USMLE Guide: Stroke Management

Introduction

Stroke is a medical emergency that occurs due to an interruption of blood flow to the brain. It is a leading cause of death and disability worldwide. Timely and appropriate management is crucial to reduce morbidity and mortality associated with stroke. This article provides a comprehensive guide to stroke management for medical professionals preparing for the USMLE examination.

Types of Stroke

1. Ischemic Stroke: Caused by a blockage or clot in a blood vessel supplying the brain. It accounts for approximately 85% of all strokes.
2. Hemorrhagic Stroke: Occurs due to bleeding within the brain, often caused by the rupture of a weakened blood vessel. It accounts for approximately 15% of all strokes.

Assessing a Stroke Patient

1. History and Physical Examination: Obtain a detailed history, including the time of symptom onset and any risk factors. Perform a thorough neurological examination to assess the severity and localization of deficits.
2. Imaging: Non-contrast CT scan is the initial imaging modality to differentiate between ischemic and hemorrhagic stroke. Magnetic Resonance Imaging (MRI) is also used to evaluate the extent of brain injury.

Ischemic Stroke Management

1. Time is Brain: Early intervention is crucial to salvage brain tissue and improve outcomes.
2. Thrombolytic Therapy: Intravenous alteplase is the gold standard for eligible patients within 4.5 hours of symptom onset.
3. Endovascular Thrombectomy: Mechanical removal of the clot using a catheter-based procedure is recommended for eligible patients within 24 hours of symptom onset.
4. Supportive Care: Maintain blood pressure control, manage complications, and prevent secondary brain injury.

Hemorrhagic Stroke Management

1. Blood Pressure Control: Rapidly lower blood pressure to reduce the risk of hematoma expansion.
2. Surgical Intervention: Consider surgery for patients with large intracranial hemorrhage or hydrocephalus.
3. Supportive Care: Manage complications such as seizures, elevated intracranial pressure, and electrolyte imbalances.

Secondary Prevention

1. Antiplatelet Therapy: Aspirin is the cornerstone for most patients unless contraindicated. Clopidogrel may be considered as an alternative.
2. Anticoagulation: Warfarin or direct oral anticoagulants may be indicated for patients with specific causes of stroke (e.g., atrial fibrillation).
3. Carotid Endarterectomy: Surgical intervention to remove atherosclerotic plaque in the carotid artery may be considered in selected patients.
4. Lifestyle Modifications: Encourage smoking cessation, weight reduction, regular exercise, and control of hypertension, diabetes, and hyperlipidemia.

Rehabilitation

1. Physical and Occupational Therapy: Start early to promote functional recovery and prevent complications.
2. Speech and Language Therapy: Address any communication or swallowing difficulties.
3. Psychological Support: Provide counseling and support for emotional and psychological well-being.

Conclusion

Effective stroke management is crucial to minimize the impact of this devastating condition. Medical professionals preparing for the USMLE examination should be well-versed in the assessment, acute management, secondary prevention, and rehabilitation strategies for stroke patients.