149 STROKE

Joel Stein, MD
Synonyms
Cerebrovascular accident
Brain attack
ICD-9 Codes
430 Subarachnoid hemorrhage
431 Intracerebral hemorrhage
432 Other and unspecified intracranial hemorrhage
433 Occlusion and stenosis of precerebral arteries
434 Occlusion of cerebral arteries
435 Transient cerebral ischemia
436 Acute but ill defined cerebrovascular disease
437 Other and ill defined cerebrovascular disease
438 Late effects of cerebrovascular disease
DEFINITION
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.
SYMPTOMS
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. Urinary urgency, increased muscle
tone, fatigue, depression, and pain are symptompsthat may be manifested after a stroke has
already occured. Reflex sympathetic dystrophy (also known as complex regional pain
syndrome type 1) may occur after stroke, although most post-stroke pain results from
mechanical (e.g. joint subluxation) or central (e.g. thalamic pain syndromes) causes.
PHYSICAL EXAMINATION
A full neurologic examination is appropriate. This includes evaluation of mental status,
cranial nerves, sensation, deep tendon reflexes, abnormal reflexes (e.g. babinski), motor
strength and coordination, muscle tone and functional mobility (sitting, transfers, and
ambulation). The protean manifestations of stroke can cause many different combinations of
abnormalities in these aspects of the neurologic examination. An assessment of mood and
affect is important, given the high prevalence of post-stroke depression. Range of motion in
affected limbs should be measured; ankle plantar flexion contractures and upper limb
contractures are common in hemiplegic stroke and interfere with rehabilitation efforts. 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.
FUNCTIONAL LIMITATIONS
Difficulties in walking, performing activities of daily living, speaking, and swallowing are
common manifestations of stroke. Cognitive impairments (memory, attention, visual-spatial
perception) and impaired communication due to aphasia or dysarthria may be present. The
impairments seen in stroke are based on the anatomy of the stroke; aphasia is generally a
result of left hemisphere damage, and neglect and attentional deficits are more common with
right hemisphere strokes. Impaired sexual function should be identified because patients may
not volunteer function impairment in this area unless the physician inquires.
As a result of these impairments, many individuals may be unable to drive or to 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 destrusor instability and urinary urgency can interfere with leaving the home and
contribute to skin breakdown and social isolation.
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 funtional loss. Among stroke survivors older than 65 years who were
evaluated 6 months after a stroke, 30% were unable to walk without some assistance, 26%
were dependent for activities of daily living, and 26% were institutionalized in a nursing
home.1
DIAGNOSTIC STUDIES
In the acute setting, computed tomography 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. Magnetic resonance imaging provides greater anatomic
resolution and avoids radiation exposure. With newer magnetic resonance imaging sequences,
such as diffusion-weighted imaging abnormalities can be demostrated at an earlier stage than
with computed tomography, providing important information for acute treatments such as
thrombolysis.2 Magnetic resonance angiography, computed tomographic angiography, non
invasive flow studies, holter monitoring, and echocardiography are important studies to help
determine the cause of a stroke and to determine the best treatment for prevention of
recurrent stroke. In selected patients (particularly young individuals or those without typical
risk factors), an evaluation for hypercoagulable states is indicated.
In patients with prior stroke, diagnostic studies are typically directed to complications of
stroke, such as persistent dysphagia or urinary incontinence. Video fluoroscopic swallowing
studies can be useful un swallowing disorders. Urodynamic studies may be useful in the
assessment of urinary symptoms, particularly if initial treatment with anticholinergic
medications is unsuccessful.

Differential Diagnosis
Hemiplegic migraine
Post-seizure (Todd) paralysis
Brain neoplasm
Multiple sclerosis
TREATMENT
Initial
When ischemic stroke is diagnosed within the first 3 hours, thrombolytic therapy has been
shown to reduce disability.3 In the other cases, intravenous heparin is commonly administered
when an embolic etiology is suspected. Aspirin (between 80 and 325 mg) has been found to
be effective when it is used in the acute setting.
Secondary prevention depends on the cause of the stroke. Warfarin (coumadin) is commonly
used for the secondary prevention of embolic stroke, with the most estensive evidence for
prevention of stroke in atrial fibrillation.4 Antiplatelet agents, including aspirin, clopidogrel
(plavix), or a combination of aspirin and dipyridamole (aggrenox), are used for prevention of
most non-cardioembolic strokes or when antocoagulation is desirable but contraindicated
because of commorbid conditions. Risk factor modification, including treatment of
hypertension, diabetes, hyperlipidemia, and obesity as well as smoking cessation and exercise
should be addressed for all stroke survivors.5
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. For all causes of cerebral hemorrhage, avoidance of anticoagulants, antiplatelet
medications and alcohol is important.6
Medications for the management of stroke and its complicatons on an outpatient basis are
shown in table 149-1. Anticholinergic medications are useful for bladder destrusor instability.
Antispasticity medications are of limited efficacy in many cases ( see chapter 144). 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 effetive. Psychostimulants may
be useful for impaired attention. Anticonvulsants are used for central pain syndromes, but
with variable benefit.
Rehabilitation
The rehabilitation program needs to be customized on the basis of the severity and nature of
the impairments caused by the stroke. For individuals with moderate to severe stroke, a
comprehensive multidiciplinary inpatient rehabilitation program in a rehabilitation hospital is
often appropriate.7 For these individuals, rehabilitation commonly continues through home
care or outpatient services. Patients with more isolated and less severe deficits may be

discharged directly from the acute care hospital to home and participate in an outpatient
rehabilitation program.8
Exercise
Therapeutic exercise programs are usually functionally oriented, with an emphasis on
restoration of functional mobility and ability to perform activities of daily living (Fig. 149-1).
Instruction in compensatory techniques and family teaching are important in assisting
individuals to return home. These is growing evidence of the impact of therapeutic exercise
on cortical reorganization after stroke, with associated improvements in motor control and
functional use.9 Newer approaches being studied to enhance motor abilities include
constraint-induced movement therapy, robot assisted exercise training, virtual reality exercise
training, and partial body weight-supported treadmill training. 10-15 These novel techniques
appear to improve motor function, but the optimal exercise program to facilitate recovery
remains to be defined.
Table 149-1 Medication Commonly Used for Treatment of Stroke and Its Complications
Class of Medication
Examples
Indication
Oxybutynin (Distropan)
Anticholinergic
Bladder detrusor instability
Tolterodine (Detrol)
Baclofen (Lioresal)
Tizanloine (Zanaflex)
Antispasticity
Muscle spasticity
Diazepam (Valium)
Dantrolene (Dantrium)
Phosphodiesterase
Sildenafil (Viagra)
Erectile dysfunction
type S inhibitors
Vardenafil (Levitra)
Fluoxetine (Prozac)
Selective
serotonin
Paroxetine (Paxil)
Post-stroke depression
reuptake inhibitors
Sertraline (Zoloft)
Methylphenidate (Ritalin)
Stimulants
Impaired attention arousal
Dextroamphetamine (Dexedrine)
Gabapentin (Neurontin)
Central pain syndromes,
Anticonvulsants
Carbamazepine (Tegretol)
seizure disorders
Dysphagia
Management of dysphagia may include the use of nasogastric or gastrostomy tube feedings,
modified diets (e.g., thickened liquids, pureed foods), and swallowing therapy (e.g., the use
of compensatory strategies, such as tucking the cin during swallowing).
Communication
The rehabilitation of aphasia relies on extensive speech therapy as its mainstay; selected
patients benefit from communication aids, such as a picture board. Speech therapy may
provide significant benefit for dysarthria as well, with improved intelligibility resulting.
Severely dysarthric or anarthric patients may benefit from the use of computer-based

communication aids, including those with speech synthesis, as well as low-tech solutions
such as spelling boards.

Figure 149-1. the time course of recovery after stroke is shown as the cumulative percentage of stroke survivors
in each category who have reached their best function in activities of daily living relative to initial functional
disability: mild disability, moderate disability, severe disability and x very severe disability. (Reprinted with
permission from Jorgensen HS, Nakayama H, Raaschou HO, et al. Outcome and time course of recovery in
stroke. Part II. Time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995;76:406412)

Cognition
Cognitive abilities are frequently affected by stroke; alterations in memory, attention, insight,
and problem solving are common. Neuropsychological testing may be useful indefining the
precise nature of these deficits and in helping to develop a remediation plan. Speech-language
and occupational therapy approaches include both attempts at remediation and teaching of
compensatory techniques. Family education and training are important components of
cognitive rehabilitation. Recognition and treatment of post stroke depression is very
important because depression can contribute to reduced cognitive performance after stroke.16
Bracing
Lower extremity bracing is frequently helpful in restoration of mobility in hemiparetic stroke
survivors. Most commonly, a plastic ankle-foot orthosis is used, although other braces are
appropriate in selected circumstances. Bracing is helpful as a compensation for impaired
ankle dorsiflexion, controlling ankle inversion and plantar flexor spasticity as well as
providing some stabilization at the knee.

Ambulatory Aids and Wheelchairs

Because of hemiparesis, many stroke survivors require ambulatory aids, which may include a
straight cane, a four-pronged (quad) cane, a hemi-walker, or, in some cases, a conventional
walker. Wheelchairs are often needed for more severely impaired stroke survivors or for
moderately impaired stroke survivors for longer distance travel. A hemi-wheelchair is lower
to the ground and allows use of the nonparetic leg to assist with propulsion. On occasion, a
one-arm drive wheelchair is useful; it allows control of both wheelchair wheels from one
side. Active, nonambulatory individuals may benefit from a power wheelchair.
Shoulder Subluxation
Shoulder Subluxation commonly occurs in the setting of hemiplegia after stroke, although the
presence of pain is highly variable. Arm boards and the selective use of slings help in
reducing subluxation. Electrical stimulation may have a beneficial effect as well.17
Splints
Splint for proper positioning of the hemiplegic arm and ankle-foot are important to prevent
contracture. These are particularly important when spasticity is present.
Vocational Rehabilitation
Although stroke is predominantly a disease of older individuals, a significant portion of
stroke survivors are of working age. Once activities of daily living have been mastered,
vocational counseling may assist individuals seeking to return to work. Coordination with the
rehabilitation team is important because retraining for certain job tasks may involve a
multidisciplinary effort. Accommodations in the workplace may be necessary, and the
Americans with Disabilities Act may require the employer to provide reasonable
accommodation for individuals with disabilities. See chapter 150 for more details.
Procedures
Phenol or botulinum toxin injections may be useful in the management of spasticity after
stroke. These injections are described in greater detail in Chapter 144.
Surgery
Selected patient require craniotomy in the acute phase for evacuation of a large intracerebral
hematoma or for severe swelling with increased intracranial pressure. Carotid endarterectomy
in appropriately selected patients has been shown to reduce the risk of recurrent stroke. 18
Carotid stenting is being studied as an alternative to endarterectomy for the treatment of
carotid stenosi. Intrathecal baclofen has been found to be effective in treatment of post stroke
spasticity,19,20 but it is infrequently use for hemiplegic stroke at this time. In patients with

chronic impairments from stroke, tendon lengthening procedures are occasionally needed for
contractures.
An experimental implantable cerebral cortical stimulator system has been found to facilitate
motor recovery when it is used in conjuction with exercise therapy in pilot studies. 21 A
multicenter study of this device is currently in progress.
POTENTIAL DISEASE COMPLICATIONS
Seizures can develop as an early or a late complication of stroke; strokes involving the
cerebral cortex and hemorrhagic stroke carry greater risk. The risk of deep venous thrombosis
is substantially elevated in hemiplegic stroke, and prophylactic treatment with subcutaneous
heparin or low molecular weight heparin is advisable during the initial recovery phase. 22 The
ideal duration of prophylaxis for deep venous thrombosis after stroke has not been
established; in most cases, this is discontinued after a period of several weeks. Stroke
reccurence is a feared complication of stroke, and individuals with a history of stroke remain
at increased risk for reccurent stroke despite risk factor reduction. Aspiration pneumonia can
occur as a complication of dysphagia, although this risk tends to abate over time except in the
most severe cases.
POTENTIAL TREATMENT COMPLICATIONS
Both anticoagulants antiplatelet medications can contribute to bleeding complications.
Aspirin can cause gastritis. Clopidogrel has been associated with thrombotic
thrombocytopenic purpura. The combined used of aspirin and clopidogrel appears to increase
the risk of gastrointestinal hemorrhage without providing significant improvement in stroke
prevention.23
Anticholinergic medications commonly cause dry mouth and may precipitate urinary
retention. Antispasticity medications can cause sedation and may exacerbate. Cognitive
impairments. Sildenafil is known to be hazardous when it is use concurrently with nitrates
and should be avoided in patients receiving these medications. Selective serotonin reuptake
inhibitors can cause gastrointestinal symptoms (especially nause and anorexia) as well as
interfere with libido and sexual function. Psychostimulants can cause anorexia, insomnia,
anxiety, or agitation and should be slowly titrated upward. Gabapentin is usually well
tolerated, although occasional sedation has been reported. Carbamazepine may cause
leukopenia.

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