weakness, sensory loss, aphasia if the dominant hemisphere is involved, or neglect if non-dominant.
    • Posterior Cerebral Artery: Contralateral hemianopia, memory impairment.
    • Lacunar Strokes: Typically present with pure motor stroke, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome.
See Stroke Syndromes
Diagnosis
  • Imaging:
    • Non-contrast CT: Initial assessment to rule out hemorrhage.
    • MRI with DWI: Superior for detecting ischemia, identifying the affected vascular territory, and differentiating acute from old infarcts.
  • Further Assessment:
    • CT/MR Angiography: To evaluate for possible large artery occlusions or stenosis.
    • Echocardiography: To detect cardiac sources of emboli.
    • Holter monitoring: To screen for intermittent atrial fibrillation.
Management
  • Acute Management:
    • IV Thrombolysis: Alteplase (tpa) or tenecteplase (TNK) within 4.5 hours of symptom onset.
    • Mechanical Thrombectomy: For large vessel occlusions, within 6-24 hours from last known well, depending on brain imaging.
  • Preventive Management:
    • Antiplatelets: Aspirin, clopidogrel, or dual antiplatelet therapy for certain patients.
    • Anticoagulation: For atrial fibrillation or other cardioembolic sources.
    • High Intensity Statins: For all patients with ischemic stroke due to atherosclerosis.
    • Blood pressure management: Essential for secondary prevention.
  • Long-Term Management:
    • Rehabilitation involving a multidisciplinary team approach to address physical, cognitive, and emotional aspects following a stroke.
Clinical Decision-Making Keys
    • Risk Stratification: Identifying patients at high risk for recurrence or complications.
    • Tailored Therapy: Adjusting treatment based on individual risk factors, comorbidities, and etiology of stroke.
    • Interprofessional Collaboration: Coordination between neurologists, cardiologists, primary care providers, and rehabilitation specialists.