1. Archana Rao, MD

2. What is it?? Stroke occurs when there is inadequate blood flow to a part of the brain Or a hemorrhage that occurs into the brain Both of which result in cell damage/death The severity of the symptoms depends on the location of the brain involved. TIA has the same pathophysiology of stroke, but the symptoms usually improve within 24 hrs.

3. Epidemiology Leading cause of disability 4 th leading cause of death 82%-92% strokes are ischemic Men are at higher risk, compared to women Although elderly are at higher risk, 1/3 rd of strokes occur in patients younger than 65 yrs 75% of strokes occur in patients over 64 yrs

4. Modifiable risk factors Hypertension (better control lowers risk by 50%) Heart disease (Afib, cardiomyopathy, valve problems) DM (patients’s risk is 5 times higher) Elevated cholesterol Smoking (doubles the risk of stroke) Abdominal obesity (commonly associated with above) Physical inactivity (regardless of ethnicity) Migraines and other inflammatory conditions

5. Blood supply of the brain

6. Location of the stroke Anterior Posterior

7. Thank you

8. Common presentation Anterior Circulation Posterior Circulation Focal unilateral weakness Dysarthria Dizziness Aphasia Gaze palsy Altered Mental Status Paresthesias Ataxia Focal unilateral weakness Dysarthria Dizziness Visual field cut Aphasia Gaze palsy Altered Mental Status Paresthesias Syncope Ataxia

9. Differential Diagnosis/Stroke Mimics The accurate diagnosis of strokes depends on several factors: Presenting complaint ( neuroanatomical knowledge is very helpful) Epidemiology (Not very reliable although younger age more in support of stroke mimic) Anterior or posterior circulation (MCA territory strokes easier to diagnose clinically than PCA territory) Modality of imaging available (MRI is more sensitive)

10. Stroke Mimics Complicated migraine Migraine auras can resemble focal neurologic deficits like unilateral numbness or weakness, dysarthria, aphasia Posterior circulation involvment can cause lethargy, vertigo, ataxia Sporadic or familial No prior history of headaches or migraines is usually the case

11. Stroke mimics Seizure Presentation in the ictal phase as paresthesias, motor stereotypical activity, or in post-ictal phase as aphasia, unilateral weakness Post ictal paresis more commonly seen in complex partial seizures Concurrence of seizure and stroke is common, 40% of ischemic stroke and 57% of hemorrhagic stroke present with seizure in the first 24 hrs.

12. Stroke mimics Intracranial neoplasm 5% of patients diagnosed as brain tumors are intially diagnosed as strokes and 12% of patients initially diagnosed as strokes were eventually diagnosed as brain tumors. Common presenting symptoms in this case were vision changes, hemiparesis, or aphasia Acute presentation is likely secondary to acute intracranial pressure changes, vascular compression or encasement, tumor apoplexy

13. Stroke mimics Syncope Can be confused with stroke involving the posterior circulation Differentiating features are usually paralysis of cranial nerves, causing diplopia, dysarthria, ataxia, and vertigo Isolated loss of consciousness is not the norm

14. Stroke Mimics Metabolic dysfunction: Hypoglycemia (confusion, personality change, autonomic complaints, and focal symptoms) Hyperglycemia (hemichorea-hemiballismus) Electrolyte abnormalities Hepatic encephalopathy

15. Stroke Mimics Sepsis Can be more likely due to encephalopathic changes, like confusion, delirium, coma, weakness and speech changes Likely due to a combination of neuro-inflammatory response, endothelial dysfunction causing microcirculatory failure, and passage of neurotoxins through the BBB CBC, CRP and ESR should be able to differentiate