Strokes: Understanding the Different Types

About this course

Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis. In comparison, transient ischemic attacks and Bell’s palsy symptoms can mimic a stroke, however there are key identifiers that can help the healthcare professional differentiate between the diagnoses. This course provides an overview of the different types of strokes and their interventions and treatments, transient ischemic attacks, and Bell’s palsy.

Learning objectives

• Differentiate between ischemic stroke and hemorrhagic stroke.
• Identify key factors of a transient ischemic attack.
• Recognize the difference between stroke and Bell’s palsy.
• Understand the use of FAST in identifying stroke symptoms.
• Review treatment options as recommended by the American Stroke Association guidelines.

Course outline

40 sections · finish in any order across devices

1. 1

   Introduction

   Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis. It is characterized by either a blockage of blood vessels, where clots form in the brain and interrupt blood flow, or a rupture of blood vessels causing them to break, which leads to

   4 min

2. 2

   Hemorrhagic Stroke

   Hemorrhagic stroke is caused by bleeding in the brain from a ruptured blood vessel.6 It accounts for approximately 10–15% of all strokes and has a high mortality rate.1 In this condition, the stress in the brain tissue and internal injury cause blood vessels to rupture. It produces toxic effects in

   4 min

3. 3

   Ischemic Stroke

   Most strokes are ischemic strokes.4 An ischemic stroke occurs when blood clots or other particles block the blood vessels to the brain.4 They contribute to around 85% of casualties in stroke patients, with the remainder caused by intracerebral bleeding.1

   4 min

4. 4

   Transient Ischemic Attack

   A transient ischemic attack (TIA) differs from other types of major strokes and is referred to as a “mini-stroke” because blood flow to the brain is blocked for only a short time, usually no more than an hour.4 It is a medical emergency and a transient episode of neurologic dysfunction from focal br

   4 min

5. 5

   Signs and Symptoms

   During a stroke, every minute counts, and faster reaction time can help lessen the brain damage that a stroke can cause.8 Thus, it is important to be aware of the common signs and symptoms so that any individual can take quick action.8

   4 min

6. 6

   Stroke Risk Factors

   The risk of stroke increases with age and doubles over the age of 55 years in both men and women.1 The risk is further increased when an individual has an existing medical condition like hypertension, coronary artery disease, or hyperlipidemia.1 Nearly 60% of strokes are in patients with a history o

   4 min

7. 7

   Genetics

   Genetic factors are known to be both modifiable and nonmodifiable risk factors for stroke, with parental history and family history increasing the risk.1,3 The following are some of the mechanisms that increase the risk of stroke.1,3

   4 min

8. 8

   Hypertension

   Hypertension is the most important modifiable risk factor for stroke, with a strong, direct, linear, and continuous relationship between blood pressure and stroke risk.3 In one study, a blood pressure (BP) of at least 160/90 mmHg and a history of hypertension were considered equally essential predis

   4 min

9. 9

   Diabetes

   Diabetes mellitus is an independent risk factor for stroke, with a 2-fold increased risk of stroke for diabetic patients. Diabetes accounts for ≈20% of stroke related deaths.3 Prediabetics are also at increased risk of stroke.3

   4 min

10. 10

    Atrial Fibrillation

    Atrial fibrillation (AF) has long been recognized as a major risk factor for stroke, which has only increased with the aging of the US population.3 The incidence of strokes related to AF has nearly tripled in the past three decades.3 Atrial fibrillation contributes to 15% of all strokes and produces

    4 min

11. 11

    Alcohol and Drug Abuse

    The relationship between stroke risk and alcohol intake follows a curvilinear pattern, with the risk related to the amount of alcohol consumed daily.1

    4 min

12. 12

    Smoking

    Cigarette smoking remains a significant risk factor for stroke, nearly doubling the risk with a dose-response relationship between pack-years and stroke risk.3 Smoking is estimated to contribute to ≈15% of all stroke deaths annually.3

    4 min

13. 13

    Poor Diet

    Insufficient physical activity and poor diet are associated with an increased risk for stroke.1 Insufficient physical activity is also linked to other health issues like elevated blood pressure, obesity, and diabetes, all related to high stroke incidence.1 Likewise, certain dietary components are we

    4 min

14. 14

    Ischemic Stroke History and Physical

    Ischemic strokes present acutely, and establishing the time of symptom onset is critical.5 If the time of symptom onset is unknown, the time the patient was last known to be without new neurological symptoms is used. The established time is then utilized to decide whether giving intravenous thrombol

    4 min

15. 15

    Evaluation

    An organized stroke protocol is highly recommended to expedite evaluation.5

    4 min

16. 16

    Hemorrhagic Stroke History and Physical

    The common presentations of stroke are headache, aphasia, hemiparesis, and facial palsy.6 The presentation of hemorrhagic stroke is usually acute and progressive.6

    4 min

17. 17

    Subarachnoid Hemorrhage

    The clinical features of subarachnoid hemorrhage are severe headaches described as a thunderclap, vomiting, syncope, photophobia, nuchal rigidity, seizures, and decreased level of consciousness.6 Signs of meningismus, such as the Kernig sign (pain on straightening the knee when the thigh is flexed t

    4 min

18. 18

    Evaluation

    Computerized tomography (CT) is usually the initial investigative tool and is considered the “gold standard” in detecting acute hemorrhage due to its sensitivity.6 However, gradient echo and T2* susceptibility-weighted magnetic resonance imaging (MRI) has the same sensitivity as CT to detect acute h

    4 min

19. 19

    Transient Ischemic Attack History and Physical

    Transient ischemic attack symptoms often resolve by the time the patient presents to the hospital.7 The history of the present illness should include onset, duration, timing, complete neurological symptoms, associated symptoms, and any aggravating or relieving factors.7

    4 min

20. 20

    Evaluation

    The 2022 AHA/ASA guidelines include "neuroimaging within 24 hours of symptom onset and further recommend MRI and diffusion-weighted MRI imaging as preferred modalities."7

    4 min

21. 21

    ABCD2 Score

    The ABCD2 score is very important for predicting subsequent risks of TIA or stroke.7 The ABCD2 score was derived from providing a more robust prediction standard. The ABCD2 score includes factors including age, blood pressure, clinical symptoms, duration, and diabetes, such as:7

    4 min

22. 22

    Difference Between Stroke and Bell’s Palsy

    Bell’s palsy (BP) is the most frequent diagnosis linked to facial nerve palsy/paralysis as well as the most frequent acute mono-neuropathy.12 It affects individuals across multiple ages and both sexes, with an annual incidence ranging from 11.5 to 53.3 per 100,000 persons.12

    4 min

23. 23

    Levels of Care

    Hospitals have differing capabilities in terms of treatment of acute ischemic stroke, and an international consensus exists on levels of care 1 through 3.14

    4 min

24. 24

    Alteplase

    The American Heart Association/American Stroke Association (AHA/ASA) recommends intravenous (IV) alteplase for patients who satisfy inclusion criteria and have symptom onset or last known baseline within 3 hours.5 Inclusion criteria include diagnosis of ischemic stroke with “measurable neurological

    4 min

25. 25

    Tenecteplase

    Tenecteplase is another tissue plasminogen activator, which has been shown to have a higher affinity for fibrin and a longer half-life than alteplase.14 It is widely used for acute coronary events and has a lower rate of systemic hemorrhage than alteplase in that setting.14

    4 min

26. 26

    Mechanical Thrombectomy

    In recent years, there has been significant advancements in acute stroke care.5 Multiple stroke trials in 2015 showed that endovascular thrombectomy in the first six hours is much better than standard medical care in patients with large vessel occlusion in the arteries of the proximal anterior circu

    4 min

27. 27

    Blood Pressure

    Management of blood pressure in acute ischemic stroke must balance multiple factors, including elevated pressures to improve tissue perfusion, with the consideration of the increased the risk of hemorrhage or secondary damage to already infarcted areas of the brain.14 It is recommended to lower the

    4 min

28. 28

    Temperature

    A retrospective study recently demonstrated an association between a peak temperature in the first 24 hours of greater than 38oC (100.4 F) and an increased risk of in-hospital mortality.5

    4 min

29. 29

    Nutrition

    Following are the different treatment options for hemorrhagic stroke:

    4 min

30. 30

    Hemostatic Therapy

    Hemostatic therapy is given to reduce the progression of hematoma. This is especially important to reverse coagulopathy in patients taking anticoagulants.6 Vitamin K, prothrombin complex concentrates (PCCs), recombinant activated factor VII (rFVIIa), fresh frozen plasma (FFP), etc., should be consid

    4 min

31. 31

    Management of Raised Intracranial Pressure

    The initial treatment for raised intracranial pressure (ICP) is elevating the head of the bed to 30 degrees and using osmotic agents (mannitol, hypertonic saline). Mannitol 20% is given at a dose of 1.0 to 1.5 g/kg.6

    4 min

32. 32

    Antiepileptic Therapy

    Approximately 3-17% of patients will have a seizure in the first two weeks following a stroke, and 30% of patients will show electrical seizure activity on EEG monitoring.6 Those with clinical seizures or electrographic seizures should be treated with antiepileptic drugs.6

    4 min

33. 33

    Blood Pressure

    Blood pressure should be reduced gradually to a minimum of 150/90 mmHg using beta-blockers (labetalol, esmolol), ACE inhibitor (enalapril), calcium channel blockers (nicardipine), or hydralazine.6 During treatment, the blood pressure should be checked every 10-15 minutes.6

    4 min

34. 34

    Surgery

    The different types of surgical interventions for hemorrhagic stroke include craniotomy, decompressive craniectomy, stereotactic aspiration, endoscopic aspiration, and catheter aspiration.6

    4 min

35. 35

    Cerebroprotection

    The secondary injury of hemorrhagic stroke comprises inflammation, oxidative stress, and toxicity of erythrocyte lysates and thrombin.6 Strategies to reduce secondary injuries are being tried, such as:6

    4 min

36. 36

    Transient Ischemic Attack

    The main aim of treatment of TIA is to decrease the risk of subsequent stroke or TIA.7 Early treatment after a TIA can significantly reduce the risk of early stroke.7

    4 min

37. 37

    Post-Stroke Complications

    For many stroke survivors and their families, an acute stroke is the beginning of an ongoing struggle with physical impairment and subsequent disability.15 Over time, the immediate clinical consequences of the stroke may be complicated by a variety of unanticipated medical, musculoskeletal, and psyc

    4 min

38. 38

    Post-Stroke Rehabilitation

    Rehabilitation helps someone who has had a stroke relearn skills that are suddenly lost when part of the brain is damaged.16 Equally important in rehabilitation is to protect the individual from developing new medical problems, including pneumonia, urinary tract infections, injury due to falls, or a

    4 min

39. 39

    Nursing Considerations

    Nurses often have difficulties with using interdisciplinary stroke guidelines for patients with stroke as they do not focus sufficiently on nursing. Therefore, the Stroke Nursing Guideline (SNG) was developed and implemented.17

    4 min

40. 40

    Conclusion

    Stroke is the second leading cause of death and a significant contributor to disability worldwide 1

    4 min

This course satisfies

Requirement summaries come from our state requirement records. Always confirm details with your board before you renew.

References and resources

• Kuriakose D, Xiao Z. Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International Journal of Molecular Sciences. 2020;21(20):7609. doi:10.3390/ijms21207609
• Feigin VL, Norrving B, Mensah GA. Global Burden of Stroke. Circulation Research. 2017;120(3):439-448. doi:10.1161/circresaha.116.308413
• Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circulation research. 2017;120(3):472-495. doi:10.1161/CIRCRESAHA.116.308398
• CDC. About Stroke | cdc.gov. Centers for Disease Control and Prevention. Published May 4, 2022. https://www.cdc.gov/stroke/about.htm#:~:text=There%20are%20two%20types%20of
• Hui C, Tadi P, Patti L. Ischemic Stroke. Nih.gov. Published 2019. https://www.ncbi.nlm.nih.gov/books/NBK499997/
• Unnithan AKA, Mehta P. Hemorrhagic Stroke. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK559173/
• Panuganti KK, Tadi P, Lui F. Transient Ischemic Attack. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK459143/
• CDC. Stroke Signs and Symptoms | cdc.gov. www.cdc.gov. Published August 28, 2020. https://www.cdc.gov/stroke/signs_symptoms.htm#:~:text=Sudden%20numbness%20or%20weakness%20in
• Stroke - Symptoms | NHLBI, NIH. www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/stroke/symptoms
• NHS. Symptoms - Stroke. NHS. Published 2019. https://www.nhs.uk/conditions/stroke/symptoms/
• Stroke - Diagnosis | NHLBI, NIH. www.nhlbi.nih.gov. Published March 24, 2022. https://www.nhlbi.nih.gov/health/stroke/diagnosis
• Zhang W, Xu L, Luo T, Wu F, Zhao B, Li X. The etiology of Bell’s palsy: a review. Journal of Neurology. Published online March 28, 2019. doi:10.1007/s00415-019-09282-4
• Induruwa I, Holland N, Gregory R, Khadjooi K. The impact of misdiagnosing Bell’s palsy as acute stroke. Clinical Medicine. 2019;19(6):494-498. doi:10.7861/clinmed.2019-0123
• Phipps MS, Cronin CA. Management of acute ischemic stroke. BMJ. 2020;368:l6983. doi:10.1136/bmj.l6983
• Chohan S, Venkatesh P, How C. Long-term complications of stroke and secondary prevention: an overview for primary care physicians. Singapore Medical Journal. 2019;60(12):616-620. doi:10.11622/smedj.2019158
• Post-Stroke Rehabilitation Fact Sheet | National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov. Published July 25, 2022. https://www.ninds.nih.gov/post-stroke-rehabilitation-fact-sheet
• Bjartmarz I, Jónsdóttir H, Hafsteinsdóttir TB. Implementation and feasibility of the stroke nursing guideline in the care of patients with stroke: a mixed methods study. BMC Nursing. 2017;16(1). doi:10.1186/s12912-017-0262-y

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