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VisualWikitext

Latest revision as of 04:08, 24 September 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parul Pahal, M.B.B.S [2], Moises Romo M.D. Fahimeh Shojaei, M.D.

Synonyms and keywords: COVID-19, SARS-CoV-2, stroke, CT scan, cerebrovascular disease, TPA, alteplase

Overview

Cerebral hemorrhage or cerebral ischemia disrupts cerebral perfusion and can lead to an acute neurologic condition, called stroke. Cerebrovascular complications have been reported in severe Coronavirus Disease 2019 (COVID-19). However, neurological complications are not very common in rapidly spreading COVID-19 which is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The presenting complaints in majority of stroke patients reported in different studies were respiratory complaints (shortness of breath, cough) and non-specific constitutional symptoms such as fever, malaise, etc., and stroke developed later in the course of the disease. This is thought to be due to COVID-19-associated coagulopathy. However, there are few case reports and studies that have mentioned specific neurological presenting complaints such as altered mental status, limb weakness, and aphasia. Various non-pulmonary features are being reported as the COVID-19 understanding is unfolding with the spike of cases and continuously rising number of cases globally.

To view general COVID-19 section, click here.

Historical Perspective

Stroke was first recognized by Hippocrates, in the fourth century BC, almost 2,400 years ago, and it was reffered to as Apoplexy, a Greek medical literature term, which means 'struk down by violence'. Later, renaissance anatomists, in mid-16th century A.D., explained the pathophysiology of stroke, differentiating the causes as bleeding or blockage of A cerebral artery.^[1]
Mao et al., in his study, first reported neurological symptoms in COVID-19 patients hospitalized in Wuhan, China from January 16, 2020, to February 19, 2020. Neurological symptoms were reported in 78 patients out of 214 COVID-19 positive hospitalized patients with COVID-19 in Wuhan, China. The stroke patients reported specifically were 14^[2]. In this study, patients with cardiovascular risk factors who presented with severe systemic symptoms were at higher risk of stroke.
Yaghi et al. retrospectively examined stroke patients admitted across different locations of NYU Langone hospital in New York. In this study, the incidence of 0.9% was observed in laboratory confirmed COVID-19 positive patients included in this study. Stroke diagnosis was proved by imaging, and cryptogenic stroke was seen in most of these patients. The mortality was much higher in stroke patients who were COVID-19 positive.^[3]

To view historical perspective of COVID-19 section, click here.

Classification

There is no specific classification established for 'Stroke in COVID-19 patients'.
It is same as the general classification of stroke.^[1]

Stroke can be classified into
- Ischemic stroke: This can be due to
  - Thrombosis (Large vessel or Small vessel thrombosis)
  - Embolism
  - Systemic hypoperfusion
  - Cryptogenic (unknown origin)
- Hemorrhagic stroke: This can be due to

To view classification of COVID-19 section, click here.

Pathophysiology

The exact pathophysiology of stroke in COVID-19 is not fully understood.
However, it is thought that stroke in COVID-19 could be due to one of the following pathophysiologies
- Sepsis induced coagulopathy:
  - Sepsis induced coagulopathy in COVID-19 patients is thought to be contributing to microthromobosis.
  - This is supported by elevation of D-dimer and C-reactive protein, which are hypercoagulability and inflammatory markers, in COVID-19 positive patients.
- The angiotensin-converting enzyme II:
  - (ACEII) receptors are also present on the vascular endothelial cells and neural cells in the brain .
  - These receptors expressed in the brain are responsible for sympathoadrenal system regulation, and vascular autoregulation^[4].
  - When the virus binds to these receptors, this vascular autoregulation is hampered and can lead to elevated blood pressure, eventually leading to rupture of the cerebral vessels and intracranial hemorrhage^[5].
  - It does so by altering the balance of renin-angiotensin system which likely triggers endothelium dysfunction, organ damage, which eventually results in stroke^[6].
- Viral neurotropism and neuroinvasion
  - Viral Neurotropism and Neuroinvasion is another possible pathogenic mechanism for cerebrovascular accidents in COVID-19 patients.
  - The coronaviruses usually cause mild respiratory illness, but the beta coronavirues are known to have a role in nervous system involvement^[7].
  - The Novel coronavirus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)” is a beta coronavirus, similar to severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)^[8].
  - It,therefore, has an infection mechanism and potential to invade the nervous system, similar to SARS-Cov and MERS-Cov^[9]. The detection of the virus in the cells of the brain on autopsy^[10] (neural and capillary endothelial cells), and viral presence in the cerebrospinal fluid of the encephalitis patient infected with SARS-Cov-2^[11] supports the neuro-invasiveness of the virus.
  - The two possible routes are retrograde axonal transport (via nasal cavity) or hematogenous spread (via blood brain barrier endothelial cells)^[10]. Once the virus reaches the brain, it attaches to the ACE II receptors.
- Direct entry into brain tissues:
  - Direct entry into brain tissues from cribriform plate to brain^[12]. This is one of the proposed mechanism as COVID-19 positive patients also presented with anosmia and hyposmia which possibly occurs due to viral effect on olfactory bulb, which is in close proximity to cribriform plate^[2]

Further investigations should be done to better understand the mechanism of Stroke in patients with COVID-19.

To view pathophysiology COVID-19 section, click here.

Causes

Coronavirus disease 2019 (COVID-19) associated stroke is caused by SARS-CoV-2.
To view causes of COVID-19 section, click here.

Differentiating COVID-19-associated stroke from other Diseases

For further information about the differential diagnosis, click here.
To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

The case fatality rate of cerebrovascular accidents is 41.7 deaths per 100, 000 population^[13]. The mortality in patients with COVID-19 associated stroke is higher.^[3]

The incidence of stroke in COVID-19 varies significantly depending on the study population.^[14] The prevalence of COVID-19-associated stroke varies in different studies.

Prevalence of stroke in patients with COVID-19
Date of publication	Country	Author	Number of patients	Severe infection	Neurological symptoms	Acute Cerebrovascular disease	Ischemic/Hemorrhagic Stroke
April 10, 2020	Wuhan, China	Mao et al.^[2]	214	88 patients (41.1%), Mean age-58.2 years	78 patients (36.4%)	5 among severe [5.7%] infection group vs 1 [0.8%]) in non-severe group	Ischemic-4, Hemorrhagic-1
May 29, 2020	Wuhan, China	Qin et al.^[15] (Retrospective cohort study)	1875	461 severe on admission		50 patients ie. 15 among severe and 35 among mild on admission (Median age-70 years), 30 males and 20 females	Ischemic-90%, Hemorrhagic-10%
May 20, 2020	New York	Yaghi et al.^[3] (Retrospective cohort study)	3556		Stroke at the time of admission-14/32 (43.8%), eventually developed stroke during hospitalization-18 (56.2%)	32 patients (0.9%)	Ischemic stroke- 32
April 28, 2020	New York city	Oxley et al.^[16]	5				Large vessel stroke-5, Mean age-<50 years
July 12, 2020	New York	Valderrama et al.	1 (52-year old male)				Ischemic stroke
Prevalence of COVID-19-associated stroke varies in different studies

The incidence of stroke in hospitalized COVID-19 patients is reported to be 0.9–2%^[17].majority of them being ischemic subtype. The mortality in COVID-19 positive stroke patients is reported to be 39%^[2].

The ischemic stroke prevalence in COVID-19 patients is 1.6%.^[17]

A New York study published in May reported that the proportion of these strokes seem to be higher in younger men.^[3] Most of these strokes are large vessel ischemic strokes and are catastrophic.

In a retrospective observational case series of six stroke patients in a hospital in Italy, with lab confirmed COVID-19, the median age reported was 69 years. Ischemic stroke subtype was seen in 4 patients(67%) as compared to hemorrhagic which was only seen in 2 patients (33%). Vascular risk factors were seen in 5/6 patients, which included diabetes mellitus, arterial hypertension

In a single center retrospective study conducted in Wuhan by Qin C. et al. which included 1875 laboratory-confirmed COVID-19 patients from january 27th, 2020, to March 5th, 2020, 50 patients had history of stroke. The median age of this study group was 63 years, with stroke patients relatively older(70 years) when compared to non-stroke patients (62 years).^[15]

Stroke is one of the neurological manifestations in patients with severe infection. There is limited information on COVID-19 patients with stroke who survived.

To view epidemiology and demographics of COVID-19 section, click here.

Risk Factors

According to one of the study conducted in New York, Stroke in COVID-19 infected patients is seen in relatively young patients as compared to with non COVID-19 patients.^[3]

A study by Mao et. al. reported COVID-19 associated stroke in seen in critically patients. The patients who developed stroke were older population with comorbidities like diabetes, hypertension, etc.

However, due to disparities in the stroke prevalence in different studies, no clear association has been established.

To view risk factors of COVID-19 section, click here.

Screening

There is insufficient evidence to recommend routine screening for stroke in COVID-19 patients. However, if the patient presents with stroke, COVID-19 screening should be done.

To view screening of COVID-19 section, click here.

Natural History, Complications, and Prognosis

Prognosis is generally poor for COVID-19 patients with stroke. A study reported a high proportion of these patients were admitted to the Intensive Care Unit(ICU) and required mechanical ventilation. The mortality of COVID-19 patients with stroke was much higher when compared to COVID-19 patients with no history of stroke^[15].

To view natural history, complications and prognosis of COVID-19 section, click here.

Diagnosis

Diagnosis of stroke associated to COVID-19 is based on history of symptoms development, physical examination, imaging findings, plus a positive COVID-19 test.
There are no standard criteria for the evaluation of stroke associated to COVID-19.
General management protocols for COVID-19-associated stroke should be established so that brain imaging can be realized as prompt as possible in patients who may be candidates for IV fibrinolysis or mechanical thrombectomy or both.^[18]
The current diagnostic approach for stroke associated to COVID-19 is the same as for people with non-COVID infection.

Diagnostic Study of Choice

Non-contrast CT Scan of the brain within 20 minutes of arrival to the emergency department is the diagnostic test of choice for stroke in patients with COVID-19 infection.^[19]
MRI may detect smaller lesions with certainty if required, once the hemorrhagic stroke is excluded by non-contrast CT Scan.^[20]
In a patient who presents with neurological symptoms, RT-PCR for SARS-CoV-2 should be done as well.

History and Symptoms

The extent of damage and symptoms which may result from stroke associated to COVID-19 highly depends on the site of infarction, the blood vessels involved, and the presence of other risk factors.^[21]^[22]^[23]

The majority of patients with COVID-19-associated stroke initially presented with respiratory symptoms (e.g. cough, shortness of breath etc) and constitutional features. These patients developed cerebrovascular signs and symptoms later in the course of disease.
The following table summarizes the signs and symptoms found in 5 patients with COVID-19 infection that later acquiered a stroke:^[24]^[25]

Patient no.	Onset of neurologic symptoms	Age and Gender	Neurologic Signs & Symptoms
1	On Admission	73-year old, Male	Respiratory distress, fever, and altered mental status ^[24]
2	On Admission	83-year old, Female	Fever, slurring of speech, facial droop, and reduced oral intake ^[24]
3	On Admission	80-year old female	Left sided weakness, altered mental status, one week history of frequent falls ^[24]
4	On Admission	88-year old, Female	An 15 minute episode of weakness and numbness of right arm and word finding difficulty ^[24]
5	On Admission	58-year old, Male	Dense Right-sided weakness and acute onset aphasia ^[25]
Reported cases of patients with COVID-19 infection and symptoms suggestive of stroke.

Most common symptoms

Less common symptoms

Aphasia
Motor impairmant
Sensory impairmant
Slurred speech
Facial droop
Frequent falls
Reduced oral intake

Physical Examination

The physical examination findings in stroke associated to COVID-19 will highly depend on the site of infarction, the blood vessels involved, and the presence of other risk factors.^[21]^[22]^[23]

**Physical examination of patients with stroke depending on vessel involved**
Vessel involved	Physical examination
Anterior cerebral artery ^[26]^[27]	Decreased motor strength- contralateral lower limb^[26] Absent or decreased sensations-contralateral lower limb^[26] Increased reflexes-contralateral lower limb Babinski's reflex positive Constructional and dressing apraxia-hemineglect ^[27]^[28] Transcortical motor aphasia(non fluent)^[27]^[28] Mutism Contralateral grasp and sucking reflex Memory impairment^[29] Confabulation^[30]
Middle cerebral artery^[31] Most common site of infarction	Decreased motor strength-contralateral arm and face ^[32]^[33]^[34] Absent or decreased sensations-contralateral left arm and face^[26] Increased deep tendon reflexes - contralateral arm Babinski's sign positive Contralateral Hemineglect Broca's aphasia^[35]^[36]^[37] Wernicke's aphasia^[37] Contralateral visual field defect
Posterior cerebral artery^[38]^[39]^[40]^[41]^[40]^[42]	Contralateral visual field defects^[38]^[41]^[43] Complex hallucinations Prosopagnosia^[44] Unable to remember names-Nominal aphasia Acalculia and agraphia -Gerstmann syndrome Memory deficit Hemisensory loss^[45] Contralateral hemiparesis^[45] Thalamic pain syndrome ^[39] Hemiballismus Occulomotor nerve palsy Intention tremors Alexia without agraphia^[42]
Vertebrobasilar artery^[46]	Midbrain Weber syndrome^[47] Contralateral decreased motor strength Deviation of eye downwards and outwards-ipsilateral 3rd nerve palsy
	Medulla Lateral medullary syndrome^[46]^[48]^[49] Impaired gag reflex Uvula deviated to the opposite side of lesion Ptosis Miosis Enophthalmos Ipsilateral impaired pain, touch and temperature sensation on the upper half of the face Contralateral decreased motor strength and sensory loss Romberg's sign Medial medullary syndrome^[46]^[50]^[51] Deviation of the tongue to the side of the lesion-hypoglossal nerve Contralateral decreased motor strength Contralateral loss of position sense, vibration and two point discrimination
	Pons Inability to close eyes Deviation of angle of mouth Facial muscle weakness-Facial nerve Loss of taste and sensation on the anterior two thirds of the tongue Affected eye deviation inwardsand down-Abducent nerve Locked-in syndrome^[52]^[53]
	Cerebellum Vertigo Romberg's sign positive Intension tremors Dysdiadochokinesia Dysarthria

The use of stroke scales helps to measure the degree of neurological impairment, ease communication, may help select patients candidates for fibrinolytic or mechanical therapy, permits the evaluation of changing clinical status, and identifies those patients at higher risk for complications (eg. intracerebral hemorrhage).^[54]
The National Institutes of Health Stroke Scale (NIHSS) is a tool used to measure the neurologic impairment caused by a stroke in a quantitative manner.^[55]^[56] The NIHSS is composed of 11 items, each of which scores a specific ability between a 0 and 4. For each item, a score of 0 typically indicates normal function in that specific ability, while a higher score is indicative of some level of impairment. The individual scores from each item are summed in order to calculate a patient's total NIHSS score. The maximum possible score is 42, with the minimum score being a 0.^[56]

National Institutes of Health Stroke Scale (NIHSS)
Tested item	Title	Response and score
1A	Level of consciousness	0—Alert
		1—Drowsy
		2—Obtunded
		3—Coma/unresponsive
1B	Orientation questions (2)	0—Answers both correctly
		1—Answers 1 correctly
		2—Answers neither correctly
2	Gaze	0—Normal horizontal movements
		1—Partial gaze palsy
		2—Complete gaze palsy
3	Visual fields	0—No visual field defect
		1—Partial hemianopia
		2—Complete hemianopia
		3—Bilateral hemianopia
4	Facial movement	0—Normal
		1—Minor facial weakness
		2—Partial facial weakness
		3—Complete unilateral palsy
5	Motor function (arm) a. Left b. Right	0—No drift
		1—Drift before 10 s
		2—Falls before 10 s
		3—No effort against gravity
		4—No movement
6	Motor function (leg) a. Left b. Right	0—No drift
		1—Drift before 5 s
		2—Falls before 5 s
		3—No effort against gravity
		4—No movement
7	Limb ataxia	0—No ataxia
		1—Ataxia in 1 limb
		2—Ataxia in 2 limbs
8	Sensory	0—No sensory loss
		1—Mild sensory loss
		2—Severe sensory loss
9	Language	0—Norma
		1—Mild aphasia
		2—Severe aphasia
		3—Mute or global aphasia
10	Articulation of words	0—Norma
		1—Mild dysarthria
		2—Severe dysarthria
11	Extinction or inattention	0—Absent
		1—Mild loss (1 sensory modality lost)
		2—Severe loss (2 modalities lost)
Adapted from Lyden et al., 1994^[57] American Heart Association, Inc.

The pre-stroke Modified Rankin Score (mRS) is an estimated score used to assess the patient’s pre-stroke level of function. An estimated mRS should be abstracted from current medical record documentation about the patient’s ability to perform activities of daily living prior to the hospitalization for the acute ischemic stroke event.^[58]

Alberta stroke program early CT score (ASPECTS)
Area affected		Score
Subganglionic Nuclei:	M1 - Frontal operculum	1
	M2 - Anterior temporal lobe	1
	M3 - Posterior temporal lobe	1
Supraganglionic Nuclei:	M4 - Anterior MCA	1
	M5 - Lateral MCA	1
	M6 - Posterior MCA	1
Basal Ganglia:	C - Caudate	1
	L - Lentiform Nucleus	1
	I - Insula	1
	IC - Internal Capsule	1
Adapted from The University of Calgary ASPECT score in Accute stroke, 2020^[59]

Alberta stroke program early CT score (ASPECTS) is a 10 point quantitative score used to asses early ischemic changes in patients suspected of having acute large vessel anterior circulation occlusion.^[59]

*Pre-Stroke Modified Rankin Score (mRS)*
Score	Item tested
0	The patient had no residual symptoms.
1	The patient had no significant disability; able to carry out all activities.
2	The patient had slight disability; unable to carry out all activities but able to look after self without daily help.
3	The patient had moderate disability; requiring some external help but able to walk without the assistance of another individual.
4	The patient had moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual.
5	The patient had severe disability; bedridden, incontinent, requires continuous care.
6	Unable to determine (UTD) from the medical record documentation.
Adapted from Specifications Manual for Joint Commission National Quality Measures, 2018^[58]

Laboratory Findings

Patients with stroke associated to COVID-19 will have a positive test for COVID-19 confirmed either through molecular tests, nucleic acid amplification test, or serological testing.

Serum glucose assessment is the only lab study that should proceed IV alteplase initiation, this should be over 50 mg/dL for its administration.^[18]
Coagulation studies and complete blood count should be delayed until after IV alteplase initiation unless there is suspicion for a coagulopathy disorder.^[18]
Troponin should be assessed in patients presenting with ischemic stroke.^[18]
In patirents 20 years or older and not on lipid-lowering therapy, baseline measurement of plasma lipid profile is effective in estimating atherosclerotic cardiovascular disease (ASCVD); after that, plasma lipid profile should be measured every 4 to 12 weeks after statin initiation.^[18]

Ultrasound

Echocardiography may be necessary in patients with ischemic stroke to identify and prevent secondary causes of stroke such as structural changes, atrial fibrillation, valvular heart disease and atherosclerosis.^[60]^[61]^[62]^[63]
Carotid ultrasound should be performed in all patients with ischemic stroke to assess for narrowing of carotids and decrease recurrence of thromboembolic events.^[64]

X-ray

Head x-rays can help rule out foreign metal objects in the head before performing an MRI,^[65] detect skull fractures, and identify intracranial calcifications that may serve as hallmarks for brain structural changes in countries with poor access to more specific imaging tests.
There is no evidence of usefulness of chest x-ray in the acute setting of stroke.^[18]

CT scan

Non-contrasted CT scan of the head should should always be performed before initiating IV alteplase.^[18]
Once hemorragic stroke is excluded, CT scan with contrast should be realized in patients with no history of renal disease without measuring creatinine concentration, taking into account that both COVID-19 infection and stroke increase the risk for renal impairment per se.^[66]^[67]
CT angiography of the brain may be needed in patients to make a decision for mechanical thrombectomy.^[66]^[68]^[69]
CT angiography's contrast can increase the risk of acute kidney injury in patients with COVID-19 infection.^[66]
CT perfusion should be done in patients who present within 24 hours of the initiation of symptoms.^[66]
Concurrent CT scan of the head and chest may be ordered at the same time in patients with COVID-19 infection.^[66]^[70]
CT angiography of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation,is recommended in patients who are potential candidates for mechanical thrombectomy.^[18]^[71]

MRI

MRI of the head before IV alteplase administration to exclude microbleeds is not recommended.^[18]
Multimodal MRI of the head should be done in patients who present within 24 hours of the initiation of symptoms.^[66]
In patients who wake up with clinical symptoms of stroke of unknown onset (more than 3 hours?), an MRI with diffusion-positive FLAIR may be useful for selecting those who can benefit from IV alteplase administration.^[18]

Electrocardiogram

Baseline electrocardiographic assessment is recommended in patients with stroke to help determine the follingow:^[18]^[72]^[73]
- Underlying cause for ischemic stroke such as embolic source in atrial fibrillation, ongoing myocardial ischemia, chronic myocardial injury and valvular abnormalities.
- ECG monitoring in first 24 hours may help determine the new onset or paroxysmal atrial fibrillation.
- May determine cardiac complications of acute ischemic stroke such as myocardial ischemia or arrythmias.

To view diagnosis of COVID-19 section, click here.

Treatment

Early assesment

The initial assesment goals of ischemic stroke may include the following:^[74]

1) Airway

2) Breathing

3) Circulation

1) O2 administration at SpO2<94%

2) Ventilatory assisstance is provided to patients who have difficulty breathting

3) IV fluids or vasopressors are given to maintain hemodynamic stability

Early Diagnosis

History and PE

1) Help assess the severity of neurological deficit
2) Give clue to the underlying cause

3) Determine the site of infarction

Initial diagnostic tests

1) Noncontrast brain CT or brain MRI
2) Blood glucose
3) Oxygen saturation
4) Serum electrolytes/renal function tests
5) Complete blood count, including platelet count
6) Markers of cardiac ischemia
7) Prothrombin time/INR
8) Activated partial thromboplastin time

9) ECG

Early assessment of ischemic stroke

Reperfusion therapy

Medical
r-tPA in eligible patients within 3-4.5 hours of onset of symptoms

Surgical

Symptomatic relief

1) Fever
2) Headache
3) Shortness of breath

Prognosis

1)NIHSS scoring
2)Glassgow coma scale

Medical therapy

The reported cases of treatment for COVID-19-associated stroke have followed the same guidelines as patients with no COVID-19 infection. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
IV alteplase is always preferred over mechanical thrombectomy when there are no contraindications.^[75]
The usefulness of anticoagulants such as thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) is not well established in the acute setting of stroke.^[76]
The use of thrombolysis via ultrasound waves concomitant to IV fibrinolysis is not recommended.^[77]
High-intensity statin therapy should be initiated in patients younger than 75 with clinical ASCVD, to achieving a reduction in LDL-C levels of at least 50%.
In patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate or high-intensity statin therapy after reviewing adverse effects and drug interactions.^[18]^[78]
Risk and beneffits should be discussed before initiation of statin therapy to weight ASCVD risk reduction against the potential for statin-associated side effects.^[18]
Continuation of statin therapy during the acute period of ischemic stroke is reasonable among patients already taking statins.

**Summarized management of ischemic stroke**
Medical treatment	Drug class	Recommendations
Medical treatment	Drug class	Acute	Long-Term
Reperfusion therapy	Tissue plasminogen activator (t-PA)	Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines^[79]^[80]^[81] and systematic reviews^[82]^[83]^[84]	None
Antithrombotic agents	Antiplatelet agents	Oral administration of aspirin (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients^[79] Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration^[79] DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease	Long term therapy with clopidogrel or aspirin extended release dipyridamole may be used for secondary prevention of non cardioembolic stroke
Antithrombotic agents	Anticoagulants	Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke^[85]	Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease^[86]
Antilipid therapy	Statins	Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable^[79]	Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
Antihypertensive therapy	Intravenous antihypertensives (Labetolol, nitroprusside)	Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA^[79]	Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihypertensive therapy	Oral antihypertensive therapy	Recommended after 24 hours in patient having hypertension	Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihyperglycemic agents	Insulin	May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke^[79]	Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with diabetes mellitus

Alteplase

IV alteplase is recommended for selected patients who can be treated within 3-4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state.^[87]^[18]^[88]
The dose of IV alteplase is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min.^[18]
IV alteplase should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.^[18]
Hyperglycemia should be treated during the first 24 hours after ischemic stroke, to achieve values of 140 to 180 mg/dL.^[18]
IV alteplase may cause bleeding and angioedema.^[18]
Glycoprotein IIb/IIIa inhibitors (tirofiban, apiximab, eptifibatide) should not be coadministered with IV alteplase.^[18]^[89]
IV alteplase may be used in patients under warfarin if the INR is lower than 1.7.^[18]
IV alteplase should not be administered to patients who have received a full dose of low-molecular-weight heparin within the previous 24 hours (including prophylactic doses).^[18]^[90]
Blood pressure should be sustained lower than 180/105 mmHg the first 24 hours after IV alteplase administration. Intensive lowering has been shown to be safe.^[18]^[91]
In case of intracranial bleeding due to alteplase administration, alteplase should be suspended, blood draws should be taken (CBC, coagulation studies), tranexamic acid should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested CT scan of the head taken.^[92]
The use of IV alteplase should be used cautiously in patients who undergone a major surgery in the past 2 weeks.^[18]
IV alteplase for ischemic stroke is contraindicated in patients with a severe head trauma or subarachnoid hemorrage in the preceding 3 months.^[18]

Tenecteplase

Tenecteplase may be useful in patients with minor neurological impairment.^[93]
The dose of tenecteplase is a single IV bolus of 0.25-mg/kg (maximum 25 mg).^[94]

Antiplatelet therapy

Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later.^[95]
The dose of aspirin is usually between 160-300mg daily.^[96]
IV aspirin administration within 90 minutes after the start of IV alteplase is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.^[18]^[97]
Dual antiplatelet therapy with aspirin and clopidogrel (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after symptom onset and continued for 21 days in patients with no cardioembolic ischemic stroke.^[98]
Aspirin should not substitute IV alteplase or mechanical thrombectomy in patients eligible for these therapies.^[18]

Surgery

The usefulness of emergency carotid endarterectomy, carotid angioplasty and stenting in the absence of an intracranial clot is not well established.^[18]

Mechanical thrombectomy with a stent retriever

Mechanical thrombectomy with stent retrievers is recommended over intra arterial fibrinolysis as first-line therapy.^[18]
Mechanical thrombectomy may be useful in selected patients with up to 24 hours of initiation of stroke.^[18]^[99]
In patients who undergo mechanical thrombectomy,blood pressure should be maintained below 180/105 mmHg during and for 24 hours after the procedure.^[18]

Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria:^[100]
1. Prestroke mRS score of 0 to 1
2. Causative occlusion of the internal carotid artery or MCA segment 1 (M1)
3. Age ≥18 years
4. NIHSS score of ≥6
5. ASPECTS of ≥6; and
6. Treatment can be initiated within 6 hours of symptom onset

Aspiration thrombectomy

Aspiration thrombectomy has not been shown to be inferior to stent retriever.^[101]

Direct aspiration thrombectomy as first-pass mechanical thrombectomy is recommended as noninferior to stent retriever for patients who meet all the following criteria:^[101]
1. Prestroke mRS score of 0 to 1;
2. Causative occlusion of the internal carotid artery or M1;
3. Age ≥18 years;
4. NIHSS score of ≥6;
5. ASPECTS ≥6; and
6. Treatment initiation within 6 hours of symptom onset.

Intra arterial fibrinolysis

Intra-arterial fibrinolysis may be initiated within 6 hours of stroke onset in selected patients in whom IV alteplase is contraindicated.

Other aspects of management

Volume expansors are not recommended in ischemic stroke.^[18]^[102]
The best head positioning after stroke is not well established.^[18]^[103]

Supplemental oxygen and mechanical ventilation support should be provided when necessary to maintain oxygen saturation higher than 93%.^[18]^[104]

Sources of hyperthermia (>38°C) should be identified and treated with antipyretics in patients with stroke.^[18]^[105]
Hypoglycemia (<60 mg/dL) should be treated in the acute setting in patients with ischemic stroke.^[18]
Blood pressure ≥220/120 in patients who did not receive TPA should be treated within the first 48 to 72 hours after the onset of ischemic stroke.^[106]
Enteral feeding should be started within 7 days of admission after an acute stroke when there is no contraindications.^[107]
Psychological screening is always recommended to exclude poststroke depression.^[108]
Early rehabilitation in patients with stroke is adviced.^[18]

Primary Prevention

There is currently no vaccine to prevent COVID-19. The best way to prevent infection is to avoid being exposed to this virus.
COVID-19 increases the probability of developing ischemic stroke, but there are several measures that can decrease the risk of stroke, among them:
Smoking cessation
Lowering blood pressure
Decreasing alcohol intake
Exercise
Treatment of atrial fibrillation
Weight loss
Procedures such as carotid endarterectomy or carotid angioplasty when necessary

Secondary Prevention

Smoking cessation should be highly encouraged in patients who suffered from stroke, behavioral interventions and nicotine replacement may be necessary.

To view treatment of COVID-19 section, click here.

References

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[AlbersMarks2018-99] Albers, Gregory W.; Marks, Michael P.; Kemp, Stephanie; Christensen, Soren; Tsai, Jenny P.; Ortega-Gutierrez, Santiago; McTaggart, Ryan A.; Torbey, Michel T.; Kim-Tenser, May; Leslie-Mazwi, Thabele; Sarraj, Amrou; Kasner, Scott E.; Ansari, Sameer A.; Yeatts, Sharon D.; Hamilton, Scott; Mlynash, Michael; Heit, Jeremy J.; Zaharchuk, Greg; Kim, Sun; Carrozzella, Janice; Palesch, Yuko Y.; Demchuk, Andrew M.; Bammer, Roland; Lavori, Philip W.; Broderick, Joseph P.; Lansberg, Maarten G. (2018). "Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging". New England Journal of Medicine. 378 (8): 708–718. doi:10.1056/NEJMoa1713973. ISSN 0028-4793.

[GoyalMenon2016-100] Goyal, Mayank; Menon, Bijoy K; van Zwam, Wim H; Dippel, Diederik W J; Mitchell, Peter J; Demchuk, Andrew M; Dávalos, Antoni; Majoie, Charles B L M; van der Lugt, Aad; de Miquel, Maria A; Donnan, Geoffrey A; Roos, Yvo B W E M; Bonafe, Alain; Jahan, Reza; Diener, Hans-Christoph; van den Berg, Lucie A; Levy, Elad I; Berkhemer, Olvert A; Pereira, Vitor M; Rempel, Jeremy; Millán, Mònica; Davis, Stephen M; Roy, Daniel; Thornton, John; Román, Luis San; Ribó, Marc; Beumer, Debbie; Stouch, Bruce; Brown, Scott; Campbell, Bruce C V; van Oostenbrugge, Robert J; Saver, Jeffrey L; Hill, Michael D; Jovin, Tudor G (2016). "Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials". The Lancet. 387 (10029): 1723–1731. doi:10.1016/S0140-6736(16)00163-X. ISSN 0140-6736.

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@@ Line 2: / Line 2: @@
 {{SI}}
-{{CMG}}; {{AE}}
+{{CMG}}; {{AE}} {{Parul}}, [[User:MoisesRomo|Moises Romo M.D.]] {{Fs}}
-{{SK}}
+{{SK}} [[COVID-19]], [[SARS-CoV-2]], [[stroke]], [[CT scan]], [[cerebrovascular disease]], [[Tissue plasminogen activator|TPA]], [[alteplase]]
+<br />
 ==Overview==
+[[Cerebral hemorrhage]] or [[cerebral ischemia]] disrupts cerebral perfusion and can lead to an acute [[Neurological|neurologic]] condition, called [[stroke]]. [[Cerebrovascular]] complications have been reported in severe Coronavirus Disease 2019 ([[COVID-19]]). However, neurological complications are not very common in rapidly spreading [[COVID-19]] which is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus-2 ([[SARS-CoV-2]]). The presenting complaints in majority of [[stroke]] [[patients]] reported in different studies were respiratory complaints ([[shortness of breath]], [[cough]]) and non-specific constitutional [[Symptom|symptoms]] such as [[fever]], [[malaise]], etc., and [[stroke]] developed later in the course of the [[disease]]. This is thought to be due to [[COVID-19-associated coagulopathy]]. However, there are few case reports and studies that have mentioned specific neurological presenting complaints such as [[altered mental status]], [[limb]] [[weakness]], and [[aphasia]]. Various non-pulmonary features are being reported as the [[COVID-19]] understanding is unfolding with the spike of cases and continuously rising number of cases globally.
+To view general COVID-19 section, click [[COVID-19|here]].
 ==Historical Perspective==
-[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
-The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
+*Stroke was first recognized by Hippocrates, in the fourth century BC, almost 2,400 years ago, and it was reffered to as [[Apoplexy]], a Greek medical literature term, which means 'struk down by violence'. Later, renaissance anatomists, in mid-16th century A.D., explained the pathophysiology of stroke, differentiating the causes as bleeding or blockage of A cerebral artery.<ref name="Theofanidis20152">{{cite journal|last1=Theofanidis|first1=Dimitrios|title=From Apoplexy to Brain Attack, a Historical Perspective on Stroke to Date|journal=Journal of Nursing & Care|volume=04|issue=01|year=2015|issn=21671168|doi=10.4172/2167-1168.1000e121}}</ref>
+*Mao et al., in his study, first reported [[Neurological disorders|neurological symptoms]] in [[COVID-19]] patients hospitalized in Wuhan, China from January 16, 2020, to February 19, 2020. [[Neurological]] symptoms were reported in 78 patients out of 214 [[COVID-19]] positive hospitalized patients with [[COVID-19]] in Wuhan, China. The stroke patients reported specifically were 14<ref name="MaoJin20202">{{cite journal|last1=Mao|first1=Ling|last2=Jin|first2=Huijuan|last3=Wang|first3=Mengdie|last4=Hu|first4=Yu|last5=Chen|first5=Shengcai|last6=He|first6=Quanwei|last7=Chang|first7=Jiang|last8=Hong|first8=Candong|last9=Zhou|first9=Yifan|last10=Wang|first10=David|last11=Miao|first11=Xiaoping|last12=Li|first12=Yanan|last13=Hu|first13=Bo|title=Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China|journal=JAMA Neurology|volume=77|issue=6|year=2020|pages=683|issn=2168-6149|doi=10.1001/jamaneurol.2020.1127}}</ref>. In this study, patients with [[cardiovascular]] [[risk factors]] who presented with severe systemic [[symptoms]] were at higher risk of [[stroke]].
-In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
+*Yaghi et al. retrospectively examined [[stroke]] patients admitted across different locations of NYU Langone hospital in New York. In this study, the incidence of 0.9% was observed in [[laboratory]] confirmed [[COVID-19]] positive patients included in this study. [[Stroke]] diagnosis was proved by imaging, and [[cryptogenic]] [[stroke]] was seen in most of these patients. The mortality was much higher in [[stroke]] patients who were [[COVID-19]] positive.<ref name="YaghiIshida20202">{{cite journal|last1=Yaghi|first1=Shadi|last2=Ishida|first2=Koto|last3=Torres|first3=Jose|last4=Mac Grory|first4=Brian|last5=Raz|first5=Eytan|last6=Humbert|first6=Kelley|last7=Henninger|first7=Nils|last8=Trivedi|first8=Tushar|last9=Lillemoe|first9=Kaitlyn|last10=Alam|first10=Shazia|last11=Sanger|first11=Matthew|last12=Kim|first12=Sun|last13=Scher|first13=Erica|last14=Dehkharghani|first14=Seena|last15=Wachs|first15=Michael|last16=Tanweer|first16=Omar|last17=Volpicelli|first17=Frank|last18=Bosworth|first18=Brian|last19=Lord|first19=Aaron|last20=Frontera|first20=Jennifer|title=SARS-CoV-2 and Stroke in a New York Healthcare System|journal=Stroke|volume=51|issue=7|year=2020|pages=2002–2011|issn=0039-2499|doi=10.1161/STROKEAHA.120.030335}}</ref>
-In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
-There have been several outbreaks of [disease name], including -----.
-In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].
+To view historical perspective of COVID-19 section, click [[COVID-19 historical perspective|here]].
 ==Classification==
-There is no established system for the classification of [disease name].
-OR
-[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
-OR
-[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
-[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
-OR
-Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
-OR
-If the staging system involves specific and characteristic findings and features:
-According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
-OR
-The staging of [malignancy name] is based on the [staging system].
+*There is no specific classification established for 'Stroke in [[COVID-19]] patients'.
+*It is same as the general classification of [[stroke]].<ref name="Theofanidis20152" />
-OR
+*[[Stroke]] can be classified into
+**[[Ischemic]] stroke: This can be due to
+***[[Thrombosis]] (Large vessel or Small vessel thrombosis)
+***[[Embolism]]
+***Systemic hypoperfusion
+***[[Cryptogenic]] (unknown origin)
+**[[Hemorrhagic]] stroke: This can be due to
+***[[Intracerebral hemorrhage]]
+***[[Subarachnoid hemorrhage]]
+***[[Subdural Hemorrhage]]
+***[[Epidural hemorrhage]]
-There is no established system for the staging of [malignancy name].
+To view classification of COVID-19 section, click [[COVID-19 classification|here]].
 ==Pathophysiology==
-The exact pathogenesis of [disease name] is not fully understood.
-OR
-It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
-OR
-[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
-OR
-Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
-OR
-[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
-OR
+*The exact [[pathophysiology]] of [[stroke]] in [[COVID-19]] is not fully understood.
+*However, it is thought that stroke in [[COVID-19]] could be due to one of the following [[Pathophysiology|pathophysiologies]]
+**Sepsis induced coagulopathy:
+***[[Sepsis]] induced [[coagulopathy]] in [[COVID-19]] patients is thought to be contributing to [[microthromobosis]].
+*** This is supported by elevation of [[D-dimer]] and [[C-reactive protein]], which are [[hypercoagulability]] and inflammatory markers, in [[COVID-19]] positive patients.
+**The [[Angiotensin-converting enzyme 2|angiotensin-converting enzyme II:]]
+***([[ACE|ACEII]]) receptors are also present on the vascular [[Endothelial cell|endothelial cells]] and neural cells in the [[brain]] .
+***These receptors expressed in the  brain are responsible for [[sympathoadrenal]] system regulation, and vascular autoregulation<ref name="Saavedra2005">{{cite journal|last1=Saavedra|first1=Juan M.|title=Brain Angiotensin II: New Developments, Unanswered Questions and Therapeutic Opportunities|journal=Cellular and Molecular Neurobiology|volume=25|issue=3-4|year=2005|pages=485–512|issn=0272-4340|doi=10.1007/s10571-005-4011-5}}</ref>.
+***When the [[virus]] binds to these receptors, this vascular autoregulation is hampered and can lead to elevated [[blood pressure]], eventually leading to rupture of the [[cerebral]] vessels and [[intracranial hemorrhage]]<ref name="Sharifi-RazaviKarimi2020">{{cite journal|last1=Sharifi-Razavi|first1=A.|last2=Karimi|first2=N.|last3=Rouhani|first3=N.|title=COVID-19 and intracerebral haemorrhage: causative or coincidental?|journal=New Microbes and New Infections|volume=35|year=2020|pages=100669|issn=20522975|doi=10.1016/j.nmni.2020.100669}}</ref>.
+***It does so by altering the balance of [[renin-angiotensin system]] which likely triggers [[endothelium]] dysfunction, organ damage, which eventually results in stroke<ref name="HessEldahshan2020">{{cite journal|last1=Hess|first1=David C.|last2=Eldahshan|first2=Wael|last3=Rutkowski|first3=Elizabeth|title=COVID-19-Related Stroke|journal=Translational Stroke Research|volume=11|issue=3|year=2020|pages=322–325|issn=1868-4483|doi=10.1007/s12975-020-00818-9}}</ref>.
+**Viral [[neurotropism]] and neuroinvasion
+***Viral [[Neurotropism]] and Neuroinvasion is another possible pathogenic mechanism for [[Cerebrovascular accident|cerebrovascular accidents]] in COVID-19 patients.
+***The [[coronaviruses]] usually cause mild [[respiratory illness]], but the beta coronavirues are known to have a role in [[nervous system]] involvement<ref name="ArbourDay2000">{{cite journal|last1=Arbour|first1=Nathalie|last2=Day|first2=Robert|last3=Newcombe|first3=Jia|last4=Talbot|first4=Pierre J.|title=Neuroinvasion by Human Respiratory Coronaviruses|journal=Journal of Virology|volume=74|issue=19|year=2000|pages=8913–8921|issn=1098-5514|doi=10.1128/JVI.74.19.8913-8921.2000}}</ref>.
+***The Novel [[coronavirus]] “[[severe acute respiratory syndrome]] coronavirus 2 ([[SARS-CoV-2]])” is a beta coronavirus, similar to severe acute respiratory syndrome coronavirus ([[SARS-CoV]]) and [[Middle East respiratory syndrome coronavirus infection|Middle East respiratory syndrome coronavirus]] ([[MERS-CoV]])<ref name="YuDu2020">{{cite journal|last1=Yu|first1=Fei|last2=Du|first2=Lanying|last3=Ojcius|first3=David M.|last4=Pan|first4=Chungen|last5=Jiang|first5=Shibo|title=Measures for diagnosing and treating infections by a novel coronavirus responsible for a pneumonia outbreak originating in Wuhan, China|journal=Microbes and Infection|volume=22|issue=2|year=2020|pages=74–79|issn=12864579|doi=10.1016/j.micinf.2020.01.003}}</ref>.
+***It,therefore, has an infection mechanism and potential to invade the [[nervous system]], similar to [[SARS-CoV-2|SARS-Cov]] and [[MERS-CoV|MERS-Cov]]<ref name="LiBai2020">{{cite journal|last1=Li|first1=Yan‐Chao|last2=Bai|first2=Wan‐Zhu|last3=Hashikawa|first3=Tsutomu|title=The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients|journal=Journal of Medical Virology|volume=92|issue=6|year=2020|pages=552–555|issn=0146-6615|doi=10.1002/jmv.25728}}</ref>. The detection of the virus in the cells of the [[brain]] on [[autopsy]]<ref name="Paniz‐MondolfiBryce20202">{{cite journal|last1=Paniz‐Mondolfi|first1=Alberto|last2=Bryce|first2=Clare|last3=Grimes|first3=Zachary|last4=Gordon|first4=Ronald E.|last5=Reidy|first5=Jason|last6=Lednicky|first6=John|last7=Sordillo|first7=Emilia Mia|last8=Fowkes|first8=Mary|title=Central nervous system involvement by severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2)|journal=Journal of Medical Virology|volume=92|issue=7|year=2020|pages=699–702|issn=0146-6615|doi=10.1002/jmv.25915}}</ref> (neural and capillary [[endothelial cells]]), and viral presence in the [[CSF|cerebrospinal fluid]] of the [[encephalitis]] patient infected with [[SARS-CoV-2|SARS-Cov-2]]<ref name="MoriguchiHarii2020">{{cite journal|last1=Moriguchi|first1=Takeshi|last2=Harii|first2=Norikazu|last3=Goto|first3=Junko|last4=Harada|first4=Daiki|last5=Sugawara|first5=Hisanori|last6=Takamino|first6=Junichi|last7=Ueno|first7=Masateru|last8=Sakata|first8=Hiroki|last9=Kondo|first9=Kengo|last10=Myose|first10=Natsuhiko|last11=Nakao|first11=Atsuhito|last12=Takeda|first12=Masayuki|last13=Haro|first13=Hirotaka|last14=Inoue|first14=Osamu|last15=Suzuki-Inoue|first15=Katsue|last16=Kubokawa|first16=Kayo|last17=Ogihara|first17=Shinji|last18=Sasaki|first18=Tomoyuki|last19=Kinouchi|first19=Hiroyuki|last20=Kojin|first20=Hiroyuki|last21=Ito|first21=Masami|last22=Onishi|first22=Hiroshi|last23=Shimizu|first23=Tatsuya|last24=Sasaki|first24=Yu|last25=Enomoto|first25=Nobuyuki|last26=Ishihara|first26=Hiroshi|last27=Furuya|first27=Shiomi|last28=Yamamoto|first28=Tomoko|last29=Shimada|first29=Shinji|title=A first case of meningitis/encephalitis associated with SARS-Coronavirus-2|journal=International Journal of Infectious Diseases|volume=94|year=2020|pages=55–58|issn=12019712|doi=10.1016/j.ijid.2020.03.062}}</ref> supports the neuro-invasiveness of the virus.
+***The two possible routes are retrograde [[axonal]] transport (via [[nasal cavity]]) or hematogenous spread (via blood brain barrier [[endothelial cells]])<ref name="Paniz‐MondolfiBryce20202" />. Once the virus reaches the brain, it attaches to the [[ACE|ACE II]] receptors.
+**Direct entry into brain tissues:
+*** Direct entry into [[brain]] tissues from cribriform plate to brain<ref name="BaigKhaleeq2020">{{cite journal|last1=Baig|first1=Abdul Mannan|last2=Khaleeq|first2=Areeba|last3=Ali|first3=Usman|last4=Syeda|first4=Hira|title=Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host–Virus Interaction, and Proposed Neurotropic Mechanisms|journal=ACS Chemical Neuroscience|volume=11|issue=7|year=2020|pages=995–998|issn=1948-7193|doi=10.1021/acschemneuro.0c00122}}</ref>. This is one of the proposed mechanism as [[COVID-19]] positive patients also presented with [[anosmia]] and hyposmia which possibly occurs due to viral effect on [[olfactory bulb]], which is in close proximity to [[cribriform plate]]'''<ref name="MaoJin20202" />'''
-The progression to [disease name] usually involves the [molecular pathway].
+*Further investigations should be done to better understand the mechanism of [[Stroke]] in patients with [[COVID-19]].
-OR
-The pathophysiology of [disease/malignancy] depends on the histological subtype.
+To view pathophysiology COVID-19 section, click [[COVID-19 classification|here]].
 ==Causes==
-Disease name] may be caused by [cause1], [cause2], or [cause3].
-OR
+*Coronavirus disease 2019 ([[COVID-19]]) associated [[stroke]] is caused by [[SARS-CoV-2]].
+*To view causes of COVID-19 section, click [[COVID-19 causes|here]].
-Common causes of [disease] include [cause1], [cause2], and [cause3].
-OR
-The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
-OR
-The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
 ==Differentiating COVID-19-associated stroke from other Diseases==
-[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
-OR
-[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
+*For further information about the differential diagnosis, [[COVID-19-associated stroke differential diagnosis|click here]].
+*To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].
 ==Epidemiology and Demographics==
-The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
-OR
-In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
-OR
-In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
+*The [[case fatality rate]] of [[Cerebrovascular accident|cerebrovascular accidents]] is 41.7 deaths per 100, 000 population<ref name="pmid26673558">{{cite journal| author=Writing Group Members. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ et al.| title=Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. | journal=Circulation | year= 2016 | volume= 133 | issue= 4 | pages= e38-360 | pmid=26673558 | doi=10.1161/CIR.0000000000000350 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26673558  }}</ref>. The [[Mortality rate|mortality]] in patients with [[COVID-19]] associated [[stroke]] is higher.<ref name="YaghiIshida20202" />
+*The [[incidence]] of [[stroke]] in [[COVID-19]] varies significantly depending on the study population.<ref name="AggarwalLippi2020">{{cite journal|last1=Aggarwal|first1=Gaurav|last2=Lippi|first2=Giuseppe|last3=Michael Henry|first3=Brandon|title=Cerebrovascular disease is associated with an increased disease severity in patients with Coronavirus Disease 2019 (COVID-19): A pooled analysis of published literature|journal=International Journal of Stroke|volume=15|issue=4|year=2020|pages=385–389|issn=1747-4930|doi=10.1177/1747493020921664}}</ref> The [[prevalence]] of [[COVID-19]]-associated [[stroke]] varies in different studies.
-Patients of all age groups may develop [disease name].
+{| class="wikitable"
+|+Prevalence of stroke in patients with COVID-19
+!Date of publication
+!Country
+!Author
+!Number of patients
+!Severe infection
+!Neurological symptoms
+!Acute Cerebrovascular disease
+!Ischemic/Hemorrhagic Stroke
+|-
+|April 10, 2020
+|Wuhan, China
+|Mao et al.<ref name="MaoJin20202" />
+|214
+|88 patients (41.1%), Mean age-58.2 years
+|78 patients (36.4%)
+|5 among severe [5.7%] infection group vs 1 [0.8%]) in non-severe group
+|Ischemic-4, Hemorrhagic-1
+|-
+|May 29, 2020
+|Wuhan, China
+| Qin et al.<ref name="QinZhou20202">{{cite journal|last1=Qin|first1=Chuan|last2=Zhou|first2=Luoqi|last3=Hu|first3=Ziwei|last4=Yang|first4=Sheng|last5=Zhang|first5=Shuoqi|last6=Chen|first6=Man|last7=Yu|first7=Haihan|last8=Tian|first8=Dai-Shi|last9=Wang|first9=Wei|title=Clinical Characteristics and Outcomes of COVID-19 Patients With a History of Stroke in Wuhan, China|journal=Stroke|volume=51|issue=7|year=2020|pages=2219–2223|issn=0039-2499|doi=10.1161/STROKEAHA.120.030365}}</ref> (Retrospective cohort study)
+|1875
+|461 severe on admission
+|
+|50 patients ie. 15 among severe and 35 among mild on admission (Median age-70 years), 30 males and 20 females
+|Ischemic-90%, [[Hemorrhagic stroke|Hemorrhagic]]-10%
+|-
+|May 20, 2020
+|New York
+|Yaghi et al.<ref name="YaghiIshida20202" /> (Retrospective cohort study)
+|3556
+|
+|[[Stroke]] at the time of admission-14/32 (43.8%), eventually developed stroke during hospitalization-18 (56.2%)
+|32 patients (0.9%)
+|Ischemic stroke- 32
+|-
+|April 28, 2020
+|New York city
+| Oxley et al.<ref name="OxleyMocco2020">{{cite journal|last1=Oxley|first1=Thomas J.|last2=Mocco|first2=J.|last3=Majidi|first3=Shahram|last4=Kellner|first4=Christopher P.|last5=Shoirah|first5=Hazem|last6=Singh|first6=I. Paul|last7=De Leacy|first7=Reade A.|last8=Shigematsu|first8=Tomoyoshi|last9=Ladner|first9=Travis R.|last10=Yaeger|first10=Kurt A.|last11=Skliut|first11=Maryna|last12=Weinberger|first12=Jesse|last13=Dangayach|first13=Neha S.|last14=Bederson|first14=Joshua B.|last15=Tuhrim|first15=Stanley|last16=Fifi|first16=Johanna T.|title=Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young|journal=New England Journal of Medicine|volume=382|issue=20|year=2020|pages=e60|issn=0028-4793|doi=10.1056/NEJMc2009787}}</ref>
+|5
+|
+|
+|
+|Large vessel stroke-5, Mean age-<50 years
+|-
+|July 12, 2020
+|New York
+| Valderrama et al.
+|1 (52-year old male)
+|
+|
+|
+|[[Ischemic stroke]]
+|-
+| colspan="8" |<small>[[Prevalence]] of [[COVID-19]]-associated [[stroke]] varies in different studies</small>
+|}<br />
-OR
+*The [[incidence]] of [[stroke]] in hospitalized [[COVID-19]] patients is reported to be 0.9–2%<ref name="TsivgoulisKatsanos20202">{{cite journal|last1=Tsivgoulis|first1=Georgios|last2=Katsanos|first2=Aristeidis H.|last3=Ornello|first3=Raffaele|last4=Sacco|first4=Simona|title=Ischemic Stroke Epidemiology During the COVID-19 Pandemic|journal=Stroke|volume=51|issue=7|year=2020|pages=1924–1926|issn=0039-2499|doi=10.1161/STROKEAHA.120.030791}}</ref>.majority of them being ischemic subtype. The mortality in [[COVID-19]] positive [[stroke]] patients is reported to be 39%<ref name="MaoJin20202" />.
-The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
+*The ischemic stroke [[prevalence]] in [[COVID-19]] patients is 1.6%.<ref name="TsivgoulisKatsanos20202" />
-OR
+* A New York study published in May reported that the proportion of these [[strokes]] seem to be higher in younger men.<ref name="YaghiIshida20202" /> Most of these [[strokes]] are large vessel [[Ischemic stroke|ischemic strokes]] and are catastrophic.
-[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
+*In a retrospective [[observational case series]] of six [[stroke]] patients in a hospital in Italy, with lab confirmed [[COVID-19]], the median age reported was 69 years. [[Ischemic stroke]] subtype was seen in 4 patients(67%) as compared to [[hemorrhagic]] which was only seen in 2 patients (33%). [[Vascular]] risk factors were seen in 5/6 patients, which included [[diabetes mellitus]], [[arterial hypertension]]
-OR
+*In a single center retrospective study conducted in Wuhan by Qin C. et al. which included 1875 laboratory-confirmed [[COVID-19]] patients from january 27th, 2020, to March 5th, 2020, 50 patients had history of [[stroke]]. The median age of this study group was 63 years, with stroke patients relatively older(70 years) when compared to non-stroke patients (62 years).<ref name="QinZhou20202" />
-[Chronic disease name] is usually first diagnosed among [age group].
+*Stroke is one of the [[neurological]] manifestations in patients with severe infection. There is limited information on [[COVID-19]] patients with [[stroke]] who survived.
-OR
-[Acute disease name] commonly affects [age group].
-There is no racial predilection to [disease name].
-OR
-[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
-[Disease name] affects men and women equally.
-OR
-[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
-The majority of [disease name] cases are reported in [geographical region].
-OR
-[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].
+To view epidemiology and demographics of COVID-19 section, click [[COVID-19 epidemiology and demographics|here]].
 ==Risk Factors==
-There are no established risk factors for [disease name].
-OR
-The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
-OR
+*According to one of the study conducted in New York, Stroke in [[COVID-19]] infected patients is seen in relatively young patients as compared to with non COVID-19 patients.<ref name="YaghiIshida20202" />
-Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
+* A study by Mao et. al. reported [[COVID-19]] associated [[stroke]] in seen in critically patients. The patients who developed [[stroke]] were older population with [[comorbidities]] like [[diabetes]], [[hypertension]], etc.
-OR
+*However, due to disparities in the [[stroke]] [[prevalence]] in different studies, no clear association has been established.
-Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
+To view risk factors of COVID-19 section, click [[COVID-19 risk factors|here]].
 ==Screening==
-There is insufficient evidence to recommend routine screening for [disease/malignancy].
-OR
+*There is insufficient evidence to recommend routine [[screening]] for [[stroke]] in [[COVID-19]] patients. However, if the patient presents with [[stroke]], [[COVID-19]] screening should be done.
-According to the [guideline name], screening for [disease name] is not recommended.
-OR
+To view screening of COVID-19 section, click [[COVID-19 screening|here]].
+==Natural History, Complications, and Prognosis ==
-According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
+*[[Prognosis]] is generally poor for [[COVID-19]] patients with stroke. A study reported a high proportion of these patients were admitted to the [[Intensive care unit|Intensive Care Unit(ICU)]] and required [[mechanical ventilation]]. The mortality of [[COVID-19]] patients with [[stroke]] was much higher when compared to [[COVID-19]] patients with no history of stroke<ref name="QinZhou20202" />.
-==Natural History, Complications, and Prognosis==
-If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
-OR
+To view natural history, complications and prognosis of COVID-19 section, click [[COVID-19 natural history, complications and prognosis|here]].
+==Diagnosis==
-Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
-OR
-Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
+*[[Diagnosis]] of [[stroke]] associated to [[COVID-19]] is based on history of [[Symptoms|symptoms development]], [[physical examination]], [[Imaging studies|imaging findings]], plus a positive [[COVID-19 diagnostic study of choice|COVID-19 test]].
+*There are no standard criteria for the evaluation of [[stroke]] associated to [[COVID-19]].
+*General management protocols for [[COVID-19]]-associated [[stroke]] should be established so that brain imaging can be realized as prompt as possible in patients who may be candidates for [[Fibrinolysis|IV fibrinolysis]] or mechanical [[thrombectomy]] or both.<ref name="PowersRabinstein20192">{{cite journal|last1=Powers|first1=William J.|last2=Rabinstein|first2=Alejandro A.|last3=Ackerson|first3=Teri|last4=Adeoye|first4=Opeolu M.|last5=Bambakidis|first5=Nicholas C.|last6=Becker|first6=Kyra|last7=Biller|first7=José|last8=Brown|first8=Michael|last9=Demaerschalk|first9=Bart M.|last10=Hoh|first10=Brian|last11=Jauch|first11=Edward C.|last12=Kidwell|first12=Chelsea S.|last13=Leslie-Mazwi|first13=Thabele M.|last14=Ovbiagele|first14=Bruce|last15=Scott|first15=Phillip A.|last16=Sheth|first16=Kevin N.|last17=Southerland|first17=Andrew M.|last18=Summers|first18=Deborah V.|last19=Tirschwell|first19=David L.|title=Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association|journal=Stroke|volume=50|issue=12|year=2019|issn=0039-2499|doi=10.1161/STR.0000000000000211}}</ref>
+*The current [[Diagnosis|diagnostic]] approach for [[stroke]] associated to [[COVID-19]] is the same as for people with non-COVID infection.
-==Diagnosis==
 ===Diagnostic Study of Choice===
-The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
-OR
+*Non-contrast [[Computed tomography|CT Scan]] of the [[brain]] within 20 minutes of arrival to the emergency department is the diagnostic test of choice for [[stroke]] in patients with [[COVID-19]] infection.<ref name="pmid25884860">{{cite journal |vauthors=Yew KS, Cheng EM |title=Diagnosis of acute stroke |journal=Am Fam Physician |volume=91 |issue=8 |pages=528–36 |date=April 2015 |pmid=25884860 |doi= |url=}}</ref>
+*[[MRI]] may detect smaller [[lesions]] with certainty if required, once the [[hemorrhagic stroke]] is excluded by non-contrast [[CT Scan]].<ref name="BouchezSztajzel2017">{{cite journal|last1=Bouchez|first1=Laurie|last2=Sztajzel|first2=Roman|last3=Vargas|first3=Maria Isabel|last4=Machi|first4=Paolo|last5=Kulcsar|first5=Zsolt|last6=Poletti|first6=Pierre-Alexandre|last7=Pereira|first7=Vitor Mendes|last8=Lövblad|first8=Karl-Olof|title=CT imaging selection in acute stroke|journal=European Journal of Radiology|volume=96|year=2017|pages=153–161|issn=0720048X|doi=10.1016/j.ejrad.2016.10.026}}</ref>
+*In a patient who presents with [[neurological]] [[Symptom|symptoms]], [[RT-PCR]] for [[SARS-CoV-2]] should be done as well.
-The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
+===History and Symptoms===
-OR
+*The extent of damage and symptoms which may result from [[stroke]] associated to [[COVID-19]] highly depends on the site of [[infarction]], the [[blood vessels]] involved, and the presence of other [[risk factors]].<ref name="pmid242518212">{{cite journal| author=Hernández-Pérez M, Pérez de la Ossa N, Aleu A, Millán M, Gomis M, Dorado L et al.| title=Natural history of acute stroke due to occlusion of the middle cerebral artery and intracranial internal carotid artery. | journal=J Neuroimaging | year= 2014 | volume= 24 | issue= 4 | pages= 354-8 | pmid=24251821 | doi=10.1111/jon.12062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24251821  }}</ref><ref name="pmid243230772">{{cite journal| author=Lima FO, Furie KL, Silva GS, Lev MH, Camargo EC, Singhal AB et al.| title=Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography. | journal=JAMA Neurol | year= 2014 | volume= 71 | issue= 2 | pages= 151-7 | pmid=24323077 | doi=10.1001/jamaneurol.2013.5007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24323077  }}</ref><ref name="pmid39759672">{{cite journal| author=Moulin DE, Lo R, Chiang J, Barnett HJ| title=Prognosis in middle cerebral artery occlusion. | journal=Stroke | year= 1985 | volume= 16 | issue= 2 | pages= 282-4 | pmid=3975967 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3975967  }}</ref>
-The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
+*The majority of patients with [[COVID-19]]-associated [[stroke]] initially presented with [[respiratory]] symptoms (''e.g.'' [[cough]], [[shortness of breath]] ''etc'') and constitutional features. These patients developed [[Cerebrovascular disease|cerebrovascular]] signs and symptoms later in the course of disease.
+*The following table summarizes the signs and symptoms found in 5 patients with COVID-19 infection that later acquiered a stroke:<ref name="AvulaNalleballe20202">{{cite journal|last1=Avula|first1=Akshay|last2=Nalleballe|first2=Krishna|last3=Narula|first3=Naureen|last4=Sapozhnikov|first4=Steven|last5=Dandu|first5=Vasuki|last6=Toom|first6=Sudhamshi|last7=Glaser|first7=Allison|last8=Elsayegh|first8=Dany|title=COVID-19 presenting as stroke|journal=Brain, Behavior, and Immunity|volume=87|year=2020|pages=115–119|issn=08891591|doi=10.1016/j.bbi.2020.04.077}}</ref><ref name="ZandiManji20202">{{cite journal|last1=Zandi|first1=Michael S|last2=Manji|first2=Hadi|last3=Jäger|first3=Hans Rolf|last4=Hoskote|first4=Chandrashekar|last5=Werring|first5=David J|last6=Vincent|first6=Angela|last7=Howard|first7=Robin|last8=Spillane|first8=Jennifer|last9=Lunn|first9=Michael P|last10=Thom|first10=Maria|last11=Houlihan|first11=Catherine|last12=Carletti|first12=Francesco|last13=Farmer|first13=Simon F|last14=Longley|first14=Nicky|last15=Checkley|first15=Anna|last16=Simister|first16=Robert|last17=Perry|first17=Richard J|last18=Chandratheva|first18=Arvind|last19=Schott|first19=Jonathan M|last20=Silber|first20=Eli|last21=Sreedharan|first21=Jemeen|last22=Attwell|first22=David|last23=Yoong|first23=Michael|last24=Davies|first24=Nicholas W S|last25=Carswell|first25=Christopher|last26=Everitt|first26=Alex D|last27=Miller|first27=Thomas D|last28=Hotton|first28=Gary|last29=Foulkes|first29=Alexander J M|last30=Trip|first30=S Anand|last31=Yong|first31=Wisdom|last32=Keddie|first32=Stephen|last33=Levee|first33=Viva|last34=Mehta|first34=Puja R|last35=Lim|first35=Soon Tjin|last36=McLoughlin|first36=Benjamin|last37=McNamara|first37=Patricia|last38=Morrow|first38=Jasper|last39=Christofi|first39=Gerry|last40=Price|first40=Gary|last41=Tuzlali|first41=Hatice|last42=Boyd|first42=Elena|last43=Chinthapalli|first43=Krishna|last44=Geraldes|first44=Ruth|last45=Khoo|first45=Anthony|last46=Vivekanandam|first46=Vinojini|last47=Zambreanu|first47=Laura|last48=Raftopoulos|first48=Rhian E|last49=Kumar|first49=Guru|last50=Jayaseelan|first50=Dipa L|last51=Bharucha|first51=Tehmina|last52=Wiethoff|first52=Sarah|last53=Nortley|first53=Ross|last54=Benjamin|first54=Laura|last55=Brown|first55=Rachel L|last56=Paterson|first56=Ross W|title=The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings|journal=Brain|year=2020|issn=0006-8950|doi=10.1093/brain/awaa240}}</ref>
-OR
+{| class="wikitable"
+|-
+!Patient no.
+!Onset of neurologic symptoms <br />
+!Age and Gender <br />
+!Neurologic Signs & Symptoms
+|-
+| 1
+|On Admission
+|73-year old, Male
+|[[Respiratory distress]], [[fever]], and [[altered mental status]] <ref name="AvulaNalleballe20202" />
+|-
+|2
+|On Admission
+|83-year old, Female
+|[[Fever]], [[Speech|slurring of speech]], [[facial droop]], and reduced oral intake <ref name="AvulaNalleballe20202" />
+|-
+|3
+|On Admission
+|80-year old female
+|[[Left sided weakness]], [[altered mental status]], one week history of frequent falls <ref name="AvulaNalleballe20202" />
+|-
+| 4
+|On Admission
+|88-year old, Female
+|An 15 minute episode of [[Muscle weakness|weakness]] and [[numbness]] of right arm and word finding difficulty <ref name="AvulaNalleballe20202" />
+|-
+| 5
+|On Admission
+|58-year old, Male
+|Dense Right-sided [[Muscle weakness|weakness]] and acute onset [[aphasia]] <ref name="ZandiManji20202" />
+|-
+| colspan="4" |<small>Reported cases of patients with COVID-19 infection and symptoms suggestive of [[stroke]].</small>
+|-
+|}
-There are no established criteria for the diagnosis of [disease name].
+==== Most common symptoms ====
-===History and Symptoms===
+* [[Cough]]
-The majority of patients with [disease name] are asymptomatic.
+* [[Dyspnea]]
+* [[Fever]]
+* Altered [[mental status]]
-OR
+==== Less common symptoms ====
-The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
+* [[Aphasia]]
+* Motor impairmant
+* Sensory impairmant
+* [[Slurred speech]]
+* [[Facial droop]]
+* Frequent falls
+* Reduced oral intake
 ===Physical Examination===
-Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
-OR
+*The physical examination findings in [[stroke]] associated to [[COVID-19]] will highly depend on the site of [[infarction]], the [[blood vessels]] involved, and the presence of other [[risk factors]].<ref name="pmid242518212" /><ref name="pmid243230772" /><ref name="pmid39759672" /><br />
-Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
+{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
+|+'''Physical examination of patients with stroke depending on vessel involved'''
+! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF|Vessel involved}}
+! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Physical examination}}
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" |'''Anterior cerebral artery '''<ref name="pmid1789511722">{{cite journal| author=Nagaratnam N, Davies D, Chen E| title=Clinical effects of anterior cerebral artery infarction. | journal=J Stroke Cerebrovasc Dis | year= 1998 | volume= 7 | issue= 6 | pages= 391-7 | pmid=17895117 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17895117  }}</ref><ref name="pmid1245307722">{{cite journal| author=Kumral E, Bayulkem G, Evyapan D, Yunten N| title=Spectrum of anterior cerebral artery territory infarction: clinical and MRI findings. | journal=Eur J Neurol | year= 2002 | volume= 9 | issue= 6 | pages= 615-24 | pmid=12453077 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12453077  }}</ref>
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Decreased motor strength- contralateral lower limb<ref name="pmid1789511722" />
+*Absent or decreased sensations-contralateral lower limb<ref name="pmid1789511722" />
+* Increased reflexes-contralateral lower limb
+*Babinski's reflex positive
+*[[Hemineglect|Constructional and dressing apraxia-hemineglect]] <ref name="pmid1245307722" /><ref name="pmid735641522">{{cite journal| author=Alexander MP, Schmitt MA| title=The aphasia syndrome of stroke in the left anterior cerebral artery territory. | journal=Arch Neurol | year= 1980 | volume= 37 | issue= 2 | pages= 97-100 | pmid=7356415 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7356415  }}</ref>
+* Transcortical motor [[aphasia]](non fluent)<ref name="pmid1245307722" /><ref name="pmid735641522" />
+*Mutism
+*Contralateral grasp and sucking reflex
+*Memory impairment<ref name="pmid165102252">{{cite journal| author=Mizuta H, Motomura N| title=Memory dysfunction in caudate infarction caused by Heubner's recurring artery occlusion. | journal=Brain Cogn | year= 2006 | volume= 61 | issue= 2 | pages= 133-8 | pmid=16510225 | doi=10.1016/j.bandc.2005.11.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16510225  }}</ref>
+*Confabulation<ref name="pmid179401692">{{cite journal| author=den Heijer T, Ruitenberg A, Bakker J, Hertzberger L, Kerkhoff H| title=Neurological picture. Bilateral caudate nucleus infarction associated with variant in circle of Willis. | journal=J Neurol Neurosurg Psychiatry | year= 2007 | volume= 78 | issue= 11 | pages= 1175 | pmid=17940169 | doi=10.1136/jnnp.2006.112656 | pmc=2117617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17940169  }}</ref>
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" |'''Middle cerebral artery'''<ref name="pmid231396842">{{cite journal| author=Lemieux F, Lanthier S, Chevrier MC, Gioia L, Rouleau I, Cereda C et al.| title=Insular ischemic stroke: clinical presentation and outcome. | journal=Cerebrovasc Dis Extra | year= 2012 | volume= 2 | issue= 1 | pages= 80-7 | pmid=23139684 | doi=10.1159/000343177 | pmc=3492997 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23139684  }}</ref>
-OR
+*Most common site of infarction
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Decreased motor strength-contralateral arm and face <ref name="pmid192101942">{{cite journal| author=Arboix A, Martí-Vilalta JL| title=Lacunar stroke. | journal=Expert Rev Neurother | year= 2009 | volume= 9 | issue= 2 | pages= 179-96 | pmid=19210194 | doi=10.1586/14737175.9.2.179 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19210194  }}</ref><ref name="pmid15652332">{{cite journal| author=Melo TP, Bogousslavsky J, van Melle G, Regli F| title=Pure motor stroke: a reappraisal. | journal=Neurology | year= 1992 | volume= 42 | issue= 4 | pages= 789-95 | pmid=1565233 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1565233  }}</ref><ref name="pmid82565702">{{cite journal| author=Tei H, Uchiyama S, Maruyama S| title=Capsular infarcts: location, size and etiology of pure motor hemiparesis, sensorimotor stroke and ataxic hemiparesis. | journal=Acta Neurol Scand | year= 1993 | volume= 88 | issue= 4 | pages= 264-8 | pmid=8256570 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8256570  }}</ref>
+*Absent or decreased sensations-contralateral left arm and face<ref name="pmid1789511722" />
+*Increased deep tendon reflexes - contralateral arm
+*Babinski's sign positive
+*[[Hemineglect|Contralateral Hemineglect]]
+*[[Broca's aphasia]]<ref name="pmid250163862">{{cite journal| author=Fridriksson J, Fillmore P, Guo D, Rorden C| title=Chronic Broca's Aphasia Is Caused by Damage to Broca's and Wernicke's Areas. | journal=Cereb Cortex | year= 2015 | volume= 25 | issue= 12 | pages= 4689-96 | pmid=25016386 | doi=10.1093/cercor/bhu152 | pmc=4669036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25016386  }}</ref><ref name="pmid40626222">{{cite journal| author=Henderson VW| title=Lesion localization in Broca's aphasia. Implications from Broca's aphasia without hemiparesis. | journal=Arch Neurol | year= 1985 | volume= 42 | issue= 12 | pages= 1210-2 | pmid=4062622 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4062622  }}</ref><ref name="pmid957766322">{{cite journal| author=Soma Y| title=[Cerebrovascular disorder and the language areas]. | journal=Rinsho Shinkeigaku | year= 1997 | volume= 37 | issue= 12 | pages= 1117-9 | pmid=9577663 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9577663  }}</ref>
+*[[Wernicke's aphasia]]<ref name="pmid957766322" />
+*Contralateral visual field defect
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Posterior cerebral artery]]<ref name="pmid1077364222">{{cite journal| author=Brandt T, Steinke W, Thie A, Pessin MS, Caplan LR| title=Posterior cerebral artery territory infarcts: clinical features, infarct topography, causes and outcome. Multicenter results and a review of the literature. | journal=Cerebrovasc Dis | year= 2000 | volume= 10 | issue= 3 | pages= 170-82 | pmid=10773642 | doi=16053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10773642  }}</ref><ref name="pmid2237787922">{{cite journal| author=Cereda C, Carrera E| title=Posterior cerebral artery territory infarctions. | journal=Front Neurol Neurosci | year= 2012 | volume= 30 | issue=  | pages= 128-31 | pmid=22377879 | doi=10.1159/000333610 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22377879  }}</ref><ref name="pmid1040498422">{{cite journal| author=Yamamoto Y, Georgiadis AL, Chang HM, Caplan LR| title=Posterior cerebral artery territory infarcts in the New England Medical Center Posterior Circulation Registry. | journal=Arch Neurol | year= 1999 | volume= 56 | issue= 7 | pages= 824-32 | pmid=10404984 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10404984  }}</ref>'''<ref name="pmid374233922">{{cite journal| author=Fisher CM| title=The posterior cerebral artery syndrome. | journal=Can J Neurol Sci | year= 1986 | volume= 13 | issue= 3 | pages= 232-9 | pmid=3742339 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3742339  }}</ref><ref name="pmid1040498422" /><ref name="pmid443417622">{{cite journal| author=Caplan LR, Hedley-Whyte T| title=Cuing and memory dysfunction in alexia without agraphia. A case report. | journal=Brain | year= 1974 | volume= 97 | issue= 2 | pages= 251-62 | pmid=4434176 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4434176  }}</ref>
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Contralateral visual field defects<ref name="pmid1077364222" /><ref name="pmid374233922" /><ref name="pmid36060352">{{cite journal| author=Pessin MS, Lathi ES, Cohen MB, Kwan ES, Hedges TR, Caplan LR| title=Clinical features and mechanism of occipital infarction. | journal=Ann Neurol | year= 1987 | volume= 21 | issue= 3 | pages= 290-9 | pmid=3606035 | doi=10.1002/ana.410210311 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3606035  }}</ref>
+* Complex hallucinations
+*[[Prosopagnosia]]<ref name="pmid71996552">{{cite journal| author=Damasio AR, Damasio H, Van Hoesen GW| title=Prosopagnosia: anatomic basis and behavioral mechanisms. | journal=Neurology | year= 1982 | volume= 32 | issue= 4 | pages= 331-41 | pmid=7199655 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7199655  }}</ref>
+*Unable to remember names-Nominal aphasia
+*[[Gerstmann syndrome|Acalculia and agraphia -Gerstmann syndrome]]
+*Memory deficit
+*Hemisensory loss<ref name="pmid164023522">{{cite journal| author=Melo TP, Bogousslavsky J| title=Hemiataxia-hypesthesia: a thalamic stroke syndrome. | journal=J Neurol Neurosurg Psychiatry | year= 1992 | volume= 55 | issue= 7 | pages= 581-4 | pmid=1640235 | doi= | pmc=489170 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1640235  }}</ref>
-The presence of [finding(s)] on physical examination is diagnostic of [disease name].
+*[[Hemiparesis|Contralateral hemiparesis]]<ref name="pmid164023522" />
+*Thalamic pain syndrome <ref name="pmid2237787922" />
+*[[Hemiballismus]]
+*[[Oculomotor nerve palsy|Occulomotor nerve palsy]]
+*Intention [[Tremor|tremors]]
+*[[Alexia]] without [[agraphia]]<ref name="pmid443417622" />
+|-
+| rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" |'''Vertebrobasilar artery<ref name="pmid1092697222">{{cite journal| author=Caplan L| title=Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis Lecture-2000. | journal=Stroke | year= 2000 | volume= 31 | issue= 8 | pages= 2011-23 | pmid=10926972 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10926972  }}</ref>'''
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Midbrain'''
+*[[Weber syndrome|'''Weber syndrome''']]<ref name="pmid247786252">{{cite journal| author=Nouh A, Remke J, Ruland S| title=Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. | journal=Front Neurol | year= 2014 | volume= 5 | issue=  | pages= 30 | pmid=24778625 | doi=10.3389/fneur.2014.00030 | pmc=3985033 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24778625  }}</ref>
-OR
+*Contralateral decreased motor strength
+*Deviation of eye downwards and outwards-ipsilateral 3rd nerve palsy
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Medulla'''
+*[[Lateral medullary syndrome|'''Lateral medullary syndrome''']]<ref name="pmid1092697222" /><ref name="pmid85037982">{{cite journal| author=Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP| title=Wallenberg's lateral medullary syndrome. Clinical-magnetic resonance imaging correlations. | journal=Arch Neurol | year= 1993 | volume= 50 | issue= 6 | pages= 609-14 | pmid=8503798 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8503798  }}</ref><ref name="pmid223462152">{{cite journal| author=Shetty SR, Anusha R, Thomas PS, Babu SG| title=Wallenberg's syndrome. | journal=J Neurosci Rural Pract | year= 2012 | volume= 3 | issue= 1 | pages= 100-2 | pmid=22346215 | doi=10.4103/0976-3147.91980 | pmc=3271596 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22346215  }}</ref>
-The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
+:*Impaired [[gag reflex]]
+:*[[Uvula]] deviated to the opposite side of lesion
+:*[[Ptosis]]
+:*[[Miosis]]
+:*[[Enophthalmos]]
+:*Ipsilateral impaired pain, touch and temperature sensation on the upper half of the face
+:*Contralateral decreased motor strength and sensory loss
+:*Romberg's sign
-===Laboratory Findings===
+*[[Medial medullary syndrome|'''Medial medullary syndrome''']]<ref name="pmid1092697222" /><ref name="pmid76603962">{{cite journal| author=Kim JS, Kim HG, Chung CS| title=Medial medullary syndrome. Report of 18 new patients and a review of the literature. | journal=Stroke | year= 1995 | volume= 26 | issue= 9 | pages= 1548-52 | pmid=7660396 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7660396  }}</ref><ref name="pmid227874952">{{cite journal| author=Kim K, Lee HS, Jung YH, Kim YD, Nam HS, Nam CM et al.| title=Mechanism of medullary infarction based on arterial territory involvement. | journal=J Clin Neurol | year= 2012 | volume= 8 | issue= 2 | pages= 116-22 | pmid=22787495 | doi=10.3988/jcn.2012.8.2.116 | pmc=3391616 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22787495  }}</ref>
-An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
-OR
+:*Deviation of the tongue to the side of the lesion-[[hypoglossal nerve]]
+:*Contralateral decreased motor strength
+:*Contralateral loss of position sense, [[vibration]] and two point discrimination
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Pons'''
+*Inability to close eyes
+*Deviation of angle of mouth
+*[[Facial muscles|Facial muscle]] weakness-[[Facial nerve]]
+*[[Ageusia|Loss of taste]] and sensation on the anterior two thirds of the tongue
+*Affected eye deviation inwardsand down-Abducent  nerve
+*[[Locked-In syndrome|Locked-in syndrome]]<ref name="pmid37389622">{{cite journal| author=Patterson JR, Grabois M| title=Locked-in syndrome: a review of 139 cases. | journal=Stroke | year= 1986 | volume= 17 | issue= 4 | pages= 758-64 | pmid=3738962 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3738962  }}</ref><ref name="pmid48108962">{{cite journal| author=Karp JS, Hurtig HI| title="Locked-in" state with bilateral midbrain infarcts. | journal=Arch Neurol | year= 1974 | volume= 30 | issue= 2 | pages= 176-8 | pmid=4810896 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4810896  }}</ref>
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Cerebellum'''
+*[[Vertigo]]
+*[[Romberg's test|Romberg's sign]] positive
+*[[Intension tremors]]
+*[[Dysdiadochokinesia]]
+*[[Dysarthria]]
+|-
+|}<br />
-Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
+*The use of [[stroke]] scales helps to measure the degree of [[neurological]] [[Disability|impairment]], ease communication, may help select patients candidates for [[Fibrinolysis|fibrinolytic]] or [[Thrombectomy|mechanical]] therapy, permits the evaluation of changing clinical status, and identifies those patients at higher risk for complications (eg. [[intracerebral hemorrhage]]).<ref name="AdamsDavis1999">{{cite journal|last1=Adams|first1=H. P.|last2=Davis|first2=P. H.|last3=Leira|first3=E. C.|last4=Chang|first4=K.-C.|last5=Bendixen|first5=B. H.|last6=Clarke|first6=W. R.|last7=Woolson|first7=R. F.|last8=Hansen|first8=M. D.|title=Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)|journal=Neurology|volume=53|issue=1|year=1999|pages=126–126|issn=0028-3878|doi=10.1212/WNL.53.1.126}}</ref>
+*The  [[National Institutes of Health Stroke Scale|National Institutes of Health Stroke Scale (NIHSS)]] is a tool used to measure the [[Neurological|neurologic]] [[Disability|impairment]] caused by a stroke in a [[quantitative]] manner.<ref name="urlwww.ninds.nih.gov">{{cite web |url=https://www.ninds.nih.gov/sites/default/files/NIH_Stroke_Scale_Booklet.pdf |title=www.ninds.nih.gov |format= |work= |accessdate=}}</ref><ref name="urlNational Institutes of Health Stroke Scale - Wikipedia2">{{cite web |url=https://en.wikipedia.org/wiki/National_Institutes_of_Health_Stroke_Scale |title=National Institutes of Health Stroke Scale - Wikipedia |format= |work= |accessdate=}}</ref> The [[National Institutes of Health Stroke Scale|NIHSS]] is composed of 11 items, each of which scores a specific ability between a 0 and 4. For each item, a score of 0 typically indicates normal function in that specific ability, while a higher score is indicative of some level of impairment. The individual scores from each item are summed in order to calculate a patient's total [[National Institutes of Health Stroke Scale|NIHSS]] score. The maximum possible score is 42, with the minimum score being a 0.<ref name="urlNational Institutes of Health Stroke Scale - Wikipedia2" />
-OR
+{| class="wikitable"
+|+National Institutes of Health Stroke Scale (NIHSS)
+!Tested item
+!Title
+!Response and score
+|-
+| rowspan="4" |1A
+| rowspan="4" |Level of [[consciousness]]
+|0—[[Alertness|Alert]]
+|-
+|1—[[Drowsiness|Drowsy]]
+|-
+|2—[[Obtundation|Obtunded]]
+|-
+|3—[[Coma]]/unresponsive
+|-
+| rowspan="3" |1B
+| rowspan="3" |Orientation questions (2)
+|0—Answers both correctly
+|-
+|1—Answers 1 correctly
+|-
+|2—Answers neither correctly
+|-
+| rowspan="3" |2
+| rowspan="3" |[[Gaze palsy|Gaze]]
+|0—Normal horizontal movements
+|-
+|1—Partial [[gaze palsy]]
+|-
+|2—Complete [[gaze palsy]]
+|-
+| rowspan="4" |3
+| rowspan="4" |[[Visual fields]]
+|0—No [[Vision loss|visual field defect]]
+|-
+|1—Partial [[Hemianopsia|hemianopia]]
+|-
+|2—Complete [[Hemianopsia|hemianopia]]
+|-
+|3—Bilateral [[hemianopia]]
+|-
+| rowspan="4" |4
+| rowspan="4" |[[Facial]] movement
+|0—Normal
+|-
+|1—Minor [[facial weakness]]
+|-
+|2—Partial [[facial weakness]]
+|-
+|3—Complete unilateral [[palsy]]
+|-
+| rowspan="5" |5
+| rowspan="5" | Motor function (arm)
+a. Left
-[Test] is usually normal among patients with [disease name].
+b. Right
+|0—No [[drift]]
+|-
+|1—Drift before 10 s
+|-
+|2—Falls before 10 s
+|-
+|3—No effort against [[gravity]]
+|-
+| 4—No movement
+|-
+| rowspan="5" |6
+| rowspan="5" |Motor function (leg)
+a. Left
-OR
+b. Right
+|0—No drift
+|-
+|1—Drift before 5 s
+|-
+|2—Falls before 5 s
+|-
+|3—No effort against gravity
+|-
+|4—No movement
+|-
+| rowspan="3" |7
+| rowspan="3" |Limb [[ataxia]]
+|0—No [[ataxia]]
+|-
+|1—[[Ataxia]] in 1 limb
+|-
+|2—[[Ataxia]] in 2 limbs
+|-
+| rowspan="3" |8
+| rowspan="3" |[[Sensory]]
+|0—No [[sensory loss]]
+|-
+|1—Mild [[sensory loss]]
+|-
+|2—Severe [[sensory loss]]
+|-
+| rowspan="4" |9
+| rowspan="4" |[[Language]]
+|0—Norma
+|-
+|1—Mild [[aphasia]]
+|-
+|2—Severe [[aphasia]]
+|-
+|3—Mute or global [[aphasia]]
+|-
+| rowspan="3" |10
+| rowspan="3" |[[Articulation disorder|Articulation]] of words
+|0—Norma
+|-
+|1—Mild [[dysarthria]]
+|-
+|2—Severe [[dysarthria]]
+|-
+| rowspan="3" |11
+| rowspan="3" |Extinction or inattention
+|0—Absent
+|-
+| 1—Mild loss (1 sensory modality lost)
+|-
+|2—Severe loss (2 modalities lost)
+|-
+| colspan="3" |<small>Adapted from Lyden et al., 1994</small><ref name="LydenBrott1994">{{cite journal|last1=Lyden|first1=P|last2=Brott|first2=T|last3=Tilley|first3=B|last4=Welch|first4=K M|last5=Mascha|first5=E J|last6=Levine|first6=S|last7=Haley|first7=E C|last8=Grotta|first8=J|last9=Marler|first9=J|title=Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group.|journal=Stroke|volume=25|issue=11|year=1994|pages=2220–2226|issn=0039-2499|doi=10.1161/01.STR.25.11.2220}}</ref> <small>American Heart Association, Inc.</small>
+|}
-Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
+*The pre-stroke Modified Rankin Score (mRS) is an estimated score used to assess the patient’s pre-[[stroke]] level of function. An estimated mRS should be abstracted from current [[medical record]] documentation about the patient’s ability to perform activities of daily living prior to the hospitalization for the acute [[ischemic stroke]] event.<ref name="urlPre-Stroke Modified Rankin Score (mRS) (v2018B)2">{{cite web |url=https://manual.jointcommission.org/releases/TJC2018B/DataElem0773.html |title=Pre-Stroke Modified Rankin Score (mRS) (v2018B) |format= |work= |accessdate=}}</ref>
-OR
+{| class="wikitable"
+|+Alberta stroke program early CT score (ASPECTS)
+! colspan="2" |Area affected
+!Score
+|-
+| rowspan="3" |'''Subganglionic Nuclei:'''
+|M1 - ''Frontal operculum''
+|1
+|-
+|M2 - ''Anterior [[temporal lobe]]''
+|1
+|-
+|M3 - ''Posterior [[temporal lobe]]''
+|1
+|-
+| rowspan="3" |'''Supraganglionic Nuclei:'''
+|M4  - ''Anterior MCA''
+|1
+|-
+|M5  - ''Lateral MCA''
+|1
+|-
+|M6  - ''Posterior MCA   ''
+|1
+|-
+| rowspan="4" |'''[[Basal Ganglia]]:'''
+|C - [[Caudate lobe|Caudate]]
+|1
+|-
+| L - Lentiform Nucleus
+|1
+|-
+|I - [[Insula]]
+|1
+|-
+|IC - Internal Capsule
+|1
+|-
+| colspan="3" |<small>Adapted from The University of Calgary ASPECT score in Accute stroke, 2020</small><ref name="urlHome2">{{cite web |url=http://aspectsinstroke.com/ |title=Home |format= |work= |accessdate=}}</ref>
+|}
-There are no diagnostic laboratory findings associated with [disease name].
+*[[ASPECT|Alberta stroke program early CT score (ASPECTS)]] is a 10 point quantitative score used to asses early [[Ischemia|ischemic]] changes in patients suspected of having acute large vessel anterior circulation [[occlusion]].<ref name="urlHome2" />
-===Electrocardiogram===
+{| class="wikitable"
-There are no ECG findings associated with [disease name].
+|+''Pre-Stroke Modified Rankin Score (mRS)''
+!Score
+!Item tested
+|-
+| 0
+|The patient had no residual [[symptoms]].
+|-
+|1
+|The patient had no significant [[disability]]; able to carry out all activities.
+|-
+|2
+|The patient had slight [[disability]]; unable to carry out all activities but able to look after self without daily help.
+|-
+|3
+|The patient had moderate [[disability]]; requiring some external help but able to walk without the assistance of another individual.
+|-
+|4
+|The patient had moderately severe [[disability]]; unable to walk or attend to bodily functions without assistance of another individual.
+|-
+|5
+|The patient had severe [[disability]]; bedridden, [[Urinary incontinence|incontinent]], requires continuous care.
+|-
+|6
+|Unable to determine (UTD) from the medical record documentation.
+|-
+| colspan="2" |<small>Adapted from Specifications Manual for Joint Commission National Quality Measures, 2018</small><ref name="urlPre-Stroke Modified Rankin Score (mRS) (v2018B)2" />
+|}<br />
+===Laboratory Findings===
-OR
+*Patients with [[stroke]] associated to [[COVID-19]] will have a positive test for [[COVID-19]] confirmed either through molecular tests, nucleic acid amplification test, or serological testing.
-An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
+*[[Serum glucose]] assessment is the only lab study that should proceed [[Alteplase|IV alteplase]] initiation, this should be over 50 mg/dL for its administration.<ref name="PowersRabinstein20192" />
+*[[Coagulation studies]] and [[complete blood count]] should be delayed until after [[Alteplase|IV alteplase]] initiation unless there is suspicion for a [[coagulopathy]] disorder.<ref name="PowersRabinstein20192" />
+*[[Troponin]] should be assessed in patients presenting with [[ischemic stroke]].<ref name="PowersRabinstein20192" />
+*In patirents 20 years or older and not on [[Lipid-lowering medication|lipid-lowering therapy]], baseline measurement of [[Lipid profile|plasma lipid profile]] is effective in estimating [[Coronary heart disease|atherosclerotic cardiovascular disease (ASCVD)]]; after that, [[Lipid profile|plasma lipid profile]] should be measured every 4 to 12 weeks after statin initiation.<ref name="PowersRabinstein20192" />
-===X-ray===
+===Ultrasound===
-There are no x-ray findings associated with [disease name].
-OR
+*[[Echocardiography]] may be necessary in patients with [[ischemic stroke]] to identify and prevent secondary causes of [[stroke]] such as structural changes, [[atrial fibrillation]], valvular heart disease and atherosclerosis.<ref name="pmid18629351">{{cite journal| author=de Abreu TT, Mateus S, Carreteiro C, Correia J| title=Therapeutic implications of transesophageal echocardiography after transthoracic echocardiography on acute stroke patients. | journal=Vasc Health Risk Manag | year= 2008 | volume= 4 | issue= 1 | pages= 167-72 | pmid=18629351 | doi= | pmc=2464746 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18629351  }}</ref><ref name="pmid218047762">{{cite journal| author=Ustrell X, Pellisé A| title=Cardiac workup of ischemic stroke. | journal=Curr Cardiol Rev | year= 2010 | volume= 6 | issue= 3 | pages= 175-83 | pmid=21804776 | doi=10.2174/157340310791658721 | pmc=2994109 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21804776  }}</ref><ref name="pmid20931511">{{cite journal| author=Kolo PM, Sanya EO, Omotosho AB, Chijoke A, Dada SA| title=The role of echocardiography in the management of stroke. | journal=West Afr J Med | year= 2010 | volume= 29 | issue= 4 | pages= 239-43 | pmid=20931511 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20931511  }}</ref><ref name="pmid27256218">{{cite journal |vauthors=Nakanishi K, Homma S |title=Role of echocardiography in patients with stroke |journal=J Cardiol |volume=68 |issue=2 |pages=91–9 |date=August 2016 |pmid=27256218 |doi=10.1016/j.jjcc.2016.05.001 |url=}}</ref>
+*[[Carotid]] [[Ultrasound guidance|ultrasound]] should be performed in all patients with [[ischemic stroke]] to assess for narrowing of [[Carotid arteries|carotids]] and decrease recurrence of thromboembolic events.<ref name="urlCarotid ultrasound - Mayo Clinic">{{cite web |url=https://www.mayoclinic.org/tests-procedures/carotid-ultrasound/about/pac-20393399#:~:text=Ischemic%20stroke,-Ischemic%20stroke%20occurs&text=A%20carotid%20ultrasound%20is%20performed,that%20circulate%20in%20the%20bloodstream. |title=Carotid ultrasound - Mayo Clinic |format= |work= |accessdate=}}</ref>
-An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
+===X-ray===
-OR
-There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
-===Echocardiography or Ultrasound===
-There are no echocardiography/ultrasound  findings associated with [disease name].
-OR
-Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
-OR
-There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
+*[[Head]] [[x-rays]] can help rule out foreign metal objects in the head before performing an [[MRI]],<ref name="pmid31536242">{{cite journal |vauthors=Shafaat O, Sotoudeh H |title= |journal= |volume= |issue= |pages= |date= |pmid=31536242 |doi= |url=}}</ref> detect skull fractures, and identify intracranial [[Calcification|calcifications]] that may serve as hallmarks for [[brain]] structural changes in countries with poor access to more specific [[imaging]] tests.
+*There is no evidence of usefulness of [[Chest X-ray|chest x-ray]] in the acute setting of [[stroke]].<ref name="PowersRabinstein20192" />
 ===CT scan===
-There are no CT scan findings associated with [disease name].
-OR
-[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
-OR
-There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
+*Non-contrasted [[Computed tomography|CT scan]] of the head should should always be performed before initiating [[Alteplase|IV alteplase]].<ref name="PowersRabinstein20192" />
+*Once [[hemorragic stroke]] is excluded, [[Computed tomography|CT scan]] with contrast should be realized in patients with no history of renal disease without measuring [[creatinine]] concentration, taking into account that both [[COVID-19]] infection and stroke increase the risk for [[Renal insufficiency|renal impairment]] per se.<ref name="QureshiAbd-Allah20202">{{cite journal|last1=Qureshi|first1=Adnan I|last2=Abd-Allah|first2=Foad|last3=Al-Senani|first3=Fahmi|last4=Aytac|first4=Emrah|last5=Borhani-Haghighi|first5=Afshin|last6=Ciccone|first6=Alfonso|last7=Gomez|first7=Camilo R|last8=Gurkas|first8=Erdem|last9=Hsu|first9=Chung Y|last10=Jani|first10=Vishal|last11=Jiao|first11=Liqun|last12=Kobayashi|first12=Adam|last13=Lee|first13=Jun|last14=Liaqat|first14=Jahanzeb|last15=Mazighi|first15=Mikael|last16=Parthasarathy|first16=Rajsrinivas|last17=Steiner|first17=Thorsten|last18=Suri|first18=M Fareed K|last19=Toyoda|first19=Kazunori|last20=Ribo|first20=Marc|last21=Gongora-Rivera|first21=Fernando|last22=Oliveira-Filho|first22=Jamary|last23=Uzun|first23=Guven|last24=Wang|first24=Yongjun|title=Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel|journal=International Journal of Stroke|volume=15|issue=5|year=2020|pages=540–554|issn=1747-4930|doi=10.1177/1747493020923234}}</ref><ref name="ChengLuo2020">{{cite journal|last1=Cheng|first1=Yichun|last2=Luo|first2=Ran|last3=Wang|first3=Kun|last4=Zhang|first4=Meng|last5=Wang|first5=Zhixiang|last6=Dong|first6=Lei|last7=Li|first7=Junhua|last8=Yao|first8=Ying|last9=Ge|first9=Shuwang|last10=Xu|first10=Gang|title=Kidney disease is associated with in-hospital death of patients with COVID-19|journal=Kidney International|volume=97|issue=5|year=2020|pages=829–838|issn=00852538|doi=10.1016/j.kint.2020.03.005}}</ref>
+*[[CT angiography]] of the brain may be needed in patients to make a decision for mechanical thrombectomy.<ref name="QureshiAbd-Allah20202" /><ref name="pmid18329713">{{cite journal |vauthors=Lövblad KO, Altrichter S, Viallon M, Sztajzel R, Delavelle J, Vargas MI, El-Koussy M, Federspiel A, Sekoranja L |title=Neuro-imaging of cerebral ischemic stroke |journal=J Neuroradiol |volume=35 |issue=4 |pages=197–209 |date=October 2008 |pmid=18329713 |doi=10.1016/j.neurad.2008.01.002 |url=}}</ref><ref name="SmithKent2018">{{cite journal|last1=Smith|first1=Eric E.|last2=Kent|first2=David M.|last3=Bulsara|first3=Ketan R.|last4=Leung|first4=Lester Y.|last5=Lichtman|first5=Judith H.|last6=Reeves|first6=Mathew J.|last7=Towfighi|first7=Amytis|last8=Whiteley|first8=William N.|last9=Zahuranec|first9=Darin B.|title=Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke|journal=Stroke|volume=49|issue=3|year=2018|issn=0039-2499|doi=10.1161/STR.0000000000000160}}</ref>
+*[[CT angiography|CT angiography's]] contrast can increase the risk of acute [[kidney injury]] in patients with [[COVID-19]] infection.<ref name="QureshiAbd-Allah20202" />
+*[[CT perfusion]] should be done in patients who present within 24 hours of the initiation of [[symptoms]].<ref name="QureshiAbd-Allah20202" />
+*Concurrent [[CT scan]] of the [[head]] and [[chest]] may be ordered at the same time in patients with [[COVID-19]] infection.<ref name="QureshiAbd-Allah20202" /><ref name="pmid32109013">{{cite journal |vauthors=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS |title=Clinical Characteristics of Coronavirus Disease 2019 in China |journal=N. Engl. J. Med. |volume=382 |issue=18 |pages=1708–1720 |date=April 2020 |pmid=32109013 |pmc=7092819 |doi=10.1056/NEJMoa2002032 |url=}}</ref>
+*[[CT angiography]] of the extracranial [[Carotid arteries|carotid]] and [[vertebral arteries]], in addition to the [[Intracranial hemorrhage|intracranial]] circulation,is recommended in patients who are potential candidates for mechanical [[thrombectomy]].<ref name="PowersRabinstein20192" /><ref name="AulickyMikulik2009">{{cite journal|last1=Aulicky|first1=P.|last2=Mikulik|first2=R.|last3=Goldemund|first3=D.|last4=Reif|first4=M.|last5=Dufek|first5=M.|last6=Kubelka|first6=T.|title=Safety of performing CT angiography in stroke patients treated with intravenous thrombolysis|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=81|issue=7|year=2009|pages=783–787|issn=0022-3050|doi=10.1136/jnnp.2009.184002}}</ref>
 ===MRI===
-There are no MRI findings associated with [disease name].
-OR
+*[[MRI]] of the head before [[Alteplase|IV alteplase]] administration to exclude microbleeds is not recommended.<ref name="PowersRabinstein20192" />
+*Multimodal [[MRI]] of the head should be done in patients who present within 24 hours of the initiation of symptoms.<ref name="QureshiAbd-Allah20202" />
+*In patients who wake up with clinical symptoms of [[stroke]] of unknown onset (more than 3 hours?), an [[MRI]] with diffusion-positive [[Fluid attenuated inversion recovery|FLAIR]] may be useful for selecting those who can benefit from [[Alteplase|IV alteplase]] administration.<ref name="PowersRabinstein20192" />
-[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
+===Electrocardiogram===
-OR
-There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
-===Other Imaging Findings===
-There are no other imaging findings associated with [disease name].
-OR
-[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
-===Other Diagnostic Studies===
-There are no other diagnostic studies associated with [disease name].
-OR
+*Baseline [[Electrocardiographic|electrocardiographic assessment]] is recommended in patients with [[stroke]] to help determine the follingow:<ref name="PowersRabinstein20192" /><ref name="pmid21804776">{{cite journal| author=Ustrell X, Pellisé A| title=Cardiac workup of ischemic stroke. | journal=Curr Cardiol Rev | year= 2010 | volume= 6 | issue= 3 | pages= 175-83 | pmid=21804776 | doi=10.2174/157340310791658721 | pmc=2994109 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21804776  }}</ref><ref name="pmid23661966">{{cite journal| author=Togha M, Sharifpour A, Ashraf H, Moghadam M, Sahraian MA| title=Electrocardiographic abnormalities in acute cerebrovascular events in patients with/without cardiovascular disease. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 66-71 | pmid=23661966 | doi=10.4103/0972-2327.107710 | pmc=3644785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661966  }}</ref>
+**Underlying cause for [[ischemic stroke]] such as [[Embolism|embolic]] source in [[atrial fibrillation]], ongoing myocardial ischemia, chronic myocardial injury and valvular abnormalities.
+**[[ECG]] monitoring in first 24 hours may help determine the new onset or [[paroxysmal atrial fibrillation]].
+**May determine cardiac complications of acute [[ischemic stroke]] such as [[myocardial ischemia]] or [[arrythmias]].
-[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
+<br />
-OR
+*To view diagnosis of COVID-19 section, click [[COVID-19 diagnostic study of choice|here]].
-Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
 ==Treatment==
-===Medical Therapy===
-There is no treatment for [disease name]; the mainstay of therapy is supportive care.
-OR
+=== Early assesment ===
-Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
+* The initial assesment goals of ischemic stroke may include the following:<ref name="pmid2337020522">{{cite journal|author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.|title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.|journal=Stroke|year=2013|volume=44|issue=3|pages=870-947|pmid=23370205|doi=10.1161/STR.0b013e318284056a|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205}}</ref>
+{{familytree/start |summary=PE diagnosis Algorithm.}}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=,|11=-|12= A01 |13=-|14= A02 |15= |16= |17= |A01=1) '''''Airway'''''<br>
+) '''''Breathing'''''<br>
+) '''''Circulation'''''|A02='''1)''' O2 administration at SpO2<94%
+'''2)''' Ventilatory assisstance is provided to patients who have difficulty breathting
+'''3)''' IV fluids or vasopressors are given to maintain hemodynamic stability}}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=!|11= |12= |13= |14= |15= |16= |17= |18= |19= |20= |21= |22= |23= |24= |25= |26= |27= |28= }}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=)|11=-|12= B01 |13=-|14= B02 |15=-|16= B03 |17= |18= |19= |B01='''''Early Diagnosis'''''|B02='''''History and PE'''''
+'''1)''' Help assess the severity of neurological deficit<br>
+'''2)''' Give clue to the underlying cause<br>
+'''3)''' Determine the site of infarction <br>|B03='''''Initial diagnostic tests'''''
+'''1)''' Noncontrast brain CT or brain MRI<br>
+'''2)''' Blood glucose<br>
+'''3)''' Oxygen saturation<br>
+'''4)''' Serum electrolytes/renal function tests<br>
+'''5)''' Complete blood count, including platelet count<br>
+'''6)''' Markers of cardiac ischemia<br>
+'''7)''' Prothrombin time/INR<br>
+'''8)''' Activated partial thromboplastin time<br>
+'''9)''' ECG}}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=!|11= |12= |13= |14= |15= |16= |17= |18= |19= |20= |21= |22= |23= |24= |25= |26= |27= |28= }}
+{{familytree |1= |2= |3= |4= |5= |6= C01 |7=-|8=+|9=-|10= C02 |11=-|12= C03 |13=-|14= C04 |15= |16= |C01='''Early assessment of ischemic stroke'''|C02='''''Reperfusion therapy'''''|C03='''''Medical'''''<br>
+r-tPA in eligible patients within 3-4.5 hours of onset of symptoms|C04='''''Surgical'''''}}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=!|11= |12= |13= |14= |15= |16= |17= |18= |19= |20= |21= |22= |23= |24= |25= |26= |27= |28= }}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=)|11=-|12= D01 |13=-|14= D02 |15= |16= |17= |D01='''''Symptomatic relief'''''|D02='''1)''' Fever<br>'''2)''' Headache<br>'''3)''' Shortness of breath<br>}}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=!|11= |12= |13= |14= |15= |16= |17= |18= |19= |20= |21= |22= |23= |24= |25= |26= |27= |28= }}
+{{familytree |1= |2= |3= |4= |5= |6= |7= |8= |9= |10=`|11=-|12= E01 |13=-|14= E02 |15= |16= |17= |E01='''''Prognosis'''''|E02='''1)'''NIHSS scoring<br>
+'''2)'''Glassgow coma scale}}
-OR
+{{familytree/end}}
+===Medical therapy===
-The majority of cases of [disease name] are self-limited and require only supportive care.
+*The reported cases of treatment for [[COVID-19]]-associated [[stroke]] have followed the same guidelines as patients with no [[COVID-19]] infection. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
+*[[Alteplase|IV alteplase]] is always preferred over mechanical [[thrombectomy]] when there are no contraindications.<ref name="SaverGoyal2016">{{cite journal|last1=Saver|first1=Jeffrey L.|last2=Goyal|first2=Mayank|last3=van der Lugt|first3=Aad|last4=Menon|first4=Bijoy K.|last5=Majoie|first5=Charles B. L. M.|last6=Dippel|first6=Diederik W.|last7=Campbell|first7=Bruce C.|last8=Nogueira|first8=Raul G.|last9=Demchuk|first9=Andrew M.|last10=Tomasello|first10=Alejandro|last11=Cardona|first11=Pere|last12=Devlin|first12=Thomas G.|last13=Frei|first13=Donald F.|last14=du Mesnil de Rochemont|first14=Richard|last15=Berkhemer|first15=Olvert A.|last16=Jovin|first16=Tudor G.|last17=Siddiqui|first17=Adnan H.|last18=van Zwam|first18=Wim H.|last19=Davis|first19=Stephen M.|last20=Castaño|first20=Carlos|last21=Sapkota|first21=Biggya L.|last22=Fransen|first22=Puck S.|last23=Molina|first23=Carlos|last24=van Oostenbrugge|first24=Robert J.|last25=Chamorro|first25=Ángel|last26=Lingsma|first26=Hester|last27=Silver|first27=Frank L.|last28=Donnan|first28=Geoffrey A.|last29=Shuaib|first29=Ashfaq|last30=Brown|first30=Scott|last31=Stouch|first31=Bruce|last32=Mitchell|first32=Peter J.|last33=Davalos|first33=Antoni|last34=Roos|first34=Yvo B. W. E. M.|last35=Hill|first35=Michael D.|title=Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis|journal=JAMA|volume=316|issue=12|year=2016|pages=1279|issn=0098-7484|doi=10.1001/jama.2016.13647}}</ref>
+*The usefulness of [[anticoagulants]] such as [[thrombin]] inhibitors ([[dabigatran]]) and [[factor Xa]] inhibitors ([[rivaroxaban]], [[apixaban]], [[edoxaban]]) is not well established in the acute setting of [[stroke]].<ref name="GioiaKate2016">{{cite journal|last1=Gioia|first1=Laura C.|last2=Kate|first2=Mahesh|last3=Sivakumar|first3=Leka|last4=Hussain|first4=Dulara|last5=Kalashyan|first5=Hayrapet|last6=Buck|first6=Brian|last7=Bussiere|first7=Miguel|last8=Jeerakathil|first8=Thomas|last9=Shuaib|first9=Ashfaq|last10=Emery|first10=Derek|last11=Butcher|first11=Ken|title=Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation|journal=Stroke|volume=47|issue=7|year=2016|pages=1917–1919|issn=0039-2499|doi=10.1161/STROKEAHA.116.013491}}</ref>
+*The use of [[thrombolysis]] via ultrasound waves concomitant to [[Fibrinolysis|IV fibrinolysis]] is not recommended.<ref name="NacuKvistad2017">{{cite journal|last1=Nacu|first1=Aliona|last2=Kvistad|first2=Christopher E.|last3=Naess|first3=Halvor|last4=Øygarden|first4=Halvor|last5=Logallo|first5=Nicola|last6=Assmus|first6=Jörg|last7=Waje-Andreassen|first7=Ulrike|last8=Kurz|first8=Kathinka D.|last9=Neckelmann|first9=Gesche|last10=Thomassen|first10=Lars|title=NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)|journal=Stroke|volume=48|issue=2|year=2017|pages=335–341|issn=0039-2499|doi=10.1161/STROKEAHA.116.014644}}</ref>
+*High-intensity [[statin]] therapy should be initiated in patients younger than 75 with clinical [[Coronary heart disease|ASCVD]], to achieving a reduction in [[LDL-C]] levels of at least 50%.
+*In patients older than 75 years of age with clinical [[Coronary heart disease|ASCVD]], it is reasonable to initiate moderate or high-intensity [[statin]] therapy after reviewing  [[adverse effects]] and [[Drug interaction|drug interactions]].<ref name="PowersRabinstein20192" /><ref name="SanossianSaver2006">{{cite journal|last1=Sanossian|first1=Nerses|last2=Saver|first2=Jeffrey L.|last3=Liebeskind|first3=David S.|last4=Kim|first4=Doojin|last5=Razinia|first5=Tannaz|last6=Ovbiagele|first6=Bruce|title=Achieving Target Cholesterol Goals After Stroke|journal=Archives of Neurology|volume=63|issue=8|year=2006|pages=1081|issn=0003-9942|doi=10.1001/archneur.63.8.1081}}</ref>
+*Risk and beneffits should be discussed before initiation of statin therapy to weight [[Coronary heart disease|ASCVD]] risk reduction against the potential for statin-associated side effects.<ref name="PowersRabinstein20192" />
+*Continuation of statin therapy during the acute period of [[ischemic stroke]] is reasonable among patients already taking [[Statins (patient information)|statins]].
-OR
+{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
+|+
+'''Summarized management of ischemic stroke'''
+! rowspan="2" style="background: #4479BA; width: 200px;" |{{fontcolor|1=#FFF|2=Medical treatment}}
+! rowspan="2" style="background: #4479BA; width: 150px;" |{{fontcolor|1=#FFF|2=Drug class}}
+! colspan="2" style="background: #4479BA; width: 350px;" |{{fontcolor|1=#FFF|2=Recommendations}}
+|-
+! style="background: #4479BA; width: 350px;" |{{fontcolor|1=#FFF|2=Acute}}
+! style="background: #4479BA; width: 350px;" |{{fontcolor|1=#FFF|2=Long-Term}}
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Reperfusion therapy'''
+| style="padding: 5px 5px; background: #F5F5F5;" |[[Tissue plasminogen activator|'''Tissue plasminogen activator''']] '''(t-PA)'''
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines<ref name="pmid233702053">{{cite journal|author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.|title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.|journal=Stroke|year=2013|volume=44|issue=3|pages=870-947|pmid=23370205|doi=10.1161/STR.0b013e318284056a|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205}}</ref><ref name="pmid 223152732">{{cite journal|author=Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE et al.|title=Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.|journal=Chest|year=2012|volume=141|issue=2 Suppl|pages=e601S-36S|pmid=22315273|doi=10.1378/chest.11-2302|pmc=3278065|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315273}}</ref><ref>{{cite web|url=http://www.aaem.org/em-resources/position-statements/clinical-practice/thrombolytic-therapy|title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke|publisher=American Academy of Emergency Medicine|accessdate=2008-01-25}}</ref> and [[systematic review]]s<ref name="pmid258716712">{{cite journal|author=Prabhakaran S, Ruff I, Bernstein RA|title=Acute stroke intervention: a systematic review.|journal=JAMA|year=2015|volume=313|issue=14|pages=1451-62|pmid=25871671|doi=10.1001/jama.2015.3058|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871671}}</ref><ref name="pmid250725282">{{cite journal|author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ|title=Thrombolysis for acute ischaemic stroke.|journal=Cochrane Database Syst Rev|year=2014|volume=7|issue=|pages=CD000213|pmid=25072528|doi=10.1002/14651858.CD000213.pub3|pmc=4153726|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528}}</ref><ref name="pmid251060632">{{cite journal|author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.|title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials.|journal=Lancet|year=2014|volume=|issue=|pages=|pmid=25106063|doi=10.1016/S0140-6736(14)60584-5|pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063}}</ref>
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*None
+|-
+| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antithrombotic agents'''
+| style="padding: 5px 5px; background: #F5F5F5;" |[[Antiplatelet agents|'''Antiplatelet agents''']]
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Oral administration of [[aspirin]] (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients<ref name="pmid233702053" />
+*Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration<ref name="pmid233702053" />
+* DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Long term therapy with [[clopidogrel]] or  aspirin extended release [[dipyridamole]] may be used for secondary prevention of non cardioembolic stroke
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Anticoagulants]]'''
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke<ref name="pmid172046812">{{cite journal  |author=Paciaroni M, Agnelli G, Micheli S, Caso V|title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials|journal=Stroke|volume=38|issue=2|pages=423-30|year=2007|pmid=17204681|doi=10.1161/01.STR.0000254600.92975.1f}} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis]</ref>
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease<ref name="pmid175770052">{{cite journal |author=Hart RG, Pearce LA, Aguilar MI|title=Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation|journal=Ann. Intern. Med.|volume=146|issue=12|pages=857-67|year=2007|pmid=17577005|doi=}}</ref>
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Antilipid therapy'''
+| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Statins]]'''
+| style="padding: 5px 5px; background: #F5F5F5;" |
+* Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable<ref name="pmid233702053" />
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease
+*Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
+|-
+| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antihypertensive therapy'''
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Intravenous [[antihypertensives]]'''
+'''([[Labetalol|Labetolol]], [[nitroprusside]])'''
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA<ref name="pmid233702053" />
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Oral antihypertensive therapy'''
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Recommended after 24 hours in patient having [[hypertension]]
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
+|-
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Antihyperglycemic agents'''
+| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Insulin]]'''
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke<ref name="pmid233702053" />
+| style="padding: 5px 5px; background: #F5F5F5;" |
+*Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with [[diabetes mellitus]]
+|-
+|}
+====Alteplase====
-[Disease name] is a medical emergency and requires prompt treatment.
+*[[Alteplase|IV alteplase]] is recommended for selected patients who can be treated within 3-4.5 hours of [[ischemic stroke]] [[symptom]] [[onset]] or patient last known well or at [[Baseline (medicine)|baseline]] state.<ref name="LeesEmberson2016">{{cite journal|last1=Lees|first1=Kennedy R.|last2=Emberson|first2=Jonathan|last3=Blackwell|first3=Lisa|last4=Bluhmki|first4=Erich|last5=Davis|first5=Stephen M.|last6=Donnan|first6=Geoffrey A.|last7=Grotta|first7=James C.|last8=Kaste|first8=Markku|last9=von Kummer|first9=Rüdiger|last10=Lansberg|first10=Maarten G.|last11=Lindley|first11=Richard I.|last12=Lyden|first12=Patrick|last13=Murray|first13=Gordon D.|last14=Sandercock|first14=Peter A.G.|last15=Toni|first15=Danilo|last16=Toyoda|first16=Kazunori|last17=Wardlaw|first17=Joanna M.|last18=Whiteley|first18=William N.|last19=Baigent|first19=Colin|last20=Hacke|first20=Werner|last21=Howard|first21=George|last22=Marler|first22=John|last23=Halls|first23=Heather|last24=Holland|first24=Lisa|last25=Mathews|first25=Clare|last26=Smith|first26=Samantha|last27=Wilson|first27=Kate|last28=Koga|first28=Masatoshi|last29=Albers|first29=Gregory|last30=Brott|first30=Thomas|last31=Cohen|first31=Geoffrey|last32=Koga|first32=Masatoshi|last33=Olivot|first33=Jean Marc|last34=Parsons|first34=Mark|last35=Tilley|first35=Barbara|last36=Wahlgren|first36=Nils|last37=del Zoppo|first37=Gregory J|title=Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes|journal=Stroke|volume=47|issue=9|year=2016|pages=2373–2379|issn=0039-2499|doi=10.1161/STROKEAHA.116.013644}}</ref><ref name="PowersRabinstein20192" /><ref>{{cite journal|title=The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial|journal=The Lancet|volume=379|issue=9834|year=2012|pages=2352–2363|issn=01406736|doi=10.1016/S0140-6736(12)60768-5}}</ref>
+*The [[dose]] of [[Alteplase|IV alteplase]] is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the [[dose]] given as a [[bolus]] over 1 min.<ref name="PowersRabinstein20192" />
+*[[Alteplase|IV alteplase]] should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.<ref name="PowersRabinstein20192" />
+*[[Hyperglycemia]] should be treated during the first 24 hours after [[ischemic stroke]], to achieve values of 140 to 180 mg/dL.<ref name="PowersRabinstein20192" />
+*[[Alteplase|IV alteplase]] may cause bleeding and [[angioedema]].<ref name="PowersRabinstein20192" />
+*[[Glycoprotein IIb/IIIa inhibitors]] ([[Tirofiban detailed information|tirofiban]], [[apiximab]], [[eptifibatide]]) should not be coadministered with [[Alteplase|IV alteplase]].<ref name="PowersRabinstein20192" /><ref name="AdeoyeSucharew2015">{{cite journal|last1=Adeoye|first1=Opeolu|last2=Sucharew|first2=Heidi|last3=Khoury|first3=Jane|last4=Tomsick|first4=Thomas|last5=Khatri|first5=Pooja|last6=Palesch|first6=Yuko|last7=Schmit|first7=Pamela A.|last8=Pancioli|first8=Arthur M.|last9=Broderick|first9=Joseph P.|title=Recombinant Tissue-Type Plasminogen Activator Plus Eptifibatide Versus Recombinant Tissue-Type Plasminogen Activator Alone in Acute Ischemic Stroke|journal=Stroke|volume=46|issue=2|year=2015|pages=461–464|issn=0039-2499|doi=10.1161/STROKEAHA.114.006743}}</ref>
+*[[Alteplase|IV alteplase]] may be used in patients under warfarin if the [[INR]] is lower than 1.7.<ref name="PowersRabinstein20192" />
+*[[Alteplase|IV alteplase]] should not be administered to patients who have received a full dose of [[low-molecular-weight heparin]] within the previous 24 hours (including [[Prophylaxis|prophylactic]] doses).<ref name="PowersRabinstein20192" /><ref name="PowersDerdeyn2015">{{cite journal|last1=Powers|first1=William J.|last2=Derdeyn|first2=Colin P.|last3=Biller|first3=José|last4=Coffey|first4=Christopher S.|last5=Hoh|first5=Brian L.|last6=Jauch|first6=Edward C.|last7=Johnston|first7=Karen C.|last8=Johnston|first8=S. Claiborne|last9=Khalessi|first9=Alexander A.|last10=Kidwell|first10=Chelsea S.|last11=Meschia|first11=James F.|last12=Ovbiagele|first12=Bruce|last13=Yavagal|first13=Dileep R.|title=2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment|journal=Stroke|volume=46|issue=10|year=2015|pages=3020–3035|issn=0039-2499|doi=10.1161/STR.0000000000000074}}</ref>
+*[[Blood pressure]] should be sustained lower than 180/105 mmHg the first 24 hours after [[Alteplase|IV alteplase]] administration. Intensive lowering has been shown to be safe.<ref name="PowersRabinstein20192" /><ref name="AndersonHuang2019">{{cite journal|last1=Anderson|first1=Craig S|last2=Huang|first2=Yining|last3=Lindley|first3=Richard I|last4=Chen|first4=Xiaoying|last5=Arima|first5=Hisatomi|last6=Chen|first6=Guofang|last7=Li|first7=Qiang|last8=Billot|first8=Laurent|last9=Delcourt|first9=Candice|last10=Bath|first10=Philip M|last11=Broderick|first11=Joseph P|last12=Demchuk|first12=Andrew M|last13=Donnan|first13=Geoffrey A|last14=Durham|first14=Alice C|last15=Lavados|first15=Pablo M|last16=Lee|first16=Tsong-Hai|last17=Levi|first17=Christopher|last18=Martins|first18=Sheila O|last19=Olavarria|first19=Veronica V|last20=Pandian|first20=Jeyaraj D|last21=Parsons|first21=Mark W|last22=Pontes-Neto|first22=Octavio M|last23=Ricci|first23=Stefano|last24=Sato|first24=Shoichiro|last25=Sharma|first25=Vijay K|last26=Silva|first26=Federico|last27=Song|first27=Lili|last28=Thang|first28=Nguyen H|last29=Wardlaw|first29=Joanna M|last30=Wang|first30=Ji-Guang|last31=Wang|first31=Xia|last32=Woodward|first32=Mark|last33=Chalmers|first33=John|last34=Robinson|first34=Thompson G|last35=Anderson|first35=Craig S.|last36=Huang|first36=Yining|last37=Lindley|first37=Richard I.|last38=Chen|first38=Xiaoying|last39=Arima|first39=Hisatomi|last40=Chen|first40=Guofang|last41=Li|first41=Qiang|last42=Billot|first42=Laurent|last43=Delcourt|first43=Candice|last44=Bath|first44=Philip M.|last45=Broderick|first45=Joseph P.|last46=Demchuk|first46=Andrew M.|last47=Donnan|first47=Geoffrey A.|last48=Durham|first48=Alice C.|last49=Lavados|first49=Pablo M.|last50=Lee|first50=Tsong-Hai|last51=Levi|first51=Christopher|last52=Martins|first52=Sheila O.|last53=Olavarria|first53=Veronica V.|last54=Pandian|first54=Jeyaraj D.|last55=Parsons|first55=Mark W.|last56=Pontes-Neto|first56=Octavio M.|last57=Ricci|first57=Stefano|last58=Sato|first58=Shoichiro|last59=Sharma|first59=Vijay K.|last60=Silva|first60=Federico|last61=Song|first61=Lili|last62=Thang|first62=Nguyen H.|last63=Wardlaw|first63=Joanna M.|last64=Wang|first64=Ji-Guang|last65=Wang|first65=Xia|last66=Woodward|first66=Mark|last67=Chalmers|first67=John|last68=Robinson|first68=Thompson G.|last69=Kim|first69=Jong S.|last70=Stapf|first70=Christian|last71=Simes|first71=R. 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Truong|last634=Cam|first634=L. Dam Thi|last635=Kim|first635=T. Ngo Thi|last636=Nguyen|first636=B. Pham|last637=Dat|first637=A. Nguyen|last638=Van|first638=C. Nguyen|last639=Duy|first639=T. Mai|last640=Viet|first640=P. Dao|last641=Tien|first641=D. Nguyen|last642=Van|first642=T. Vo|last643=Le Kim|first643=K.|last644=Ngoc|first644=T. Bui|last645=Le Thanh|first645=T. Tran|last646=Hoanh|first646=S. Nguyen|last647=Phuoc|first647=S. Pham|last648=Van|first648=T. Tran|last649=Thi|first649=B. Doan|last650=Thu|first650=H. Nguyen Thi|last651=Duy|first651=M. Nguyen|last652=Van|first652=D. Ngo|title=Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial|journal=The Lancet|volume=393|issue=10174|year=2019|pages=877–888|issn=01406736|doi=10.1016/S0140-6736(19)30038-8}}</ref>
+*In case of [[Intracranial hemorrhage|intracranial bleeding]] due to [[alteplase]] administration, [[alteplase]] should be suspended, blood draws should be taken ([[Complete blood count|CBC]], [[coagulation studies]]), [[tranexamic acid]] should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested [[Computed tomography|CT scan]] of the head taken.<ref name="SloanPrice1995">{{cite journal|last1=Sloan|first1=M. A.|last2=Price|first2=T.R.|last3=Petito|first3=C. K.|last4=Randall|first4=A. M. Y.|last5=Solomon|first5=R. E.|last6=Terrin|first6=M. L.|last7=Gore|first7=J.|last8=Collen|first8=D.|last9=Kleiman|first9=N.|last10=Feit|first10=F.|last11=Babb|first11=J.|last12=Herman|first12=M.|last13=Roberts|first13=W. C.|last14=Sopko|first14=G.|last15=Bovill|first15=E.|last16=Forman|first16=S.|last17=Knatterud|first17=G. L.|title=Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: The Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial Combined experience|journal=Neurology|volume=45|issue=4|year=1995|pages=649–658|issn=0028-3878|doi=10.1212/WNL.45.4.649}}</ref>
+*The use of [[Alteplase|IV alteplase]] should be used cautiously in patients who undergone a [[major surgery]] in the past 2 weeks.<ref name="PowersRabinstein20192" />
+*[[Alteplase|IV alteplase]] for [[ischemic stroke]] is contraindicated in patients with a severe [[head trauma]] or [[Subarachnoid hemorrhage|subarachnoid hemorrage]] in the preceding 3 months.<ref name="PowersRabinstein20192" />
-OR
+====Tenecteplase====
-The mainstay of treatment for [disease name] is [therapy].
+*[[Tenecteplase]] may be useful in patients with minor [[neurological]] impairment.<ref name="HuangCheripelli2015">{{cite journal|last1=Huang|first1=Xuya|last2=Cheripelli|first2=Bharath Kumar|last3=Lloyd|first3=Suzanne M|last4=Kalladka|first4=Dheeraj|last5=Moreton|first5=Fiona Catherine|last6=Siddiqui|first6=Aslam|last7=Ford|first7=Ian|last8=Muir|first8=Keith W|title=Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study|journal=The Lancet Neurology|volume=14|issue=4|year=2015|pages=368–376|issn=14744422|doi=10.1016/S1474-4422(15)70017-7}}</ref>
+*The dose of [[tenecteplase]] is a single IV [[bolus]] of 0.25-mg/kg (maximum 25 mg).<ref name="CampbellMitchell2018">{{cite journal|last1=Campbell|first1=Bruce C.V.|last2=Mitchell|first2=Peter J.|last3=Churilov|first3=Leonid|last4=Yassi|first4=Nawaf|last5=Kleinig|first5=Timothy J.|last6=Dowling|first6=Richard J.|last7=Yan|first7=Bernard|last8=Bush|first8=Steven J.|last9=Dewey|first9=Helen M.|last10=Thijs|first10=Vincent|last11=Scroop|first11=Rebecca|last12=Simpson|first12=Marion|last13=Brooks|first13=Mark|last14=Asadi|first14=Hamed|last15=Wu|first15=Teddy Y.|last16=Shah|first16=Darshan G.|last17=Wijeratne|first17=Tissa|last18=Ang|first18=Timothy|last19=Miteff|first19=Ferdinand|last20=Levi|first20=Christopher R.|last21=Rodrigues|first21=Edrich|last22=Zhao|first22=Henry|last23=Salvaris|first23=Patrick|last24=Garcia-Esperon|first24=Carlos|last25=Bailey|first25=Peter|last26=Rice|first26=Henry|last27=de Villiers|first27=Laetitia|last28=Brown|first28=Helen|last29=Redmond|first29=Kendal|last30=Leggett|first30=David|last31=Fink|first31=John N.|last32=Collecutt|first32=Wayne|last33=Wong|first33=Andrew A.|last34=Muller|first34=Claire|last35=Coulthard|first35=Alan|last36=Mitchell|first36=Ken|last37=Clouston|first37=John|last38=Mahady|first38=Kate|last39=Field|first39=Deborah|last40=Ma|first40=Henry|last41=Phan|first41=Thanh G.|last42=Chong|first42=Winston|last43=Chandra|first43=Ronil V.|last44=Slater|first44=Lee-Anne|last45=Krause|first45=Martin|last46=Harrington|first46=Timothy J.|last47=Faulder|first47=Kenneth C.|last48=Steinfort|first48=Brendan S.|last49=Bladin|first49=Christopher F.|last50=Sharma|first50=Gagan|last51=Desmond|first51=Patricia M.|last52=Parsons|first52=Mark W.|last53=Donnan|first53=Geoffrey A.|last54=Davis|first54=Stephen M.|title=Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke|journal=New England Journal of Medicine|volume=378|issue=17|year=2018|pages=1573–1582|issn=0028-4793|doi=10.1056/NEJMoa1716405}}</ref>
-OR
+====Antiplatelet therapy====
-The optimal therapy for [malignancy name] depends on the stage at diagnosis.
-OR
+*Administration of [[aspirin]] is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with [[Alteplase|IV alteplase]], aspirin administration is generally delayed until 24 hours later.<ref name="JeongKim2016">{{cite journal|last1=Jeong|first1=Han-Gil|last2=Kim|first2=Beom Joon|last3=Yang|first3=Mi Hwa|last4=Han|first4=Moon-Ku|last5=Bae|first5=Hee-Joon|last6=Lee|first6=Seung-Hoon|title=Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment|journal=Neurology|volume=87|issue=10|year=2016|pages=996–1002|issn=0028-3878|doi=10.1212/WNL.0000000000003083}}</ref>
+*The dose of [[aspirin]] is usually between 160-300mg daily.<ref name="pmid9174558">{{cite journal |vauthors= |title=The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group |journal=Lancet |volume=349 |issue=9065 |pages=1569–81 |date=May 1997 |pmid=9174558 |doi= |url=}}</ref>
+*[[Aspirin|IV aspirin]] administration within 90 minutes after the start of [[Alteplase|IV alteplase]] is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.<ref name="PowersRabinstein20192" /><ref name="ZinkstokRoos2012">{{cite journal|last1=Zinkstok|first1=Sanne M|last2=Roos|first2=Yvo B|title=Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial|journal=The Lancet|volume=380|issue=9843|year=2012|pages=731–737|issn=01406736|doi=10.1016/S0140-6736(12)60949-0}}</ref>
+*[[Dual antiplatelet therapy]] with [[aspirin]] and [[clopidogrel]] (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after [[symptom]] onset and continued for 21 days in patients with no cardioembolic [[ischemic stroke]].<ref name="JohnstonEaston2018">{{cite journal|last1=Johnston|first1=S. Claiborne|last2=Easton|first2=J. Donald|last3=Farrant|first3=Mary|last4=Barsan|first4=William|last5=Conwit|first5=Robin A.|last6=Elm|first6=Jordan J.|last7=Kim|first7=Anthony S.|last8=Lindblad|first8=Anne S.|last9=Palesch|first9=Yuko Y.|title=Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA|journal=New England Journal of Medicine|volume=379|issue=3|year=2018|pages=215–225|issn=0028-4793|doi=10.1056/NEJMoa1800410}}</ref>
+*[[Aspirin]] should not substitute [[Alteplase|IV alteplase]] or mechanical thrombectomy in patients eligible for these therapies.<ref name="PowersRabinstein20192" />
-[Therapy] is recommended among all patients who develop [disease name].
+===Surgery===
-OR
+*The usefulness of emergency carotid endarterectomy, [[carotid]] [[angioplasty]] and stenting in the absence of an intracranial clot is not well established.<ref name="PowersRabinstein20192" />
-Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
+====Mechanical thrombectomy with a stent retriever====
-OR
+*Mechanical [[thrombectomy]] with stent retrievers is recommended over intra arterial [[fibrinolysis]] as first-line [[therapy]].<ref name="PowersRabinstein20192" />
+*Mechanical [[thrombectomy]] may be useful in selected patients with up to 24 hours of initiation of [[stroke]].<ref name="PowersRabinstein20192" /><ref name="AlbersMarks2018">{{cite journal|last1=Albers|first1=Gregory W.|last2=Marks|first2=Michael P.|last3=Kemp|first3=Stephanie|last4=Christensen|first4=Soren|last5=Tsai|first5=Jenny P.|last6=Ortega-Gutierrez|first6=Santiago|last7=McTaggart|first7=Ryan A.|last8=Torbey|first8=Michel T.|last9=Kim-Tenser|first9=May|last10=Leslie-Mazwi|first10=Thabele|last11=Sarraj|first11=Amrou|last12=Kasner|first12=Scott E.|last13=Ansari|first13=Sameer A.|last14=Yeatts|first14=Sharon D.|last15=Hamilton|first15=Scott|last16=Mlynash|first16=Michael|last17=Heit|first17=Jeremy J.|last18=Zaharchuk|first18=Greg|last19=Kim|first19=Sun|last20=Carrozzella|first20=Janice|last21=Palesch|first21=Yuko Y.|last22=Demchuk|first22=Andrew M.|last23=Bammer|first23=Roland|last24=Lavori|first24=Philip W.|last25=Broderick|first25=Joseph P.|last26=Lansberg|first26=Maarten G.|title=Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging|journal=New England Journal of Medicine|volume=378|issue=8|year=2018|pages=708–718|issn=0028-4793|doi=10.1056/NEJMoa1713973}}</ref>
+*In patients who undergo mechanical [[thrombectomy]],[[blood pressure]] should be maintained below 180/105 mmHg during and for 24 hours after the procedure.<ref name="PowersRabinstein20192" />
-Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
+*Patients should receive mechanical [[thrombectomy]] with a stent retriever if they meet all the following criteria:<ref name="GoyalMenon2016">{{cite journal|last1=Goyal|first1=Mayank|last2=Menon|first2=Bijoy K|last3=van Zwam|first3=Wim H|last4=Dippel|first4=Diederik W J|last5=Mitchell|first5=Peter J|last6=Demchuk|first6=Andrew M|last7=Dávalos|first7=Antoni|last8=Majoie|first8=Charles B L M|last9=van der Lugt|first9=Aad|last10=de Miquel|first10=Maria A|last11=Donnan|first11=Geoffrey A|last12=Roos|first12=Yvo B W E M|last13=Bonafe|first13=Alain|last14=Jahan|first14=Reza|last15=Diener|first15=Hans-Christoph|last16=van den Berg|first16=Lucie A|last17=Levy|first17=Elad I|last18=Berkhemer|first18=Olvert A|last19=Pereira|first19=Vitor M|last20=Rempel|first20=Jeremy|last21=Millán|first21=Mònica|last22=Davis|first22=Stephen M|last23=Roy|first23=Daniel|last24=Thornton|first24=John|last25=Román|first25=Luis San|last26=Ribó|first26=Marc|last27=Beumer|first27=Debbie|last28=Stouch|first28=Bruce|last29=Brown|first29=Scott|last30=Campbell|first30=Bruce C V|last31=van Oostenbrugge|first31=Robert J|last32=Saver|first32=Jeffrey L|last33=Hill|first33=Michael D|last34=Jovin|first34=Tudor G|title=Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials|journal=The Lancet|volume=387|issue=10029|year=2016|pages=1723–1731|issn=01406736|doi=10.1016/S0140-6736(16)00163-X}}</ref>
+*#Pre[[stroke]] mRS score of 0 to 1
+*#Causative occlusion of the internal carotid artery or MCA segment 1 (M1)
+*#Age ≥18 years
+*#[[National Institutes of Health Stroke Scale|NIHSS]] score of ≥6
+*#[[ASPECT|ASPECTS]] of ≥6; and
+*#[[Treatment]] can be initiated within 6 hours of [[Symptom|symptom onset]]
-OR
+====Aspiration thrombectomy====
-Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
+*Aspiration [[thrombectomy]] has not been shown to be inferior to [[stent]] retriever.<ref name="TurkSiddiqui20192">{{cite journal|last1=Turk|first1=Aquilla S|last2=Siddiqui|first2=Adnan|last3=Fifi|first3=Johanna T|last4=De Leacy|first4=Reade A|last5=Fiorella|first5=David J|last6=Gu|first6=Eugene|last7=Levy|first7=Elad I|last8=Snyder|first8=Kenneth V|last9=Hanel|first9=Ricardo A|last10=Aghaebrahim|first10=Amin|last11=Woodward|first11=B Keith|last12=Hixson|first12=Harry R|last13=Chaudry|first13=Mohammad I|last14=Spiotta|first14=Alejandro M|last15=Rai|first15=Ansaar T|last16=Frei|first16=Donald|last17=Almandoz|first17=Josser E Delgado|last18=Kelly|first18=Mike|last19=Arthur|first19=Adam|last20=Baxter|first20=Blaise|last21=English|first21=Joey|last22=Linfante|first22=Italo|last23=Fargen|first23=Kyle M|last24=Mocco|first24=J|title=Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial|journal=The Lancet|volume=393|issue=10175|year=2019|pages=998–1008|issn=01406736|doi=10.1016/S0140-6736(19)30297-1}}</ref>
-OR
+*Direct aspiration [[thrombectomy]] as first-pass mechanical [[thrombectomy]] is recommended as noninferior to stent retriever for patients who meet all the following criteria:<ref name="TurkSiddiqui20192" />
+*#Pre[[stroke]] mRS score of 0 to 1;
+*#Causative occlusion of the internal carotid artery or M1;
+*#Age ≥18 years;
+*#[[National Institutes of Health Stroke Scale|NIHSS]] score of ≥6;
+*#[[ASPECT|ASPECTS]] ≥6; and
+*#[[Treatment]] initiation within 6 hours of symptom onset.
-Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
+====Intra arterial fibrinolysis====
-===Surgery===
+*Intra-arterial [[fibrinolysis]] may be initiated within 6 hours of [[stroke]] onset in selected patients in whom [[Alteplase|IV alteplase]] is contraindicated.
-Surgical intervention is not recommended for the management of [disease name].
-OR
-Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
-OR
-The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
+===Other aspects of management===
-OR
+*Volume expansors are not recommended in [[ischemic stroke]].<ref name="PowersRabinstein20192" /><ref name="GulumaLiebeskind2015">{{cite journal|last1=Guluma|first1=Kama Z.|last2=Liebeskind|first2=David S.|last3=Raman|first3=Rema|last4=Rapp|first4=Karen S.|last5=Ernstrom|first5=Karin B.|last6=Alexandrov|first6=Andrei V.|last7=Shahripour|first7=Reza B.|last8=Barlinn|first8=Kristian|last9=Starkman|first9=Sidney|last10=Grunberg|first10=Ileana D.|last11=Hemmen|first11=Thomas M.|last12=Meyer|first12=Brett C.|last13=Alexandrov|first13=Anne W.|title=Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke—The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial|journal=Journal of Stroke and Cerebrovascular Diseases|volume=24|issue=11|year=2015|pages=2596–2604|issn=10523057|doi=10.1016/j.jstrokecerebrovasdis.2015.07.013}}</ref>
+*The best head positioning after [[stroke]] is not well established.<ref name="PowersRabinstein20192" /><ref name="AndersonArima2017">{{cite journal|last1=Anderson|first1=Craig S.|last2=Arima|first2=Hisatomi|last3=Lavados|first3=Pablo|last4=Billot|first4=Laurent|last5=Hackett|first5=Maree L.|last6=Olavarría|first6=Verónica V.|last7=Muñoz Venturelli|first7=Paula|last8=Brunser|first8=Alejandro|last9=Peng|first9=Bin|last10=Cui|first10=Liying|last11=Song|first11=Lily|last12=Rogers|first12=Kris|last13=Middleton|first13=Sandy|last14=Lim|first14=Joyce Y.|last15=Forshaw|first15=Denise|last16=Lightbody|first16=C. Elizabeth|last17=Woodward|first17=Mark|last18=Pontes-Neto|first18=Octavio|last19=De Silva|first19=H. Asita|last20=Lin|first20=Ruey-Tay|last21=Lee|first21=Tsong-Hai|last22=Pandian|first22=Jeyaraj D.|last23=Mead|first23=Gillian E.|last24=Robinson|first24=Thompson|last25=Watkins|first25=Caroline|title=Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke|journal=New England Journal of Medicine|volume=376|issue=25|year=2017|pages=2437–2447|issn=0028-4793|doi=10.1056/NEJMoa1615715}}</ref>
-The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
+*Supplemental [[oxygen]] and [[mechanical ventilation]] support should be provided when necessary to maintain [[oxygen saturation]] higher than 93%.<ref name="PowersRabinstein20192" /><ref name="RoffeNevatte2017">{{cite journal|last1=Roffe|first1=Christine|last2=Nevatte|first2=Tracy|last3=Sim|first3=Julius|last4=Bishop|first4=Jon|last5=Ives|first5=Natalie|last6=Ferdinand|first6=Phillip|last7=Gray|first7=Richard|title=Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke|journal=JAMA|volume=318|issue=12|year=2017|pages=1125|issn=0098-7484|doi=10.1001/jama.2017.11463}}</ref>
-OR
+*Sources of [[hyperthermia]] (>38°C) should be identified and treated with [[Antipyretic|antipyretics]] in patients with [[stroke]].<ref name="PowersRabinstein20192" /><ref name="SaxenaYoung2015">{{cite journal|last1=Saxena|first1=Manoj|last2=Young|first2=Paul|last3=Pilcher|first3=David|last4=Bailey|first4=Michael|last5=Harrison|first5=David|last6=Bellomo|first6=Rinaldo|last7=Finfer|first7=Simon|last8=Beasley|first8=Richard|last9=Hyam|first9=Jonathan|last10=Menon|first10=David|last11=Rowan|first11=Kathryn|last12=Myburgh|first12=John|title=Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection|journal=Intensive Care Medicine|volume=41|issue=5|year=2015|pages=823–832|issn=0342-4642|doi=10.1007/s00134-015-3676-6}}</ref>
+*[[Hypoglycemia]] (<60 mg/dL) should be treated in the acute setting in patients with [[ischemic stroke]].<ref name="PowersRabinstein20192" />
-Surgery is the mainstay of treatment for [disease or malignancy].
+*[[Blood pressure]] ≥220/120 in patients who did not receive [[Tissue plasminogen activator|TPA]] should be treated within the first 48 to 72 hours after the onset of [[ischemic stroke]].<ref name="SchraderLüders2003">{{cite journal|last1=Schrader|first1=Joachim|last2=Lüders|first2=Stephan|last3=Kulschewski|first3=Anke|last4=Berger|first4=Jürgen|last5=Zidek|first5=Walter|last6=Treib|first6=Johannes|last7=Einhäupl|first7=Karl|last8=Diener|first8=Hans Christoph|last9=Dominiak|first9=Peter|title=The ACCESS Study|journal=Stroke|volume=34|issue=7|year=2003|pages=1699–1703|issn=0039-2499|doi=10.1161/01.STR.0000075777.18006.89}}</ref>
+*[[Enteral feeding]] should be started within 7 days of admission after an acute [[stroke]] when there is no [[Contraindication|contraindications]].<ref name="pmid16409880">{{cite journal |vauthors=Dennis M, Lewis S, Cranswick G, Forbes J |title=FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke |journal=Health Technol Assess |volume=10 |issue=2 |pages=iii–iv, ix–x, 1–120 |date=January 2006 |pmid=16409880 |doi=10.3310/hta10020 |url=}}</ref>
+*[[Psychological]] screening is always recommended to exclude poststroke depression.<ref name="MeaderMoe-Byrne2013">{{cite journal|last1=Meader|first1=N.|last2=Moe-Byrne|first2=T.|last3=Llewellyn|first3=A.|last4=Mitchell|first4=A. J.|title=Screening for poststroke major depression: a meta-analysis of diagnostic validity studies|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=85|issue=2|year=2013|pages=198–206|issn=0022-3050|doi=10.1136/jnnp-2012-304194}}</ref>
+*Early [[Rehabilitation counseling|rehabilitation]] in patients with [[stroke]] is adviced.<ref name="PowersRabinstein20192" />
 ===Primary Prevention===
-There are no established measures for the primary prevention of [disease name].
-OR
+*There is currently no [[vaccine]] to prevent [[COVID-19]]. The best way to prevent [[infection]] is to avoid being exposed to this [[virus]].
+*[[COVID-19]] increases the probability of developing [[ischemic stroke]], but there are several measures that can decrease the risk of [[stroke]], among them:
-There are no available vaccines against [disease name].
+*[[Smoking cessation]]
+*Lowering [[blood pressure]]
-OR
+*Decreasing [[alcohol intake]]
+*[[Exercise]]
-Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
+*Treatment of [[atrial fibrillation]]
+*[[Weight loss]]
-OR
+*Procedures such as [[carotid endarterectomy]] or [[carotid]] [[angioplasty]] when necessary
-[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
 ===Secondary Prevention===
-There are no established measures for the secondary prevention of [disease name].
-OR
-Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
+*[[Smoking cessation]] should be highly encouraged in patients who suffered from [[stroke]], behavioral interventions and [[Nicotine replacement therapy|nicotine replacement]] may be necessary.
+To view treatment of COVID-19 section, click [[COVID-19 medical therapy|here]].
 ==References==
 {{reflist|2}}
+[[Category:Up-To-Date]]
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