Elsevier

The Lancet

Volume 396, Issue 10244, 11–17 July 2020, Pages 129-142
The Lancet

Seminar
Stroke

https://doi.org/10.1016/S0140-6736(20)31179-XGet rights and content

Summary

Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.

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

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

References (142)

  • K Martinod et al.

    Thrombosis: tangled up in NETs

    Blood

    (2014)
  • BCV Campbell et al.

    Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data

    Lancet Neurol

    (2019)
  • LS Roman et al.

    Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data

    Lancet Neurol

    (2018)
  • MD Hill et al.

    Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial

    Lancet

    (2020)
  • MD Hill et al.

    Safety and efficacy of NA-1 in patients with iatrogenic stroke after endovascular aneurysm repair (ENACT): a phase 2, randomised, double-blind, placebo-controlled trial

    Lancet Neurol

    (2012)
  • K Vahedi et al.

    Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials

    Lancet Neurol

    (2007)
  • TJ Moullaali et al.

    Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data

    Lancet Neurol

    (2019)
  • T Steiner et al.

    Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial

    Lancet Neurol

    (2016)
  • MI Baharoglu et al.

    Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial

    Lancet

    (2016)
  • N Sprigg et al.

    Tranexamic acid for hyperacute primary intracerebral haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial

    Lancet

    (2018)
  • DF Hanley et al.

    Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial

    Lancet

    (2019)
  • S Walter et al.

    Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial

    Lancet Neurol

    (2012)
  • PD Ziegler et al.

    Long-term detection of atrial fibrillation with insertable cardiac monitors in a real-world cryptogenic stroke population

    Int J Cardiol

    (2017)
  • VL Feigin et al.

    Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016

    N Engl J Med

    (2018)
  • RL Sacco et al.

    An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

    Stroke

    (2013)
  • Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

    Lancet Neurol

    (2019)
  • LF Zhang et al.

    Proportion of different subtypes of stroke in China

    Stroke

    (2003)
  • D Calvet et al.

    DWI lesions and TIA etiology improve the prediction of stroke after TIA

    Stroke

    (2009)
  • AE Arch et al.

    Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services

    Stroke

    (2016)
  • PJ Hand et al.

    Distinguishing between stroke and mimic at the bedside: the Brain Attack Study

    Stroke

    (2006)
  • SS Chugh et al.

    Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study

    Circulation

    (2014)
  • HT Tu et al.

    Pathophysiological determinants of worse stroke outcome in atrial fibrillation

    Cerebrovasc Dis

    (2010)
  • JS Kim et al.

    Location of cerebral atherosclerosis: why is there a difference between East and West?

    Int J Stroke

    (2018)
  • J Astrup et al.

    Thresholds in cerebral ischemia—the ischemic penumbra

    Stroke

    (1981)
  • S Warach et al.

    Clinical outcome in ischemic stroke predicted by early diffusion-weighted and perfusion magnetic resonance imaging: a preliminary analysis

    J Cereb Blood Flow Metab

    (1996)
  • BCV Campbell et al.

    Comparison of computed tomography perfusion and magnetic resonance imaging perfusion-diffusion mismatch in ischemic stroke

    Stroke

    (2012)
  • GW Albers et al.

    Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging

    N Engl J Med

    (2018)
  • J Bai et al.

    Revisiting cerebral postischemic reperfusion injury: new insights in understanding reperfusion failure, hemorrhage, and edema

    Int J Stroke

    (2015)
  • P Langhorne et al.

    Organised inpatient (stroke unit) care for stroke: network meta-analysis

    Cochrane Database Syst Rev

    (2020)
  • B Snelling et al.

    Extended window for stroke thrombectomy

    J Neurosci Rural Pract

    (2019)
  • BK Menon et al.

    Efficacy of endovascular thrombectomy in patients with M2 segment middle cerebral artery occlusions: meta-analysis of data from the HERMES collaboration

    J Neurointerv Surg

    (2019)
  • Z Chen et al.

    Indications for early aspirin use in ischemic stroke—a combined analysis of 40 000 randomised patients from the Chinese Acute Stroke Trial and the International Stroke Trial

    Stroke

    (2000)
  • CS Anderson et al.

    Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage

    N Engl J Med

    (2013)
  • BA Gregson et al.

    Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage

    Stroke

    (2012)
  • J Scaggiante et al.

    Minimally invasive surgery for intracerebral hemorrhage

    Stroke

    (2018)
  • KC Johnston et al.

    Intensive vs standard treatment of hyperglycemia and functional outcome in patients with acute ischemic stroke: the SHINE randomized clinical trial

    JAMA

    (2019)
  • Tissue plasminogen activator for acute ischemic stroke

    N Engl J Med

    (1995)
  • MG Lansberg et al.

    Treatment time-specific number needed to treat estimates for tissue plasminogen activator therapy in acute stroke based on shifts over the entire range of the modified Rankin Scale

    Stroke

    (2009)
  • P Khatri et al.

    Effect of alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: the PRISMS randomized clinical trial

    JAMA

    (2018)
  • H Ma et al.

    Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke

    N Engl J Med

    (2019)
  • Cited by (536)

    View all citing articles on Scopus
    View full text