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Stroke, Acute (Cerebrovascular Accident [CVA])

Stroke, Acute (Cerebrovascular Accident [CVA]) is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

Stroke is the sudden onset of a focal neurologic deficit(s) resulting from either infarction or hemorrhage within the brain.

  • Two broad categories: ischemic (thrombotic or embolic; 87%) and hemorrhagic (13%)
  • Hemorrhage can be intracerebral or subarachnoid.
  • System(s) affected: neurologic; vascular
  • Synonym(s): CVA; cerebral infarct; brain attack
  • Related terms: transient ischemic attack (TIA), a transient episode of neurologic dysfunction due to focal ischemia without permanent infarction on imaging (see topic “Transient Ischemic Attack [TIA]”)
Pediatric Considerations
  • Cardiac abnormalities (congenital heart disease, paradoxical embolism, rheumatic fever, bacterial endocarditis)
  • Metabolic: homocystinuria, Fabry disease

Epidemiology

Incidence
Annual incidence in the United States is ~795,000.


Prevalence
  • Prevalence in the United States: 550/100,000
  • Predominant age: Risk increases >45 years of age and is highest during the 7th and 8th decades.
  • Predominant sex: male > female at younger age but higher incidence in women with age ≥75 years

Etiology and Pathophysiology

  • 87% of stroke is ischemic, three main subtypes: thrombosis, embolism, and systemic hypoperfusion. Large vessel atherothrombotic strokes often involve the origin of the internal carotid artery. Small vessel lacunar strokes are commonly due to lipohyalinotic occlusion. Embolic strokes are largely from a cardiac source (due to left atrial thrombus, atrial fibrillation, recent MI, valve disease, or mechanical valves) or ascending aortic atheromatous disease (>4 mm).
  • 13% of stroke is hemorrhagic; most commonly due to HTN. Other causes include intracranial vascular malformations (cavernous angiomas, AVMs), cerebral amyloid angiopathy (lobar hemorrhages in elderly), and anticoagulation.
  • Other causes include fibromuscular dysplasia (rare), vasculitis, or drug use (cocaine, amphetamines).

Genetics
Stroke is a polygenic multifactorial disease.

Risk Factors

  • Uncontrollable: age, gender, race, family history/genetics, prior stroke or TIA
  • Controllable/modifiable/treatable
    • Metabolic: diabetes, dyslipidemia
    • Lifestyle: smoking, cocaine and amphetamine use
    • Cardiovascular: hypertension, atrial fibrillation, valvular heart disease, endocarditis, recent MI, severe carotid artery stenosis, hypercoagulable states, and patent foramen ovale

General Prevention

Smoking cessation, regular exercise, weight control to maintain nonobese BMI and prevent type 2 diabetes, moderate alcohol use; control BP; manage hyperlipidemia; use antiplatelet agent (e.g., aspirin) in high-risk persons; treat nonvalvular atrial fibrillation with dose-adjusted warfarin or dabigatran, apixaban, and rivaroxaban.

Commonly Associated Conditions

Coronary artery disease is the major cause of death during the first 5 years after a stroke.

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Citation

Stephens, Mark B., et al., editors. "Stroke, Acute (Cerebrovascular Accident [CVA])." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688020/all/Stroke__Acute__Cerebrovascular_Accident_[CVA]_.
Stroke, Acute (Cerebrovascular Accident [CVA]). In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688020/all/Stroke__Acute__Cerebrovascular_Accident_[CVA]_. Accessed April 19, 2019.
Stroke, Acute (Cerebrovascular Accident [CVA]). (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688020/all/Stroke__Acute__Cerebrovascular_Accident_[CVA]_
Stroke, Acute (Cerebrovascular Accident [CVA]) [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688020/all/Stroke__Acute__Cerebrovascular_Accident_[CVA]_.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Stroke, Acute (Cerebrovascular Accident [CVA]) ID - 1688020 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688020/all/Stroke__Acute__Cerebrovascular_Accident_[CVA]_ PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -