1. Etiology of stroke
Sanjeeva Onteddu

2. 60 yo smoking, htn, hlpd, DM presents with right sided weakness.
Patient 1
Patient 2

3. This matters for secondary stroke prevention
All our work up is figure out etiology only

4. TOAST Classification
1 large vessel athero
2 lacunar
3 cardio embolic
4 strokes of other known causes
5 strokes of unknown or 2 or more etiologies

5. Other types of classifications
Thrombosis
Embolism
SSS-TOAST
CCS Classification etc

7. 40 Year old with no hx with left sided weakness

9. Lacunar Strokes Pure motor hemiparesis. Pure sensory hemi anesthesia.
Ataxic hemiparesis.
Dysarthria–clumsy hand syndrome.
Absence of cortical deficits plus one of the following

10. Cortical vs subcortical.
Cortical signs.  
Aphasia (if the dominant hemisphere is affected) and
Sensory neglect (if the non dominant hemisphere is affected), apraxia, asomatognosia, anosognosia.
Gaze deviation.
Cortical blindness.
Contralateral hemiparesis (worse in the arm and face than in the leg).
Cortical Sensory Loss
Graphestesia, stereognosis, extinction
Warning: all cortical signs can be seen in subcortical lesions!

11. Diagnostic Evaluations
Hyper Acute:
CT Head/MRI Brain, Accucheck Only.
CTA Head or MRA head and neck to see of they qualify for Intervention.
Brain function: Perfusion scans : CTP, MRP

12. Diagnostic Evaluations to find the etiology of stroke
Acute to evaluate for Cause of stroke.
Athero thrombotic: Catotid/vertebral or intracranial atherosclerosis
Cardioembolic: TTE, ECG, Tele.
Lacunar strokes: risk factors, absence of other etiologies, Lipids, HbA1c
Stroke of other determined etiologies: Dissections. Hypercoagulability panel. Vasculitis , Urine Tox Screen, Troponins, Genetic testing Etc.
Cryptogenic strokes.

13. Other Available diagnostic Options

14. Cardiac Extended Cardiac Monitoring Event monitor: Who
TEE: Why not all and start with it
Cardiac MRI: …hMMM
Loop Recorders ..

15. Blood Work
Hyper coag Work up
Vasculi… work up
Homocysteine…

16. DSA: 4 Vessel Angio When do we do it: Dissection ?? Vasculi….
Intracranial atherooo
CVT causing venous infarcts…..
Renal Injections to look for FMD

17. Other Uncommon Work up ECHO: bubbles in 2 second cycle
ECHO: bubbles in 8th cycle
What about TCD??

18. LE Duplex for PFO for paradoxical emboli
CT Chest to look for Pul AVM’s
CT or MRV of pelvis for venous thrombosis

19. Hmm How about Undetected CA
No Clear guidelines

20. Vessel Wall Imaging
Extracranial:
Intracranial:

21. Treatments for secondary Prevention:
Antiplatelet therapy- small vessel or large vessel embolic disease
ASA 81 mg vs. 325 mg
Clopidogrel 75 mg
ASA plus Extended Release Dipyridamol 25/200 mg BID (Aggrenox)
Anticoagulation- Best for Cardio embolic disease or thrombotic disease.
Warfarin
New Oral Anticoagulants or NOACs (Dabigatran, Apixaban, Edoxaban, and Rivaroxaban)
Risk Factor Control:
Treat all other identified causes:

22. What About ICH
Most common cause of spontaneous ICH Lobar ICH ICH in Children Intra cranial ICH

23. Most common cause of
spontaneous ICH: Hypertensive
Lobar ICH: Amyloid
ICH in Children: AVM
Intra cranial ICH: Traumatic

24. Other causes
Hemorrhagic infarction (including venous sinus thrombosis)
Septic embolism, mycotic aneurysm
Brain tumor
Bleeding disorders, liver disease, anticoagulants, thrombolytic therapy
Central nervous system (CNS) infection (eg, herpes simplex encephalitis)
Moyamoya
Vasculitis
Drugs (cocaine, amphetamines)

25. ACUTE Imaging CT brain CTA ?? Almost always done may not need it
Repeat HCT in 6 hrs
Other options
CTV, MRI, MRV.

26. Questions