We searched the Cochrane Library, MEDLINE, and Embase for articles published in English between Jan 1, 2015, and Dec 31, 2019. We used the search terms “ischaemic/ischemic stroke” or “intracerebral haemorrhage/hemorrhage”, and “clinical trial” or “meta-analysis”. We also searched the reference lists of articles identified by this search strategy and selected those that we judged to be relevant. We largely selected publications in the past 5 years but did not exclude commonly referenced and
SeminarStroke
Introduction
Stroke is a common disease, with one in four people affected over their lifetime, and is the second leading cause of death and third leading cause of disability in adults worldwide.1 Substantial advances in therapy have occurred in the past 5 years, particularly for the acute treatment of ischaemic stroke. New strategies for preventing recurrence have also been identified. This Seminar outlines the diagnosis and management of ischaemic stroke and intracerebral haemorrhage in contemporary stroke units.
Section snippets
Definition of stroke
Stroke is defined as a neurological deficit attributed to an acute focal injury of the CNS (ie, brain, retina, or spinal cord) by a vascular cause.2 Most strokes are ischaemic due to reduced blood flow, generally resulting from arterial occlusion. A rarer type of ischaemic stroke is venous infarction due to occlusion of cerebral veins or venous sinuses. The remaining 10–40% of stroke presentations, depending on regional epidemiology, are haemorrhagic and result from the rupture of cerebral
Diagnosis of stroke and mimics
The key clinical feature of stroke is the sudden onset of a focal neurological deficit. The timing of this sudden onset can be masked if the patient awakens with stroke symptoms or if the onset is unwitnessed and the patient is unable to communicate or does not have the insight to recognise the timing of deficit. The time of stroke onset is therefore defined as the time that the patient was last known to be well.
Knowledge of neuroanatomical structures and vascular territories allows
Epidemiology and risk factors
The 2016 Global Burden of Disease data that were published in 2019 indicate that one in four people will have a stroke in their lifetime.3 There are estimated to be 9·6 million ischaemic strokes and 4·1 million haemorrhagic strokes (including intracerebral and subarachnoid haemorrhage) globally each year, with a relatively stable incidence adjusted for age in high-income countries but an increasing incidence in low-income and middle-income countries.3 The absolute incidence is expected to
Ischaemic stroke
Most ischaemic stroke is due to embolism, either from atherosclerotic plaque in the aortic arch or in the cervical arteries or from the heart (panel, figure 2). Intracranial atherosclerosis with in-situ thrombosis is also an important mechanism of stroke, particularly in Asian and Black ethnic groups.12 Small vessel disease causes small subcortical infarcts (ie, lacunar stroke) and deep intracerebral haemorrhage. Cervical artery dissection is one of the common causes of stroke in younger
Acute management
Acute management of patients with stroke should occur in a stroke unit that is organised and geographically defined. Care in a stroke unit has been clearly shown to increase survival without disability for patients of all ages, severities, and stroke subtypes,21 and comprises an expert integrated medical, nursing, and allied health team applying evidence-based clinical protocols (table). Care in a stroke unit is the foundation on which acute stroke interventions can be delivered. The aims are
Ischaemic stroke and transient ischaemic attack
The general principles of secondary stroke prevention involve an approach to absolute cardiovascular risk with treatment of all risk factors in a patient who is, as a result of having had a stroke, at high risk of recurrent stroke and cardiovascular disease. However, secondary prevention also needs to be tailored to the specific mechanism of the incident stroke, and this requires thorough investigation for causative factors.
CT angiography from aortic arch to cerebral vertex is the favoured
Rehabilitation and recovery
For people who have had stroke, the ability to return to work and social functions is the key priority. Structured rehabilitation is the accepted practice in most high-income countries but is non-existent in many low-income or middle-income regions where the family are responsible for postacute care. Developing evidence for rehabilitation interventions has been challenging. Most randomised trials have not shown a benefit of the intervention of interest. For example, the largest trial for stroke
Conclusions
Care for patients with stroke has transformed over the past 5 years, particularly with reperfusion therapies for ischaemic stroke and improved secondary prevention, although large gaps between evidence and practice still exist. Interventions for intracerebral haemorrhage might similarly revolutionise our approach to that condition in the future. There is reinvigorated interest in the fields of cytoprotection and recovery enhancement. Improved implementation of our existing knowledge about
Search strategy and selection criteria
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