Ischemic stroke natural history

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

Ischemic stroke is a medical emergency requiring urgent diagnosis and treatment. Neurological tissue is highly time sensitive when there is decreased or absent blood supply to the brain.[1] If left untreated, brain tissue may irreversibly be damaged causing permanent neurological deficit and in certain cases death. The extent of damage and complications which may result highly depends on the site of infarction, the blood vessels involved and the presence of other risk factors.[2][3][4] Complications of ischemic stroke may include cerebral edema, cerebral herniation, hemorrhagic transformation of ischemic stroke, deep venous thrombosis, pulmonary embolism, aspiration pneumonia, seizures, pressure sores, depression and anxiety.[5][6][7][8][9][10][11][12][13][14][15][16] [17] [18][19] Prognosis of ischemic stroke depends on volume and size of infarct, degree of neurological deficit, presence of co morbid conditions and complications such as fever, hyperglycemia and cerebral edema.[20][21][22][23][24][25][26][27]

Natural History

Ischemic stroke is a medical emergency requiring urgent diagnosis and treatment. Neurological tissue is highly time sensitive when there is decreased or absent blood supply to the brain.[1] If left untreated, brain tissue may irreversibly be damaged causing permanent neurological deficit and in certain cases death. The extent of damage and complications which may result highly depends on the site of infarction, the blood vessels involved and the presence of other risk factors.[2][3][4]

Complications

Common complications of ischemic stroke may include:[5][6][7][8][9][10][11][12][13][14][15][16] [17] [18][19]

Duration Complications
Early complications

( <7 days )

Late complications

( >7 days )

Prognosis

Prognosis of stroke depends on factors such as:[20][21][22][23][24][25][26][27]

Good prognostic factors Bad Prognostic factors
Small size of infarct Large size and volume of infarct[28]
Mild neurological defect Severe neurological deficit[21][23][29][30][31][27]
NIHSS score >16 NIHSS score <16[32][33][34]
Lacunar infarcts Location of the infarct[25][29][35][36][37][38]
Absence of fever, cerebral edema and hyperglycemia Presence of fever, cerebral edema, hyperglycemia[25][29][42][43]
No co morbid conditions Presence of co morbid conditions[25][44]
Younger age group Advanced age[23][50]
Early diagnosis and treatment Delay in seeking treatment
Good nutritional status Poor nutritional status [51]

References

  1. ↑ 1.0 1.1 Saver JL (2006). "Time is brain--quantified". Stroke. 37 (1): 263–6. doi:10.1161/01.STR.0000196957.55928.ab. PMID 16339467.
  2. ↑ 2.0 2.1 Hernández-Pérez M, Pérez de la Ossa N, Aleu A, Millán M, Gomis M, Dorado L; et al. (2014). "Natural history of acute stroke due to occlusion of the middle cerebral artery and intracranial internal carotid artery". J Neuroimaging. 24 (4): 354–8. doi:10.1111/jon.12062. PMID 24251821.
  3. ↑ 3.0 3.1 Lima FO, Furie KL, Silva GS, Lev MH, Camargo EC, Singhal AB; et al. (2014). "Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography". JAMA Neurol. 71 (2): 151–7. doi:10.1001/jamaneurol.2013.5007. PMID 24323077.
  4. ↑ 4.0 4.1 Moulin DE, Lo R, Chiang J, Barnett HJ (1985). "Prognosis in middle cerebral artery occlusion". Stroke. 16 (2): 282–4. PMID 3975967.
  5. ↑ 5.0 5.1 5.2 Ropper AH, Shafran B (1984). "Brain edema after stroke. Clinical syndrome and intracranial pressure". Arch Neurol. 41 (1): 26–9. PMID 6606414.
  6. ↑ 6.0 6.1 6.2 Sherman DG, Easton JD (1980). "Cerebral edema in stroke: a common, often fatal complication". Postgrad Med. 68 (1): 107–13, 116, 119–20. PMID 6771748.
  7. ↑ 7.0 7.1 7.2 7.3 Davenport RJ, Dennis MS, Warlow CP (1996). "Gastrointestinal hemorrhage after acute stroke". Stroke. 27 (3): 421–4. PMID 8610306.
  8. ↑ 8.0 8.1 8.2 8.3 O'Donnell MJ, Kapral MK, Fang J, Saposnik G, Eikelboom JW, Oczkowski W; et al. (2008). "Gastrointestinal bleeding after acute ischemic stroke". Neurology. 71 (9): 650–5. doi:10.1212/01.wnl.0000319689.48946.25. PMID 18685137.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Indredavik B, Rohweder G, Naalsund E, Lydersen S (2008). "Medical complications in a comprehensive stroke unit and an early supported discharge service". Stroke. 39 (2): 414–20. doi:10.1161/STROKEAHA.107.489294. PMID 18096834.
  10. ↑ 10.0 10.1 10.2 Kamran SI, Downey D, Ruff RL (1998). "Pneumatic sequential compression reduces the risk of deep vein thrombosis in stroke patients". Neurology. 50 (6): 1683–8. PMID 9633711.
  11. ↑ 11.0 11.1 11.2 11.3 Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005). "Dysphagia after stroke: incidence, diagnosis, and pulmonary complications". Stroke. 36 (12): 2756–63. doi:10.1161/01.STR.0000190056.76543.eb. PMID 16269630.
  12. ↑ 12.0 12.1 12.2 Kelly J, Rudd A, Lewis RR, Coshall C, Moody A, Hunt BJ (2004). "Venous thromboembolism after acute ischemic stroke: a prospective study using magnetic resonance direct thrombus imaging". Stroke. 35 (10): 2320–5. doi:10.1161/01.STR.0000140741.13279.4f. PMID 15322298.
  13. ↑ 13.0 13.1 13.2 Dennis M, Mordi N, Graham C, Sandercock P, CLOTS trials collaboration (2011). "The timing, extent, progression and regression of deep vein thrombosis in immobile stroke patients: observational data from the CLOTS multicenter randomized trials". J Thromb Haemost. 9 (11): 2193–200. doi:10.1111/j.1538-7836.2011.04486.x. PMID 21883879.
  14. ↑ 14.0 14.1 14.2 Amin AN, Lin J, Thompson S, Wiederkehr D (2013). "Rate of deep-vein thrombosis and pulmonary embolism during the care continuum in patients with acute ischemic stroke in the United States". BMC Neurol. 13: 17. doi:10.1186/1471-2377-13-17. PMC 3571887. PMID 23391151.
  15. ↑ 15.0 15.1 15.2 Minet LR, Peterson E, von Koch L, Ytterberg C (2015). "Occurrence and Predictors of Falls in People With Stroke: Six-Year Prospective Study". Stroke. 46 (9): 2688–90. doi:10.1161/STROKEAHA.115.010496. PMID 26243230.
  16. ↑ 16.0 16.1 16.2 Korpelainen JT, Kauhanen ML, Kemola H, Malinen U, Myllylä VV (1998). "Sexual dysfunction in stroke patients". Acta Neurol Scand. 98 (6): 400–5. PMID 9875618.
  17. ↑ 17.0 17.1 17.2 17.3 Langhorne P, Stott DJ, Robertson L, MacDonald J, Jones L, McAlpine C; et al. (2000). "Medical complications after stroke: a multicenter study". Stroke. 31 (6): 1223–9. PMID 10835436.
  18. ↑ 18.0 18.1 18.2 Senelick Richard C., Rossi, Peter W., Dougherty, Karla (1994). Living with Stroke: A Guide For Families. Contemporary Books, Chicago.
  19. ↑ 19.0 19.1 19.2 Korpelainen JT, Nieminen P, Myllylä VV (1999). "Sexual functioning among stroke patients and their spouses". Stroke. 30 (4): 715–9. PMID 10187867.
  20. ↑ 20.0 20.1 Faraji F, Ghasami K, Talaie-Zanjani A, Mohammadbeigi A (2013). "Prognostic factors in acute stroke, regarding to stroke severity by Canadian Neurological Stroke Scale: A hospital-based study". Asian J Neurosurg. 8 (2): 78–82. doi:10.4103/1793-5482.116378. PMC 3775186. PMID 24049549.
  21. ↑ 21.0 21.1 21.2 Holloway RG, Benesch CG, Burgin WS, Zentner JB (2005). "Prognosis and decision making in severe stroke". JAMA. 294 (6): 725–33. doi:10.1001/jama.294.6.725. PMID 16091575.
  22. ↑ 22.0 22.1 Heinsius T, Bogousslavsky J, Van Melle G (1998). "Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns". Neurology. 50 (2): 341–50. PMID 9484351.
  23. ↑ 23.0 23.1 23.2 23.3 Matthews WB, Oxbury JM (1975). "Prognostic factors in stroke". Ciba Found Symp (34): 279–89. PMID 1045995.
  24. ↑ 24.0 24.1 Hankey GJ (2013). "Stroke in young adults: implications of the long-term prognosis". JAMA. 309 (11): 1171–2. doi:10.1001/jama.2013.2319. PMID 23512064.
  25. ↑ 25.0 25.1 25.2 25.3 25.4 25.5 Dávalos A, Toni D, Iweins F, Lesaffre E, Bastianello S, Castillo J (1999). "Neurological deterioration in acute ischemic stroke: potential predictors and associated factors in the European cooperative acute stroke study (ECASS) I." Stroke. 30 (12): 2631–6. PMID 10582989.
  26. ↑ 26.0 26.1 Censori B, Camerlingo M, Casto L, Ferraro B, Gazzaniga GC, Cesana B; et al. (1993). "Prognostic factors in first-ever stroke in the carotid artery territory seen within 6 hours after onset". Stroke. 24 (4): 532–5. PMID 8465357.
  27. ↑ 27.0 27.1 27.2 Sumer MM, Ozdemir I, Tascilar N (2003). "Predictors of outcome after acute ischemic stroke". Acta Neurol Scand. 107 (4): 276–80. PMID 12675701.
  28. ↑ Schiemanck SK, Kwakkel G, Post MW, Prevo AJ (2006). "Predictive value of ischemic lesion volume assessed with magnetic resonance imaging for neurological deficits and functional outcome poststroke: A critical review of the literature". Neurorehabil Neural Repair. 20 (4): 492–502. doi:10.1177/1545968306289298. PMID 17082505.
  29. ↑ 29.0 29.1 29.2 Weimar C, Mieck T, Buchthal J, Ehrenfeld CE, Schmid E, Diener HC; et al. (2005). "Neurologic worsening during the acute phase of ischemic stroke". Arch Neurol. 62 (3): 393–7. doi:10.1001/archneur.62.3.393. PMID 15767504.
  30. ↑ Racosta JM, Di Guglielmo F, Klein FR, Riccio PM, Giacomelli FM, González Toledo ME; et al. (2014). "Stroke Severity Score based on Six Signs and Symptoms The 6S Score: A Simple Tool for Assessing Stroke Severity and In-hospital Mortality". J Stroke. 16 (3): 178–83. doi:10.5853/jos.2014.16.3.178. PMC 4200591. PMID 25328876.
  31. ↑ Heldner MR, Zubler C, Mattle HP, Schroth G, Weck A, Mono ML; et al. (2013). "National Institutes of Health stroke scale score and vessel occlusion in 2152 patients with acute ischemic stroke". Stroke. 44 (4): 1153–7. doi:10.1161/STROKEAHA.111.000604. PMID 23471266.
  32. ↑ Adams HP, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR; et al. (1999). "Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)". Neurology. 53 (1): 126–31. PMID 10408548.
  33. ↑ Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC, Broderick JP; et al. (2000). "Predicting prognosis after stroke: a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial". Neurology. 55 (7): 952–9. PMID 11061250.
  34. ↑ Muir KW, Weir CJ, Murray GD, Povey C, Lees KR (1996). "Comparison of neurological scales and scoring systems for acute stroke prognosis". Stroke. 27 (10): 1817–20. PMID 8841337.
  35. ↑ Huttner HB, Schwab S (2009). "Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives". Lancet Neurol. 8 (10): 949–58. doi:10.1016/S1474-4422(09)70224-8. PMID 19747656.
  36. ↑ Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R (1996). "'Malignant' middle cerebral artery territory infarction: clinical course and prognostic signs". Arch Neurol. 53 (4): 309–15. PMID 8929152.
  37. ↑ Treadwell SD, Thanvi B (2010). "Malignant middle cerebral artery (MCA) infarction: pathophysiology, diagnosis and management". Postgrad Med J. 86 (1014): 235–42. doi:10.1136/pgmj.2009.094292. PMID 20354047.
  38. ↑ Di Carlo A, Lamassa M, Baldereschi M, Pracucci G, Consoli D, Wolfe CD; et al. (2006). "Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project". J Neurol Sci. 244 (1–2): 143–50. doi:10.1016/j.jns.2006.01.016. PMID 16530226.
  39. ↑ Schiemanck SK, Kwakkel G, Post MW, Kappelle LJ, Prevo AJ (2008). "Impact of internal capsule lesions on outcome of motor hand function at one year post-stroke". J Rehabil Med. 40 (2): 96–101. doi:10.2340/16501977-0130. PMID 18509572.
  40. ↑ Abboud H, Berroir S, Labreuche J, Orjuela K, Amarenco P, GENIC Investigators (2006). "Insular involvement in brain infarction increases risk for cardiac arrhythmia and death". Ann Neurol. 59 (4): 691–9. doi:10.1002/ana.20806. PMID 16566012.
  41. ↑ Colivicchi F, Bassi A, Santini M, Caltagirone C (2005). "Prognostic implications of right-sided insular damage, cardiac autonomic derangement, and arrhythmias after acute ischemic stroke". Stroke. 36 (8): 1710–5. doi:10.1161/01.STR.0000173400.19346.bd. PMID 16020766.
  42. ↑ Bruno A, Biller J, Adams HP, Clarke WR, Woolson RF, Williams LS; et al. (1999). "Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators". Neurology. 52 (2): 280–4. PMID 9932944.
  43. ↑ Baird TA, Parsons MW, Phan T, Phanh T, Butcher KS, Desmond PM; et al. (2003). "Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome". Stroke. 34 (9): 2208–14. doi:10.1161/01.STR.0000085087.41330.FF. PMID 12893952.
  44. ↑ 44.0 44.1 44.2 Saposnik G, Kapral MK, Liu Y, Hall R, O'Donnell M, Raptis S; et al. (2011). "IScore: a risk score to predict death early after hospitalization for an acute ischemic stroke". Circulation. 123 (7): 739–49. doi:10.1161/CIRCULATIONAHA.110.983353. PMID 21300951.
  45. ↑ Kimberly WT, Lima FO, O'Connor S, Furie KL (2013). "Sex differences and hemoglobin levels in relation to stroke outcomes". Neurology. 80 (8): 719–24. doi:10.1212/WNL.0b013e31828250ff. PMC 3589294. PMID 23365064.
  46. ↑ Barlas RS, Honney K, Loke YK, McCall SJ, Bettencourt-Silva JH, Clark AB; et al. (2016). "Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke: Analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis". J Am Heart Assoc. 5 (8). doi:10.1161/JAHA.115.003019. PMC 5015269. PMID 27534421.
  47. ↑ 47.0 47.1 Andersen KK, Andersen ZJ, Olsen TS (2011). "Predictors of early and late case-fatality in a nationwide Danish study of 26,818 patients with first-ever ischemic stroke". Stroke. 42 (10): 2806–12. doi:10.1161/STROKEAHA.111.619049. PMID 21817152.
  48. ↑ McGrath ER, Kapral MK, Fang J, Eikelboom JW, Conghaile Aó, O'Conghaile A; et al. (2013). "Association of atrial fibrillation with mortality and disability after ischemic stroke". Neurology. 81 (9): 825–32. doi:10.1212/WNL.0b013e3182a2cc15. PMID 23902702.
  49. ↑ Iseki K, Fukiyama K, Okawa Dialysis Study (OKIDS) Group (2000). "Clinical demographics and long-term prognosis after stroke in patients on chronic haemodialysis. The Okinawa Dialysis Study (OKIDS) Group". Nephrol Dial Transplant. 15 (11): 1808–13. PMID 11071969.
  50. ↑ Wijdicks EF, Diringer MN (1998). "Middle cerebral artery territory infarction and early brain swelling: progression and effect of age on outcome". Mayo Clin Proc. 73 (9): 829–36. doi:10.4065/73.9.829. PMID 9737218.
  51. ↑ FOOD Trial Collaboration (2003). "Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial". Stroke. 34 (6): 1450–6. doi:10.1161/01.STR.0000074037.49197.8C. PMID 12750536.


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