Can you provide a brief overview of stroke, including its types, clinical presentation, acute management, and secondary prevention?

Stroke Overview

Stroke is a clinical syndrome of acute focal neurological deficit caused by vascular injury to the central nervous system, classified into ischemic (85%) and hemorrhagic (15%) subtypes, requiring immediate recognition and treatment to minimize permanent disability and death. 1

Types of Stroke

Ischemic Stroke (85% of cases)

• Thrombotic: Small vessel arteriolosclerosis affecting deep perforating arteries
• Cardioembolic: From atrial fibrillation, prosthetic valves, or cardiac thrombi
• Large artery atherothromboembolism: Carotid or vertebrobasilar disease
• Dissection: Particularly in younger patients (<50 years) 1

Hemorrhagic Stroke (15% of cases)

• Intracerebral hemorrhage (10%):
  • Deep (basal ganglia, brainstem) from hypertensive arteriopathy
  • Lobar from cerebral amyloid angiopathy
  • Macrovascular lesions (aneurysms, AVMs) especially in young patients 1
• Subarachnoid hemorrhage (3%): Typically from ruptured aneurysms 2

Clinical Presentation

The WHO defines stroke as "rapidly developing clinical signs of focal cerebral disturbance lasting more than 24 hours with no apparent cause other than vascular origin." 2

Key presenting features depend on vascular territory:

• Sudden weakness or numbness (face, arm, leg - typically unilateral)
• Acute speech disturbance (aphasia, dysarthria)
• Visual field defects or diplopia
• Ataxia, vertigo, or balance problems
• Sudden severe headache (particularly with hemorrhage)
• Altered consciousness

Use the NIHSS (National Institutes of Health Stroke Scale) for standardized neurological assessment 2

Acute Management

Initial Assessment (Time-Critical)

The primary goals are: (1) exclude intracranial hemorrhage, (2) assess contraindications to thrombolytics, (3) characterize the infarct 2

Essential immediate workup:

• Time of symptom onset (most critical piece of information)
• Non-contrast CT head (to exclude hemorrhage)
• Glucose level (hypoglycemia mimics stroke)
• PT/INR, complete blood count
• ECG
• NIHSS score 2

Reperfusion Therapy

Intravenous thrombolysis should be administered to eligible patients based on the 2026 AHA/ASA guidelines, with updated criteria for thrombolytic choice and eligibility 3

Endovascular thrombectomy is indicated for eligible patients with large vessel occlusion, with determination based on updated 2026 evidence regarding patient selection 3

Supportive Care

• Blood pressure management (avoid aggressive lowering in acute phase unless specific indications)
• Glucose control (hyperglycemia management per 2026 guidelines) 3
• Dysphagia screening before oral intake 3
• Monitor for neurological deterioration

Secondary Prevention

Secondary prevention must be tailored to the specific ischemic stroke subtype identified through systematic diagnostic workup 4

Risk Factor Management (Critical Foundation)

Hypertension control is the single most important modifiable risk factor 4, 1

Intensive medical management targets:

• Blood pressure: Aggressive control with individualized targets
• Lipids: Statin therapy for most patients
• Diabetes: Optimize glycemic control
• Smoking cessation: Mandatory 4

A multidisciplinary outpatient team-based approach with active medication adjustment from advanced practice providers, nurses, or pharmacists is effective for controlling BP, lipids, and other vascular risk factors 4

Lifestyle Modifications

Low-salt and Mediterranean diets are specifically recommended for stroke risk reduction 4

Physical activity in a supervised and safe manner is essential, as stroke patients are particularly prone to sedentary behavior 4

Behavioral change requires more than simple advice - use programs with theoretical models of behavior change, proven techniques, and multidisciplinary support 4

Antithrombotic Therapy

Nearly all patients without contraindications require antithrombotic therapy (antiplatelet or anticoagulant) 4

Critical principles:

• Combination of antiplatelet + anticoagulation is typically NOT indicated (with very few exceptions) 4
• Long-term dual antiplatelet therapy is NOT recommended 4
• Short-term dual antiplatelet therapy is indicated only for:
  • Early-arriving minor stroke
  • High-risk TIA
  • Severe symptomatic intracranial stenosis 4

Etiology-Specific Prevention

Cardioembolic stroke: Anticoagulation for atrial fibrillation and other cardiac sources

Large artery atherosclerosis: Antiplatelet therapy + aggressive risk factor control; consider carotid revascularization for significant stenosis

Small vessel disease: Intensive BP control + antiplatelet therapy

Systems-Based Approach

Voluntary hospital-based or outpatient-focused quality monitoring and improvement programs improve both short-term and long-term adherence to evidence-based secondary prevention guidelines 4

For patients presenting to primary care after TIA or minor stroke, decision support tools that improve diagnostic accuracy, stratify risk, and prompt medication initiation reduce 90-day recurrence risk 4

Common Pitfalls

• Missing the therapeutic window: Every minute counts - "time is brain"
• Failing to identify stroke subtype: This determines the entire secondary prevention strategy 4
• Inadequate risk factor control post-discharge: Treatment targets are frequently unmet, increasing recurrence risk 4
• Prescribing dual antiplatelet + anticoagulation: This combination is almost never appropriate 4
• Giving simple advice without structured support: Behavioral change requires intensive, theory-based programs 4
• Neglecting caregiver support and rehabilitation: These are essential for recovery 5