Stroke is among the most common causes of acquired disability among adults in the United States and throughout the world, and rehabilitation is commonly required. Although some recovery of neurologic impairments is typical, this recovery is usually incomplete and compensatory approaches are also needed to restore function and independence. Rehabilitation efforts should be initiated promptly after a stroke occurs: these often include post-acute care in an inpatient rehabilitation facility or, if appropriate, a skilled nursing facility. Issues of mobility, activities of daily living, cognition, and communication are addressed during the rehabilitation period, as are common medical complications of stroke. These include post-stroke depression and deep venous thrombosis. Secondary stroke prevention should be addressed through a combination of medical interventions and lifestyle modifications.
Keywordsaphasia, cerebral hemorrhage, hemiplegia, stroke
|I60.9||Nontraumatic subarachnoid hemorrhage|
|I61.9||Nontraumatic intracerebral hemorrhage|
|I62.9||Nontraumatic intracranial hemorrhage|
|I65.9||Occlusion and stenosis of precerebral artery|
|I66.9||Occlusion and stenosis of unspecified cerebral artery|
|G45.9||Transient cerebral ischemic attack, unspecified|
|I67.89||Other cerebrovascular disease|
|I67.9||Cerebrovascular disease, unspecified|
|I69.30||Unspecified sequelae of cerebral infarction|
Stroke is an acquired injury of the brain caused by occlusion of a blood vessel or inadequate blood supply leading to infarction or a hemorrhage within the parenchyma of the brain. Ischemic stroke is most commonly due to atherosclerosis of large extracranial or intracranial blood vessels, hypertensive disease of small vessels (lipohyalinosis), or embolism from cardiac or other sources. Approximately 15% of strokes in the United States are hemorrhagic, resulting most commonly from hypertensive hemorrhages, aneurysms, vascular malformations, or cerebral amyloid angiopathy. Approximately 800,000 strokes occur annually in the United States and approximately 10.3 million globally, with a large population of survivors being permanently disabled. Important modifiable risk factors for ischemic stroke include hypertension, smoking, diabetes, obesity, sedentary lifestyle, and hyperlipidemia; nonmodifiable risk factors include age, sex, and race/ethnicity. Risk factors for hemorrhage include hypertension and smoking as well as alcohol consumption.
The symptoms of stroke depend on the location of the injury in the brain. For example, a stroke in the distribution of the left middle cerebral artery will typically result in right hemiplegia, aphasia, and right homonymous hemianopia, whereas a lacunar infarct in the left internal capsule may result in a less severe degree of right-sided hemiparesis and few other symptoms. Left hemiplegia, left hemispatial neglect, and impaired attention are common features of right hemispheric stroke. Ischemic strokes generally conform to the vascular territory of a specific artery within the brain and therefore result in characteristic combinations of neurologic impairments that constitute a particular stroke syndrome.
In general, difficulties in walking, performing activities of daily living (ADLs), speaking, and swallowing are common manifestations of stroke. Cognitive impairments (memory, attention, visuospatial perception) and impaired communication due to aphasia or dysarthria may be present. Impaired sexual function should be identified because patients may not volunteer functional impairments in this area unless the physician inquires.
Weakness, difficulty in speaking or swallowing, aphasia, cognitive disturbance, sensory loss, and visual disturbance are the most common presenting symptoms of stroke, and deficits in these areas often persist even after initial rehabilitation. Weakness (typically hemiparesis) results from loss of motor control primarily, and some stroke survivors retain good muscle strength despite limited ability to perform isolated precise movements of the affected side. Sensory loss is another common impairment after stroke, although complete loss of sensation in the affected area is uncommon. Urinary urgency, increased muscle tone, fatigue, depression, and pain are symptoms that may be manifested after a stroke has already occurred. Reflex sympathetic dystrophy (also known as complex regional pain syndrome type I) may occur after stroke, although most post-stroke pain results from mechanical (e.g., joint subluxation) or central (e.g., thalamic pain syndromes) causes.
Depression is common after stroke, affecting as many as 40% of stroke survivors. Depression should be identified as a treatable complication of stroke rather than accepted as a consequence of functional loss.
A full neurologic examination is appropriate. This includes evaluation of mental status, cranial nerves, sensation, deep tendon reflexes, abnormal reflexes (e.g., Babinski), muscle tone and strength, coordination, and functional mobility (sitting, transfers, and ambulation). The protean manifestations of stroke can cause many different combinations of abnormalities in the neurologic examination. Common findings include hyperreflexia and hemiparesis on the affected side with variable degrees of sensory loss. Dysarthria may be present, as can aphasia or hemineglect, depending on the areas affected. Hemiplegic gait is commonly seen, with reduced stride length, reduced knee flexion (“stiff-legged gait”), ankle plantar flexion and inversion, and circumduction to allow clearance of the affected leg. Given the high prevalence of post-stroke depression, an assessment of mood and affect is important. Some degree of sadness is typically present as a normal grief reaction to a sudden disabling event and should be distinguished from true major depression on the basis of how pervasive the symptoms are, their duration, and associated symptoms such as anhedonia. Emotional lability may also occur, with brief bouts of crying or laughing on minimal provocation. Range of motion in affected limbs should be measured; ankle plantar flexion contractures and upper limb contractures are common in patients with long-standing hemiplegic stroke and interfere with rehabilitation efforts. Shoulder subluxation may occur in hemiparetic patients and should be noted and quantified. Skin is examined for any areas of breakdown. Limb swelling is common and should be noted. The fit and function of leg braces, upper extremity splints, slings, wheelchairs, and ambulatory aids are assessed as part of the routine physical examination.
Reduced mobility is among the most common and disabling limitations after stroke. Loss of independence in ADLs is common as well, with reduced mobility, upper limb impairment, and cognitive impairments contributing. Among stroke survivors above 65 years of age who were evaluated 6 months after a stroke, 30% were unable to walk without some assistance, 26% were dependent for ADL, and 26% were institutionalized in a nursing home.
Stroke survivors may be unable to drive or use public transportation. Communication difficulties can lead to social isolation. Some individuals require ongoing supervision because of cognitive limitations. In severe cases, individuals with aphasia or cognitive impairments may not be able to live independently. Incontinence due to detrusor instability and urinary urgency can interfere with leaving the home and contribute to skin breakdown and social isolation.
In the acute setting, computed tomography (CT) is often the first diagnostic test performed because of the rapidity with which it can be obtained, its widespread availability, and its high sensitivity for cerebral hemorrhage. In some cities, mobile stroke units have been deployed that house CT scanners within modified ambulances, thus allowing for the rapid prehospital diagnosis of stroke. Magnetic resonance imaging provides greater anatomic resolution and avoids radiation exposure. With diffusion- and perfusion-weighted sequences, magnetic resonance imaging abnormalities can be demonstrated at a very early stage. Magnetic resonance angiography, computed tomographic angiography, noninvasive flow studies, ambulatory electrocardiographic monitoring, and echocardiography are important studies to help determine the cause of a stroke and to determine the best treatment for the prevention of recurrent stroke. In selected patients (particularly young individuals or those without typical risk factors), an evaluation for a hypercoagulable state is indicated. In patients with prior stroke, diagnostic studies are typically directed to complications of stroke, such as persistent dysphagia or urinary incontinence. Videofluoroscopic swallowing studies can be useful in swallowing disorders, as can flexible endoscopic evaluation of swallowing (see Chapter 130 ). Urodynamic studies may be useful in the assessment of urinary symptoms, particularly if initial treatment with anticholinergic medications is unsuccessful.
Post-seizure (Todd) paralysis
When ischemic stroke is diagnosed within the first 3 hours, thrombolytic therapy has been shown to reduce disability. There is evidence that thrombolysis may be useful in selected individuals between 3 and 4.5 hours after stroke onset as well. Mechanical clot retrieval is effective for patients who do not experience resumption of flow in the occluded artery with intravenous thrombolysis and appears effective within a 6-hour window. Aspirin (between 80 and 325 mg) has been found to be effective when it is used in the acute setting. In younger patients with large ischemic strokes, increased intracranial pressure due to swelling may require hemicraniectomy to prevent herniation and death. Large intracranial hemorrhages may require surgical evacuation, which can be lifesaving in some circumstances.
Secondary prevention depends on the cause of the stroke. Warfarin, dabigatran, apixaban, or rivaroxaban are commonly used for the secondary prevention of embolic stroke, with the most extensive evidence for prevention of stroke in atrial fibrillation. Antiplatelet agents—including aspirin, clopidogrel, or a combination of aspirin and dipyridamole—are used for prevention of most noncardioembolic strokes or when anticoagulation is desirable but contraindicated because of comorbid conditions. Risk factor modification—including the treatment of hypertension, diabetes, hyperlipidemia, and obesity as well as smoking cessation and exercise—should be addressed for all stroke survivors.
Treatment of cerebral hemorrhage is based in part on the presumed cause. For hypertensive hemorrhages, control of blood pressure with antihypertensive medications is the mainstay of treatment. Embolization or surgical resection may be needed for arteriovenous malformations; coiling and/or surgical clipping may be used in treating cerebral aneurysms. For all causes of cerebral hemorrhage, avoidance of anticoagulants, antiplatelet medications, and alcohol is important.
Medications for the management of post-stroke symptoms on an outpatient basis are shown in Table 159.1 . Anticholinergic medications are useful for bladder detrusor instability. Oral antispasticity medications are of limited efficacy in many cases (see Chapter 154 ). For sexual dysfunction in men, phosphodiesterase type 5 inhibitors may be effective. Treatment with selective serotonin reuptake inhibitors for post-stroke depression is widely employed, although a wide range of antidepressant medications can be effective. Psychostimulants (e.g., methylphenidate) and eugeroics (e.g., modafinil) may be useful for impaired attention or arousal. Anticonvulsants are used for central pain syndromes, but with variable benefit.