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Cardiac Ultrasound in Stroke Investigation

Abbreviations AF atrial fibrillation ASA atrial septal aneurysm INR international normalized ratio LA left atrium, left atrial LAA left atrial appendage LV left ventricle, left ventricular MAC mitral annular calcification MRI magnetic resonance imaging PFO patent foramen ovale TTE transthoracic echocardiography TEE transesophageal echocardiography Cardiac sources of stroke may account for 20–30% of the near 800,000 strokes that occur annually in the United States. Conventional transthoracic…

Cardiac Electrophysiology in Stroke Investigation: Holter, Event Monitor, and Long-Term Monitoring

Identifying the etiology of ischemic stroke is critical to providing optimum therapy and preventing future events. Unfortunately, it is not always a simple task to establish the source, which all too often results in the diagnosis of “cryptogenic” stroke. Since cardiac sources of emboli are a well-known and significant cause of ischemic stroke, and may require different patient management, substantial effort has been made into the…

Clinical Stroke Diagnosis

Information Used for Stroke Diagnosis Clinicians must first decide on the key questions to be asked. Answers are difficult unless the questions are clearly framed. In neurology, two diagnostic questions always require an answer: (1) what is the disease mechanism—the pathology and pathophysiology? and (2) where is the lesion(s)—the anatomy of the disorder? In stroke patients, the “what” question concerns which of the five stroke mechanisms…

Cerebrovascular Complications of Cardiac Surgery

Background Cardiac surgery has undergone a rapid and extraordinary development since mid-1940s. Many operations that were once considered experimental are now commonplace, with thousands of open heart procedures performed annually in the United States. At present, an estimated 1 million patients undergo cardiac surgery throughout the world every year. Neurological impairment is a well-known complication of cardiac surgery, resulting in longer hospitalizations, increased costs, and an…

Stroke-Induced Immunodepression and Clinical Consequences

Introduction Infections are common complications in the acute phase after stroke affecting about one-third of all patients with stroke . The most frequent poststroke infections are urinary tract infections and stroke-associated pneumonia (SAP), the latter showing consistent association with poor outcome . Initial concepts on the etiology of SAP focused on stroke-facilitated aspiration. In fact, dysphagic patients have an increased risk for SAP. However, dysphagia alone…

HIV and Stroke

Introduction There is an elevated risk of ischemic stroke in human immunodeficiency virus (HIV)-infected compared to HIV-uninfected individuals, independent of age and traditional vascular risk factors. In individuals with untreated HIV infection, the odds of an ischemic stroke are more than five times greater than in uninfected individuals matched for age and sex . The risk is highest in the setting of worse virological control, low…

Stroke and Infection: Tuberculosis, Brucellosis, Syphilis, Lyme Disease and Listeriosis

Neurological complications may occur as sequelae of systemic infection, but can be a presenting feature with certain pathogens. An association exists between ischemic strokes and infection, with a number of proposed mechanisms by which vascular disease develops into central nervous system (CNS) infections. The pathophysiological mechanisms may involve vasculitis, affecting primarily the vessels at the base of the brain in the setting of meningitis, an immune-mediated…

CADASIL

Introduction The acronym CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is for an autosomal dominant inherited cerebral small-vessel disease responsible in adults for subcortical infarcts and leukoencephalopathy . Mutations in NOTCH3 gene on chromosome 19 are responsible for the disease. CADASIL is observed in all countries worldwide. Hundreds of families have been reported in Europe. In a region of the West of Scotland…

Functional Disorders Presenting to the Stroke Service

Introduction About one-quarter of patients admitted to specialist stroke units will be discharged with a diagnosis other than stroke; these patients are commonly referred to as stroke mimics . Functional neurological disorder (FND) is one of the commonest causes of stroke mimic, representing with a reported range of 7–45% . FND can be broadly defined as a condition characterized by neurological symptoms that lack internal consistency,…

Toxicity/Substance Abuse

Introduction Stroke is the second leading cause of mortality and most common cause of disability worldwide. About 30% of stroke survivors are permanently disabled, and 20% require institutionalized care. In 2002, the cost of stroke was estimated at $49.4 billion . Although stroke in adults younger than 55 years comprises only 10% of stroke, it remains a significant source of morbidity and mortality . At a…

Pregnancy, Hormonal Contraception, and Postmenopausal Estrogen Replacement Therapy

There is an increasing emphasis on gender-specific issues in stroke, such as the role of endogenous and exogenous female hormones. This chapter reviews available data on the risk of stroke related to pregnancy, hormonal contraception, and postmenopausal hormone replacement therapy (HRT). Stroke in Pregnancy Epidemiology The reported incidence of stroke during pregnancy and the puerperium ranges from 4 to 34 per 100,000 deliveries or pregnancies .…

Stroke and Sickle Cell Disease

Introduction Sickle cell disease (SCD) is a powerful risk factor for stroke. Individuals with SCD are at risk for hemolytic anemia, painful vaso-occlusive crises, infection, and cerebrovascular disorders. Those with sickle cell anemia (SCA), defined as homozygous hemoglobin S or hemoglobin S-beta thalassemia, have an even greater risk for stroke beginning in early childhood, as up to 10% will have stroke without primary prevention. Red blood…

Primary Platelet Disorders

Introduction Platelets are small anucleated discoid-shaped blood cells 2–3 μm in diameter, which are essential for regulating hemostasis. They are produced in the bone marrow by megakaryocytes, circulating in the blood stream for 5–10 days before being destroyed by phagocytosis in the spleen and liver. A normal platelet count is between 150,000 and 450,000/mm 3 of blood. Platelets provide hemostasis through adhesion, aggregation, and coagulation properties.…

Antiphospholipid Antibody Syndrome

Introduction The antiphospholipid syndrome (APS) is defined as a constellation of clinical and laboratory features including thrombosis and/or obstetrical complications associated with the presence of the following antiphospholipid antibodies (aPL): anticardiolipin antibody (aCL), anti-β2-glycoprotein 1 antibody (a-β2-GP1) or the lupus anticoagulant (LA) . The unfortunate misnomer used for the coagulation-based tests, “Lupus Anticoagulant,” is a historical phenomenon. Phospholipid-dependent coagulation assays were found to be prolonged in…

Coagulopathies and Ischemic Stroke

Introduction In ischemic stroke coagulopathies are characterized by a condition in which blood is too quick to clot. Such coagulation abnormalities may be genetic or acquired. Coagulation abnormalities are identified as the cause of ischemic stroke in less than 1% of unselected series. Accordingly, in the vast majority of patients with ischemic stroke an extensive evaluation to identify a coagulopathy is not warranted. In few specific…

Aortic Dissection and Stroke

Introduction Aortic dissection occurs in about 3–4 per 100,000 persons per year. A common clinical error is to equate aortic dissection with aneurysm. This misconception unfortunately has been propagated since the earliest descriptions of these diseases, describing a “Dissecting Aneurysm of the Aorta” . While some aneurysms can be complicated by, and predispose to, dissection, and dissections can become aneurysmal over time, the disease processes are…

Radiation Vasculopathy

Acknowledgments We acknowledge Dr. David Liebeskind for assistance with the angiographic images of radiation vasculopathy. Introduction Radiation-induced arterial damage was described shortly after the advent of the X-ray by Roentgen in the late 1800s . In the setting of radiation therapy for malignancy, this arterial change has been described in multiple vessels throughout the body, from the capillary bed to the aorta. Pertinent to stroke, radiation…

Cerebrovascular Complications of Cancer

As cancer and stroke are the second and fifth leading causes of mortality in the United States, it is not surprising to encounter a patient with these concomitant diagnoses . Various cerebrovascular disorders can occur within the oncological population, complicating the overall clinical course, treatment, and long-term outcome of cancer patients. Detailed investigation and precise diagnosis of cerebrovascular disorders in cancer patients is important for several…

Stroke and Migraine

Introduction Migraine headache is both a prevalent and potentially debilitating condition attributed to both environmental and hereditary factors. It is associated with significant comorbidities including depression, dysautonomia, cognitive dysfunction, vertigo, and stroke. Migraine accounts for approximately one-third of neurologic disease burden in daily adjusted life years and ranked in the top 30 (of 176) of the highest burdens of disease in most areas of the world…

Varicella Zoster Virus and Stroke

Acknowledgments Supported in part by National Institutes of Health grants AG032958 and NS094758. Introduction Varicella zoster virus (VZV) is a ubiquitous, neurotropic alphaherpesvirus. Primary infection usually causes varicella (chickenpox), after which virus becomes latent in cranial nerve, dorsal root, and autonomic ganglionic neurons, including enteric ganglionic neurons and adrenal cells. With a decline in VZV-specific cell-mediated immunity in elderly and immunocompromised individuals, virus reactivates from one…