Acute stroke evaluation and management

Stroke is the fourth leading cause of death and the leading cause of disability in the United States. Several new therapeutic strategies such as institution of recanalization therapies in the first few hours after ischemic stroke are now available to reduce death and stroke-related disability. Understanding the stroke epidemiology and pathophysiology, and knowledge of evidencebased guidelines are the cornerstones of high-quality emergent acute stroke management. Stroke is typically characterized by sudden onset of focal neurological deficits. Advanced neuroimaging (CT and MRI) can help confirm the clinical diagnosis and guide treatment. Ischemic stroke is by far the most common form of stroke resulting from sudden arterial occlusion in a vascular territory. Common etiologies include cardiogenic embolism, extracranial and intracranial large artery atherosclerosis, lacunar stroke, and cryptogenic stroke. In acute ischemic stroke, intravenous tPA should be given with 4.5 h after symptom onset in patients without contraindications. Endovascular therapy shows benefit in selected patients within certain time window. Most strokes after transient ischemic attack occur within 90 days, and majority within 48 h. Urgent evaluation and treatment of patient with TIA especially in high-risk patients are important. Intracerebral hemorrhage and subarachnoid hemorrhage are devastating diseases. Hypertension and smoking are common risk factors. The clinical symptoms are characterized by focal neurological deficits associated with headache and other signs of high intracranial pressure. Blood pressure management is critical in managing intracerebral hemorrhage. Recently clinical trials suggested that aggressive blood pressure reduction does not worse the outcome. In subarachnoid hemorrhage, emergent aneurysm occlusion with coiling or clipping to prevent rebleed is crucial in acute phase. Delayed cerebral vasospasm should be monitored closely. Cerebral venous thrombosis (CVT) is uncommon. Headache and seizures are the common symptoms. Anticoagulation is the primary therapy for CVT.