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Source: Fagan SC, Hess DC. Chapter 27. Stroke. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed June 27, 2012.

  • Apoplexy
  • Cerebrovascular accident (CVA)

  • Interruption of blood flow to area of brain, causing death of brain cells in area.

  • Local thrombus formation (e.g., cerebral atherosclerosis)
  • Emboli from intra- or extracranial arteries that occlude cerebral artery
  • Unknown causes

  • Carotid atherosclerosis: Ruptured plaques lead to thrombus formation that may cause local occlusion or dislodge and travel distally, eventually occluding cerebral vessel.
  • Cardiogenic embolism: Stasis of blood flow in atria or ventricles leads to formation of clots that dislodge and travel through aorta to cerebral circulation.
  • Resulting arterial occlusion decreases cerebral blood flow and causes ischemia and infarction distal to occlusion.

  • Stroke (including ischemic and hemorrhagic types) leading cause of adult disability in United States.
  • African Americans have stroke rates twice those of whites.
  • Some states in southeastern United States have stroke mortality rates more than twice national average.

  • Preventive measures directed toward reducing or eliminating modifiable risk factors for stroke.

  • Nonmodifiable risk factors:
    • Increased age
    • Male sex
    • Race (African Americans, Asian–Pacific Islanders, Hispanics)
    • Family history of stroke
    • Low birth weight
  • Major modifiable risk factors:
    • Hypertension
    • Cardiac disease (especially atrial fibrillation)
  • Other risk factors:

  • May need to obtain medical history from family members or others because cognitive or language deficits may preclude patient from giving reliable history.

Signs and Symptoms

  • Symptoms:
    • Weakness on one side of body
    • Inability to speak
    • Loss of vision
    • Vertigo
    • Falling
    • Headache
  • Signs of neurologic dysfunction depend on brain area involved.
    • Hemi- or monoparesis and hemisensory deficits common.
    • Posterior circulation involvement may present with vertigo and diplopia.
    • Anterior circulation strokes result in aphasia.
    • Other potential signs:
      • Dysarthria
      • Visual field defects
      • Altered levels of consciousness may be present.

Laboratory Tests

  • Obtain tests for hypercoagulable states (protein C, protein S, antithrombin III) only when cause cannot be determined based on review of risk factors.
  • Obtain antiphospholipid antibodies in patients younger than age 50 and those who have had multiple thrombotic events or livedo reticularis.


  • Computed tomography (CT) head scan
  • Magnetic resonance imaging (MRI) of head reveals ischemic areas with higher resolution and earlier than CT scan.
  • Carotid Doppler (CD) studies can identify degree of stenosis in carotid arteries.
  • Transthoracic echocardiogram (TTE) can detect valve or wall motion abnormalities that are sources of emboli.
  • Transesophageal echocardiogram (TEE) more sensitive for left atrial thrombus.
  • Transcranial Doppler (TCD) can determine presence of intracranial sclerosis (e.g., middle cerebral artery stenosis).

Diagnostic Procedures

  • Electrocardiogram (ECG) will determine whether atrial fibrillation is possible cause.

Differential Diagnosis

  • Hypoglycemia
  • Transient ischemic attack
  • Intracerebral hemorrhage or other mass lesion (e.g., tumor)
  • Focal seizure
  • Migraine
  • Peripheral causes of vertigo (Meniere’s disease)
  • ...

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