Mrs. Mwirigi, a 68-year-old woman with risk factors of hypertension, diabetes, and hyperlipidemia, presented with sudden onset right-sided weakness and speech difficulties. On examination, she had right facial droop and neurological deficits consistent with an ischemic stroke in the left middle cerebral artery territory. Her risk factors included age, gender, medical history of hypertension, diabetes and hyperlipidemia. Treatment focused on controlling blood pressure and glucose to preserve the ischemic penumbra and potentially improve outcomes with therapies like tPA or endovascular thrombectomy.

1. ISCHEMIC STROKE
GROUP DISCUSSION

2. • Patient Information:
• Name: Mrs. Mwirigi
• Age: 68 years
• Gender: Female
• Medical History: Hypertension, Type 2 Diabetes Mellitus, Hyperlipidemia
• Medications: Lisinopril, Metformin, Atorvastatin
• Social History: Former smoker (quit 10 years ago), occasional alcohol, no
drug use
• Family History: Father had a stroke at age 72, mother has hypertension
• Presenting Complaint:
• She was found by her husband in the bathroom, confused and with slurred
speech. She seemed to have a droop on the right side of her face, and her
right arm appeared weak. The symptoms started roughly 45 minutes ago.

3. • Vital Signs:
• BP: 205/110 mmHg
• Heart Rate: 102 bpm
• Respiratory Rate: 16/min
• Temperature: 98.6°F (37°C)
• Oxygen Saturation: 98% on room air
• Examination:
• Neurological Exam: Noted right-sided facial droop, dysarthria, right arm
drift, and mild right leg weakness. The patient is alert but appears anxious.
• Cardiovascular Exam: Regular rate and rhythm, no murmurs, rubs, or
gallops.
• Other Exams: Unremarkable.

4. WHAT ARE THE RISK FACTORS?

5. • Nonmodifiable risk factors [1][2][3]
• Age ≥ 65 years
• Sex ♂ > ♀
• African Americans, Native Americans, Alaska Natives, and Hispanics are
at higher risk.
• Family history of cardiovascular or cerebrovascular disease
• Genetic disorders (e.g., sickle cell disease)
• History of TIA
• Migraine with aura
• Low birth weight

6. • Modifiable risk factors [1][3]
• Systemic hypertension
• Hyperlipidemia
• Diabetes mellitus
• Atherosclerosis
• Cardiovascular disease
• Carotid artery stenosis
• Atrial fibrillation
• Obesity
• Coagulopathy (e.g., protein C or S deficiency), hyperhomocysteinemia
• Heavy alcohol use
• Tobacco use
• Recreational drug use (e.g., cocaine can cause cerebral vasospasm)
• Oral contraceptive use
• Hormone replacement therapy
• Sedentary lifestyle
• Suboptimal diet (e.g., high salt intake, inadequate fruit and vegetable intake)

7. WHAT ARE THE TYPES?

8. • Embolic strokes (∼ 20% of all strokes)
• Most commonly affect the middle cerebral artery (MCA)
• Dislodged emboli can affect multiple cerebral vascular
territories simultaneously.
• Cardiac emboli
• Atrial fibrillation
• Atheroemboli
• Internal carotid artery
• Infectious emboli: bacterial endocarditis
• Paradoxical embolism: venous thromboembolism (especially due
to deep vein thrombosis) in patients with right-to-left cardiac
shunt (e.g., persistent foramen ovale or atrial septal defect)

9. • Thrombotic strokes (∼ 40%)
• Large vessel atherosclerosis (∼ 20%)
• Rupture of an atherosclerotic plaque and exposure of
subendothelial collagen → formation of a thrombus
• Thrombus formation most commonly occurs at branch points
in arteries (e.g., ; where the MCA branches from the circle of Willis).
• Small vessel occlusion (e.g., lacunar infarct) (∼ 20%)

10. PATHOPHYSIOLOGY OF ISCHEMIC
STROKE

11. • Necrotic Pathway of Focal Cerebral Infarction:
1. Energy Failure
2. Ion Pump Dysfunction
3. Calcium Influx

12. • 4. Glutamate Excitotoxicity
• 5. Axonal, Dendritic, and Glial Damage
• 6. Free Radical Formation

13. • Apoptotic Pathway of Focal Cerebral Infarction:
• 1. Ischemic Penumbra:
• 2. Delayed Cell Death:
• Influence of Fever and Hyperglycemia:
• - Exacerbation of Damage by Fever:
• - Role of Hyperglycemia:

14. Therapeutic Interventions and Considerations:
- Temperature Management:
- Glucose Control:
- Hypothermia Research:
• - Mild induced hypothermia is being studied for its
neuroprotective effects in the setting of stroke.

15. TREATMENT

16. Preserve the penumbra!
Manage Fever
Monitor sugars
tPA

18. Endovascular mechanical thrombectomy
DAWN AND DEFUSE -3 TRIALS