Ischemic stroke

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

In 2021, there were 3.59 million deaths worldwide as a result of ischemic stroke.[10] Stroke is a leading cause of serious long-term disability in the US and worldwide.[9][53] Prognosis of functional outcome can be reliably assessed using well-validated prognostic scores like the ASTRAL score or the iScore.[295]

Intravenous thrombolysis and mechanical thrombectomy, both together and separately, have been shown to improve stroke outcome. Treating patients in dedicated stroke units is effective.[135][263][264] [ ]

Overall, patients with cerebral venous thrombosis have a favorable outcome.[8] Most patients with CVT achieve functional independence and survive without physical disability.[8] However, residual symptoms related to cognition, mood, fatigue, and headache, which negatively affect quality of life, are not uncommon.[8][243][296][297][298] Factors associated with poor prognosis include advanced age, active cancer, decreased level of consciousness, and intracerebral hemorrhage.[7][8][299]

Common medical complications related to stroke include aspiration pneumonia, urinary tract infection, depression, malnutrition, pulmonary embolism, and deep vein thrombosis.[262]

A meta-analysis on the efficacy of physical therapy following stroke found that a variety of interventions improved functional outcomes, even when they were applied late after stroke.[300]

The risk of stroke within 90 days after a first stroke is ≈5%, but the risk can vary greatly from >10% to <1%, depending in part on mechanism.[113] In one registry-based study the overall 1-year and 10-year risks of recurrence were 4% and 13% following first-time ischemic stroke.[301] The risk of recurrence increased with age and was higher for men and higher following mild versus more severe stroke. For ischemic stroke, the 1-year and 10-year risks of all-cause mortality were 17% and 56% after a first-time stroke and 25% and 70% after a recurrent stroke.[301] The highest recurrence rate is seen in large artery atherosclerosis and cardio embolic stroke subtypes.[302] Studies examining decreasing trends in stroke recurrence over 20 years suggest secondary prevention measures have been effective and effective secondary prevention can reduce the risk of recurrent events by up to 80%.[303]

Patients with atrial fibrillation

Patients with atrial fibrillation and first ischemic stroke remain at increased risk of recurrent ischemic stroke and death even while taking oral anticoagulation. Recurrent ischemic stroke (cumulative incidence at 1 year: 7.0%) and cumulative incidence of mortality at 3 months after stroke was 12.4%.[304] The etiology of ischemic stroke despite anticoagulation therapy in people with atrial fibrillation (excluding those patients in whom anticoagulation was stopped or paused for medical reasons) includes causes related to atrial fibrillation such as inadequate intensity of anticoagulation due to underdosing, non-compliance, failure to account for food interaction (particularly for rivaroxaban, or drug-drug interactions), inappropriate perioperative management, and cardioembolism despite anticoagulation.[305] The etiology of ischemic stroke despite anticoagulation therapy in people with atrial fibrillation may also include causes unrelated to atrial fibrillation (i.e., stroke caused by large vessel arteriosclerosis, cerebral small vessel disease, aortic arch disease, or occult cancer). In these patients, a complete etiological work-up is recommended to assess adequate drug dosing and adherence, as well as the presence of other potential causes of stroke unrelated to atrial fibrillation.[305] In these patients, non-atrial fibrillation related causes should be considered along with drug-related issues (e.g., nonadherence or inadequate dose).[305]

Patients receiving intravenous thrombolysis

These patients are more likely to have a better outcome than patients not treated with intravenous thrombolysis, despite a 6% risk of symptomatic intracranial hemorrhage.[180]

Estimates of the number needed to treat (NNT) to prevent one additional case of stroke-related disability within 4.5 hours of symptom onset are:[179]

3 (following administration of alteplase or tenecteplase)
2-4 (following administration of alteplase or tenecteplase plus thrombectomy).

Estimate of NNT to prevent one additional case of stroke-related disability within 4.5 to 9.0 hours of symptom onset is:

25 (following administration of alteplase or tenecteplase).

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