Ischemic Stroke

Ischemic Stroke Overview

• Defined by the sudden loss of blood circulation to a brain region, resulting in neurological deficits.
• Typically caused by thrombotic or embolic occlusion of a cerebral artery.
• Ischemic strokes are more common than hemorrhagic strokes.
• ICD-10-CM Classification:
  • Categorised as “cerebral infarction” under code I63.
  • Includes occlusion and stenosis of cerebral and precerebral arteries.
• World Health Organization Definition:
  • Stroke is described as a syndrome involving rapidly developing focal (or global) cerebral dysfunction.
  • Symptoms last more than 24 hours or lead to death.
  • Vascular origin is the primary cause.

TOAST Classification of Ischemic Stroke

• Large artery atherosclerosis:
  • Thrombosis or embolism due to atherosclerotic changes in large arteries.
• Cardioembolism:
  • Emboli originating in the heart, often associated with atrial fibrillation or cardiac anomalies.
• Small vessel occlusion (lacunar stroke):
  • Thrombosis in small penetrating arteries, commonly linked to hypertension or diabetes.
• Stroke of other determined aetiology:
  • Rare causes such as arterial dissections, vasculitis, or hypercoagulable states.
• Stroke of undetermined aetiology:
  • Cryptogenic strokes or those with multiple potential causes.

Risk Factors

1. Nonmodifiable Risk Factors:
   • Age: Increased risk with advancing age.
   • Sex and Race: Variations in risk based on demographic factors.
   • Genetic Factors: Family history of stroke or transient ischemic attack (TIA).
   • Migraine with Aura: Particularly in younger women, significantly increases stroke risk.
2. Modifiable Risk Factors:
   • Hypertension: The most critical risk factor.
   • Diabetes Mellitus: Promotes vascular disease and thrombosis.
   • Cardiac Disease: Includes atrial fibrillation, heart failure, and valvular disorders.
   • Hyperlipidemia: Increases atherosclerotic plaque formation.
   • Lifestyle Factors: Smoking, excessive alcohol use, sedentary lifestyle, and obesity.
   • Hormonal Factors: Oral contraceptives and postmenopausal hormone therapy.
   • Sickle Cell Disease: Increases susceptibility to vascular stenosis and ischemia.

Genetic and Inflammatory Mechanisms

• Atherosclerosis:
  • Driven by chronic inflammation and endothelial injury.
  • Risk factors include oxidised low-density lipoprotein (LDL) cholesterol and smoking.
• Genetic Mutations:
  • Mutations in F2, F5, and other genes (e.g., NOS3, ALOX5AP) increase susceptibility.
  • Conditions like CADASIL and amyloid angiopathy are associated with genetic variants affecting vascular integrity.
• Hyperhomocysteinemia:
  • Caused by mutations in the MTHFR gene or CBS deficiency.
  • Elevated homocysteine levels are linked to vascular damage.

Mechanisms of Ischemic Stroke

• General Pathogenesis:
  • Ischemic stroke results from events that limit or stop cerebral blood flow, such as:
    • Thrombotic embolism from extracranial or intracranial sources.
    • Thrombosis in situ within an affected artery.
    • Relative hypoperfusion due to systemic conditions like hypotension or heart failure.
  • Neurons cease functioning as blood flow decreases, with irreversible neuronal damage occurring below 18 mL/100 g of tissue/min and cell death at rates below 10 mL/100 g of tissue/min.
• Large Artery Occlusion:
  • Often results from embolisation of atherosclerotic debris from the carotid arteries or cardiac sources.
  • Plaque ulceration and in situ thrombosis are additional contributors.
  • Most commonly affects the middle cerebral artery (MCA) territory.
• Lacunar Strokes:
  • Represent 13–20% of ischemic strokes, caused by occlusion of small penetrating arteries.
  • Commonly associated with chronic hypertension, leading to lipohyalinosis, microatheroma, or fibrinoid necrosis.
• Cardioembolic Strokes:
  • Account for up to 20% of ischemic strokes.
  • Sources include valvular thrombi (e.g., mitral stenosis), mural thrombi, or atrial myxoma.
  • Associated with conditions like atrial fibrillation and myocardial infarction.
• Watershed Infarcts:
  • Occur in distal arterial territories due to embolic phenomena or severe hypoperfusion.
  • Commonly found in border zones between major cerebral arteries.

Global and National Burden

• Global Statistics:
  • Stroke is a leading cause of disability and a significant contributor to global mortality.
  • Annually, 15 million people suffer from stroke worldwide, with 5 million deaths and 5 million left permanently disabled.
• United States:
  • Stroke ranks as the fifth leading cause of death and a major cause of long-term disability in the U.S.
  • Approximately 795,000 strokes occur annually, with 610,000 being first-time events and 185,000 recurrent strokes.
  • Ischemic strokes account for 87% of all strokes.
  • Financial burden: Between 2018 and 2019, stroke costs totaled approximately $56.5 billion in healthcare, medication, and lost productivity.
• United Kingdom:
  • More than 100,000 strokes occur annually, leading to 38,000 deaths.
  • Stroke is a significant cause of disability and mortality, with increasing prevalence among individuals aged over 55.
    
    

Race, Sex, and Age Disparities

• Race and Ethnicity:
  • In the U.S., African Americans have nearly double the risk of first stroke compared to White populations, with the highest mortality rates observed among non-Hispanic Black and Pacific Islander adults.
  • Hispanic populations have a lower overall incidence but experience lacunar strokes more frequently and at younger ages.
  • Indigenous populations in high-income countries face a higher stroke incidence compared to non-Indigenous groups.
• Sex Differences:
  • Men have a higher stroke incidence compared to women; however, women experience higher mortality rates following stroke.
• Age-Related Trends:
  • Stroke predominantly affects individuals aged over 65, with 75% of cases occurring in this demographic.
  • However, one-third of strokes occur in individuals under 65 years of age.
  • Incidence in younger adults is reportedly increasing, particularly in low- and middle-income countries.
    
    

Regional and Socioeconomic Patterns

• Global Patterns:
  • Stroke burden disproportionately affects low- and middle-income countries, accounting for 86% of deaths and 89% of disability-adjusted life-years (DALYs).
  • Highest risks for stroke are observed in East Asia, Central Europe, and Eastern Europe, while the lowest risks are in eastern sub-Saharan Africa.
• High-Income Countries:
  • Stroke incidence and mortality rates have declined over recent decades due to advances in prevention and care.
  • Socioeconomic factors, such as lower educational attainment, are linked to higher stroke prevalence.

Stroke Subtypes in Ischemic Cases

• Ischemic strokes are classified by pathophysiology:
  • Extracranial atherosclerosis: 10%.
  • Intracranial atherosclerosis: 10%.
  • Cardioembolic strokes: 25%.
  • Lacunar infarctions (small vessel disease): 15%.
  • Cryptogenic strokes (indeterminate aetiology): 30%.
  • Other defined causes: 10%.
    
    

Focused Medical History

• Key Risk Factors:
  • Hypertension, diabetes mellitus, tobacco use, high cholesterol.
  • History of coronary artery disease, atrial fibrillation, or coronary artery bypass surgery.
• In Younger Patients:
  • History of recent trauma, coagulopathies, illicit drug use (e.g., cocaine), migraines, and oral contraceptive use.
• Presentation of Symptoms:
  • Sudden onset of acute neurologic deficits or altered level of consciousness.
  • Common stroke symptoms include:
    • Hemiparesis, hemisensory deficits, facial droop, dysarthria.
    • Monocular or binocular visual loss, visual field deficits, diplopia.
    • Ataxia, vertigo, aphasia, and sudden decrease in consciousness.
  • Symptoms may present alone or in combination.
• Establishing Time of Symptom Onset:
  • Critical for considering fibrinolytic therapy.
  • Time of onset is defined as the last known normal time or when the patient was last without symptoms.
  • Input from family, coworkers, or bystanders may assist, especially in "wake-up" strokes.

Neurological 

• Motor Deficits:
  • Hemiparesis or monoparesis typically involving the face, arm, or leg.
  • Quadriparesis is rare and suggests a more severe condition.
  • Lacunar syndromes like pure motor hemiparesis or ataxic hemiparesis may occur with small vessel occlusion.
• Language Impairments:
  • Dysphasia indicates dominant hemispheric ischemia.
  • Dysarthria often accompanies facial weakness or brainstem dysfunction.
• Ataxia:
  • Suggests cerebellar ischemia or its connections.
  • More common in posterior circulation strokes, often affecting fine motor coordination and gait.
• Visual Disturbances:
  • Amaurosis fugax may indicate cervical carotid stenosis.
  • Homonymous hemianopia involves vision loss in the same visual field of both eyes.
  • Diplopia can occur in posterior circulation ischemia.
• Sensory Loss:
  • Unilateral sensory deficits may involve primary modalities or fine sensory processing.

Examination 

1. Detect extracranial causes of stroke symptoms.
2. Differentiate stroke from stroke mimics.
3. Document the degree of neurologic deficit for future comparison.
4. Localise the lesion.
5. Identify comorbidities and conditions influencing treatment, such as recent surgery, trauma, active bleeding, or infection.

General Physical Examination

• Vital Signs:
  • May indicate clinical deterioration or assist in narrowing the differential diagnosis.
  • Hypertension is common in stroke patients but often decreases spontaneously over time.
• Head and Neck Examination:
  • Inspect for trauma, infection, or meningeal irritation.
  • Auscultation for carotid bruits may reveal carotid disease.
• Cardiac and Peripheral Vascular Examination:
  • Look for arrhythmias like atrial fibrillation, murmurs, or gallops, which are associated with embolic strokes.
  • Unequal pulses or blood pressure differences in extremities may suggest aortic dissection.

Neurological Examination

• Purpose:
  • Confirm the presence of a stroke syndrome.
  • Establish a neurological baseline using tools like the NIH Stroke Scale (NIHSS).
  • Assess stroke severity for prognosis and therapeutic decisions.
• Key Components:
  • Cranial Nerve Examination:
    • Assesses deficits that may help localise the lesion.
  • Motor and Sensory Function:
    • Detect hemiparesis, monoparesis, or sensory loss.
  • Cerebellar Function:
    • Evaluate for ataxia, which may indicate cerebellar involvement or posterior circulation ischemia.
  • Gait and Coordination:
    • Assess for abnormalities linked to stroke.
  • Language and Mental Status:
    • Identify expressive or receptive aphasia and cognitive impairments.
  • Consciousness:
    • Establish level of alertness and responsiveness.

National Institutes of Health Stroke Scale (NIHSS)

• A 42-point scale used to quantify stroke severity and localise the lesion.
• Focuses on six major areas:
  • Level of consciousness.
  • Visual function.
  • Motor function.
  • Sensory function and neglect.
  • Cerebellar function.
  • Language abilities.
• Scores correlate with outcomes:
  • <5: Minor stroke.
  • >10: High likelihood of proximal vessel occlusion.

Stroke Syndromes and Vascular Localization

• Middle Cerebral Artery (MCA):
  • Symptoms: Contralateral hemiparesis (worse in arm and face), hemianopsia, aphasia (dominant hemisphere), neglect (non-dominant hemisphere).
• Anterior Cerebral Artery (ACA):
  • Symptoms: Leg weakness greater than arm, gait apraxia, impaired judgment, urinary incontinence.
• Posterior Cerebral Artery (PCA):
  • Symptoms: Visual disturbances (homonymous hemianopia), cortical blindness, memory impairment.
• Vertebrobasilar Artery:
  • Symptoms: Cranial nerve deficits, ataxia, vertigo, dysarthria, and ipsilateral cranial nerve/contralateral motor deficits.
• Lacunar Strokes:
  • Symptoms: Pure motor or sensory deficits without cortical signs (e.g., aphasia, neglect).
    
    

Additional Clinical Observations

• Visual Disturbances:
  • Amaurosis fugax or transient monocular blindness may indicate carotid stenosis.
  • Homonymous hemianopia suggests cortical involvement.
• Dysarthria:
  • May accompany brainstem or cerebellar strokes.
• Ataxia:
  • Points to posterior circulation or cerebellar involvement.
• Vertigo:
  • Common in posterior circulation ischemia, often accompanied by nystagmus.
• Nausea and Vomiting:
  • May reflect posterior circulation involvement or increased intracranial pressure.
• Seizures:
  • More frequently associated with hemorrhagic stroke.

Primary and Essential Investigations

1. Non-Contrast CT (NCCT) Head:
   • Purpose: First-line imaging to differentiate ischemic from hemorrhagic stroke.
   • Key Points:
     • Must be performed within 1 hour of arrival at the hospital.
     • Hypoattenuation and loss of gray-white matter differentiation are early ischemic signs.
     • Hyperattenuation indicates clot presence.
   • Practical Considerations:
     • A normal CT does not exclude stroke, especially within the first few hours.
     • Requires immediate interpretation by trained personnel for critical treatment decisions.
2. Serum Glucose:
   • Purpose: Exclude hypoglycemia, a stroke mimic, and assess for hyperglycemia, which is associated with worse outcomes in ischemic stroke.
   • Practical Considerations: Always check prior to administering thrombolytic therapy.
3. Electrocardiogram (ECG):
   • Purpose: Identify arrhythmias like atrial fibrillation or ischemia that might suggest a cardioembolic source.
   • Key Points:
     • Prolonged monitoring, including implantable loop recorders, may be needed in cryptogenic strokes.
4. Serum Electrolytes, Urea, and Creatinine:
   • Purpose: Evaluate for electrolyte imbalances and renal dysfunction, which can mimic stroke or impact treatment.
5. Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and INR:
   • Purpose: Rule out coagulopathies and assess anticoagulation status.
   • Practical Considerations: Do not delay thrombolysis unless anticoagulation history is known.
6. Full Blood Count (FBC):
   • Purpose: Identify anemia or thrombocytopenia that could influence treatment options.
7. Cardiac Enzymes:
   • Purpose: Evaluate for myocardial infarction as a concurrent or contributing condition.

Advanced Imaging Techniques

1. MRI with Diffusion-Weighted Imaging (DWI):
   • Purpose:
     • More sensitive than NCCT in detecting early ischemic changes and cerebral edema.
     • Provides greater anatomical detail and detects infarction earlier.
   • Practical Considerations:
     • Contraindicated in patients with certain implants or pacemakers.
     • Limited availability in emergency settings compared to CT.
2. CT Angiography (CTA):
   • Purpose:
     • Identify large vessel occlusions and assess suitability for thrombectomy.
   • Practical Considerations:
     • Can be performed alongside NCCT without delaying thrombolysis.
3. Perfusion Imaging (CT or MRI):
   • Purpose: Detect areas of salvageable brain tissue in delayed presentations or when considering thrombectomy (6–24 hours post-onset).
   • Key Points:
     • Highlights mismatch between ischemic core and penumbra.
4. Carotid Ultrasound:
   • Purpose:
     • Identify critical stenosis or occlusion in patients considered for carotid intervention.
   • Practical Considerations:
     • Often used for stroke patients evaluated for endarterectomy or stenting.
5. Echocardiography (TTE/TEE):
   • Purpose:
     • Detect potential cardioaortic embolic sources like atrial thrombi, vegetations, or patent foramen ovale.
       
       

Laboratory Studies and Other Investigations

1. Toxicology Screen:
   • Purpose: Identify substance use (e.g., cocaine) mimicking stroke or causing ischemia/hemorrhage.
2. Cardiac Biomarkers:
   • Purpose: Assess for concurrent cardiac pathology.
3. Arterial Blood Gas (ABG):
   • Purpose: Diagnose acid-base disturbances in suspected hypoxemic patients.
4. Coagulation Studies:
   • Purpose: Identify coagulopathies influencing stroke pathophysiology or treatment.
     
     

Practical Workflow and Tips

• Immediate Actions:
  • Conduct NCCT within 1 hour of arrival and follow with CTA for thrombectomy candidates.
  • Monitor glucose levels and assess coagulation before thrombolysis.
• Communication:
  • Radiologist collaboration is crucial for timely imaging interpretation.
  • Engage cardiology services for detailed cardiac evaluations in suspected embolic strokes.

Transient Ischemic Attack (TIA)

• Signs and Symptoms:
  • Sudden onset of focal neurological symptoms resolving within minutes to hours, usually within 24 hours.
  • Complete recovery is typical, with no residual deficits.
• Investigations:
  • Brain imaging (CT or MRI) may be normal or reveal evidence of previous infarcts.

Hypertensive Encephalopathy

• Signs and Symptoms:
  • Severe hypertension above baseline, accompanied by headache, confusion, visual changes, or reduced consciousness.
  • May present with signs of increased intracranial pressure.
• Investigations:
  • Brain imaging (CT or MRI) may show cerebral edema.

Intracerebral Hemorrhage

• Signs and Symptoms:
  • Presents with sudden headache, vomiting, reduced consciousness, and focal neurological deficits.
  • Increased intracranial pressure may be evident.
• Investigations:
  • Brain imaging (CT or MRI) demonstrates hyperattenuation consistent with hemorrhage.

Hypoglycemia

• Signs and Symptoms:
  • Often associated with diabetes and the use of insulin or hypoglycemic agents.
  • Symptoms include confusion, altered consciousness, or focal neurological deficits mimicking stroke.
• Investigations:
  • Low serum glucose levels during symptom onset confirm diagnosis.

Complicated Migraine

• Signs and Symptoms:
  • History of similar events with preceding aura and positive symptoms, such as visual or sensory disturbances.
  • Negative symptoms, such as weakness or numbness, are more typical of stroke.
• Investigations:
  • MRI excludes infarction.
    
    

Seizure and Postictal Deficits

• Signs and Symptoms:
  • History of seizures or witnessed convulsions followed by transient neurological deficits.
  • Wrong-way eye deviation (gaze away from the side of the lesion) may occur.
• Investigations:
  • Electroencephalogram confirms seizure activity.
  • MRI excludes infarction.

Functional Neurological Disorder

• Neurological symptoms inconsistent with vascular territories.
• May lack cranial nerve deficits or show multiple inconsistent signs.
• Psychological comorbidities like anxiety and depression are common.
• Investigations:
  • MRI is normal, with no evidence of infarction.

Brain Tumor

• Signs and Symptoms:
  • Gradual onset of neurological symptoms.
  • May present with a history of known malignancy or systemic cancer.
• Investigations:
  • CT or MRI shows space-occupying lesions.

Wernicke’s Encephalopathy

• Signs and Symptoms:
  • History of alcohol abuse or malnutrition.
  • Presents with confusion, ataxia, and ophthalmoplegia.
• Investigations:
  • Low blood thiamine levels.
  • Improvement with thiamine administration supports the diagnosis.

Ingestion of Toxic Substances

• Signs and Symptoms:
  • History of alcohol or drug use, with symptoms mimicking stroke.
• Investigations:
  • Positive toxicology screen for alcohol or drugs.

Urgent Initial Management

• Stroke as an Emergency:
  • "Time is brain" underscores the need for rapid intervention to minimise neurological damage.
  • Early reperfusion strategies, including intravenous thrombolysis and mechanical thrombectomy, improve outcomes when initiated within 4.5 hours of symptom onset.
• Stabilisation:
  • Airway and Breathing:
    • Endotracheal intubation is recommended for patients with a Glasgow Coma Scale (GCS) score ≤8 or those unable to protect their airway.
    • Supplemental oxygen is indicated only when oxygen saturation drops below 93%; higher saturation targets (>96%) may increase mortality risk.
  • Circulation:
    • Blood pressure management is critical but should only be actively reduced in hypertensive emergencies, such as hypertensive encephalopathy, cardiac failure, or aortic dissection.
• Hospital Admission and Monitoring:
  • All suspected stroke patients should be admitted directly to a hyperacute stroke unit within 4 hours of hospital arrival to enable early thrombolysis and prevent complications.
  • Monitor for elevated intracranial pressure (ICP), presenting as worsening consciousness, severe headache, or abrupt hypertension. Prompt imaging and neurosurgical referral are required for suspected ICP.

Reperfusion Therapy

• Intravenous Thrombolysis:
  • Administer alteplase within 4.5 hours of symptom onset for eligible patients after excluding contraindications (e.g., intracranial hemorrhage or coagulopathy).
  • Thrombolysis with tenecteplase is a potential alternative (off-label in the UK).
  • Do not delay thrombolysis awaiting additional tests unless contraindications are suspected.
• Mechanical Thrombectomy:
  • Perform within 6 hours of symptom onset for proximal anterior circulation occlusions.
  • For wake-up strokes or those presenting 6–24 hours after symptom onset, thrombectomy is indicated if imaging demonstrates salvageable brain tissue, such as perfusion mismatch.
  • Consider thrombectomy alone in patients ineligible for thrombolysis, such as those on anticoagulants or with recent surgery.

Secondary and Supportive Care

• Antiplatelet Therapy:
  • Start aspirin within 24 hours of excluding intracerebral hemorrhage, delaying its use if thrombolysis was performed. A repeat CT scan is required to rule out post-thrombolysis bleeding.
  • Dual antiplatelet therapy (aspirin and clopidogrel or ticagrelor) is recommended for 21–30 days in minor strokes (NIHSS ≤3), transitioning to single therapy for long-term prevention.
• Blood Pressure Management:
  • For thrombolysis candidates, target a blood pressure of ≤185/110 mmHg before treatment.
  • In non-thrombolysis patients, reduce blood pressure cautiously (>220/120 mmHg) to avoid abrupt declines.
• Glycemic Control:
  • Maintain blood glucose between 4–11 mmol/L to prevent complications.
• Statins:
  • Initiate high-intensity statin therapy 48 hours after stroke if atherosclerosis is confirmed.
  • Adjust or continue existing statin regimens as needed.
• Temperature Regulation:
  • Treat fever with antipyretics. Avoid therapeutic hypothermia as it does not reduce secondary brain damage.
• Swallowing and Nutrition:
  • Assess swallowing before oral intake. Provide tube feeding for patients unable to swallow adequately and address malnutrition when present.

Neurosurgical Interventions

• Decompressive Hemicraniectomy:
  • Consider for large middle cerebral artery infarcts meeting imaging and clinical criteria, such as decreased consciousness (GCS ≤8) or infarcts involving >50% of the MCA territory.
  • Perform within 48 hours of symptom onset to reduce mortality and prevent herniation.

Preventing and Managing Complications

• Intracranial Pressure Monitoring:
  • Monitor for signs of ICP elevation, including altered consciousness and headache.
  • Surgical options include ventriculostomy for cerebellar infarctions or decompressive craniectomy for malignant MCA syndrome.
• Seizures:
  • Treat with anticonvulsants such as levetiracetam or sodium valproate. Consult specialists for uncontrolled seizures or status epilepticus.
• Deep Vein Thrombosis (DVT) Prevention:
  • Use intermittent pneumatic compression devices. Low-molecular-weight heparin is an option if contraindications to compression exist.

Rehabilitation and Long-Term Management

• Early Mobilization:
  • Begin light mobilisation (e.g., sitting or standing) 24–48 hours after symptom onset if clinically appropriate.
  • Avoid high-intensity mobilisation in the first 24 hours.
• Long-Term Anticoagulation:
  • Start anticoagulation in patients with atrial fibrillation or cardioembolic stroke once bleeding risks are addressed.

Overview 

• Prognosis is influenced by stroke type, severity, pre-existing comorbidities, treatment response, and post-stroke complications.
• Clinical tools like the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and imaging studies are key for predicting outcomes.

Mortality and Survival Rates

• Approximately 19% of patients with ischemic stroke die within 30 days, and 77% survive at one year.
• Cardiogenic emboli have the highest one-month mortality among stroke subtypes.

Predictive Models

• NIHSS: High scores indicate greater early mortality and poorer outcomes.
• CT Findings: Early evidence of infarction correlates with worse outcomes and higher hemorrhagic transformation risk.
• Mortality Prediction Score:
  • Developed using data from Austrian stroke registries.
  • Factors include age, NIHSS score, pre-stroke functional status, diabetes, heart disease, and stroke subtype.
  • Scores ≥10 predict a 35% mortality risk within seven days.

Functional Outcomes

• Recovery varies:
  • Some patients achieve full or near-full recovery with timely and intensive rehabilitation.
  • Moderate to severe strokes often result in persistent motor, cognitive, or sensory impairments.
• Stroke remains a leading cause of long-term global disability.

Impact of Acute Interventions

• Intravenous Thrombolysis:
  • Alteplase improves functional outcomes when given within 4.5 hours of symptom onset.
  • While it increases intracerebral hemorrhage risk, long-term mortality or dependency rates are not significantly affected.
• Tenecteplase:
  • Non-inferior to alteplase for achieving functional independence (90-day mRS 0–1).
  • May be superior for moderate disability outcomes (90-day mRS 0–2).
  • Not advised for wake-up strokes without advanced imaging confirmation.

• Common Complications:
  • Include aspiration pneumonia, depression, and deep vein thrombosis, which contribute to poorer outcomes.
• Hyperglycemia:
  • Associated with larger infarct sizes and worse functional recovery.
• Hemorrhagic Transformation:
  • Occurs in 5% of ischemic strokes without fibrinolysis.
  • Can range from small petechial hemorrhages to significant hematomas.
    
    

Rehabilitation and Recovery

• Physiotherapy improves outcomes, even when initiated late.
• Specialised stroke units with early, intensive rehabilitation enhance recovery and reduce disability.

Global Burden

• Stroke accounted for 6.5 million deaths globally in 2019 and remains a major cause of long-term disability.
• Early interventions like thrombolysis and specialised stroke care are proven to improve outcomes.

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