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LEARNING OBJECTIVES
Upon completion of the chapter, the reader will be able to:
Differentiate types of cerebrovascular disease including transient ischemic attack (TIA), ischemic stroke (cerebral infarction), and hemorrhagic stroke.
Identify modifiable and nonmodifiable risk factors associated with ischemic stroke and hemorrhagic stroke.
Explain the pathophysiology of ischemic stroke and hemorrhagic stroke.
Describe the clinical presentation of TIA, ischemic stroke, and hemorrhagic stroke.
Formulate strategies for primary prevention of acute ischemic stroke.
Evaluate treatment options for acute ischemic stroke.
Determine whether fibrinolytic therapy is indicated in a patient with acute ischemic stroke.
Evaluate the role of endovascular therapy in a patient with acute ischemic stroke.
Formulate strategies for secondary prevention of acute ischemic stroke.
Evaluate treatment options for acute hemorrhagic stroke.
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Cerebrovascular disease comprises stroke, as well as carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations. Stroke is the second most common cause of death worldwide and is the fifth leading cause of death in the United States. Stroke is an acute medical emergency, and rapid treatment dependent on the type of stroke (ischemic or hemorrhagic) is critical. Treatment of risk factors and preventive measures are also paramount in the management of stroke. Decades of progress in treatment and prevention have resulted in a decrease in both stroke incidence and stroke case fatality rates.1 Stroke mortality rates are higher in women than men and geographic variability exists, with higher mortality rates observed in the southeastern United States, termed the “stroke belt.”
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Approximately 795,000 strokes occur in the United States each year. New strokes account for 610,000 of this total; recurrent strokes account for the remaining 185,000. Stroke incidence increases with age, especially after age 55 years, resulting in an increased incidence in the elderly population.2 Stroke is the leading cause of long-term disability in adults, with 90% of survivors having residual deficits. Moderate-to-severe disability is seen in 70% of stroke survivors, and 15% to 30% of survivors are permanently disabled. The American Heart Association estimates there are currently over 7 million stroke survivors in the United States. Societal impact and economic burden are great, with total costs of $33.9 billion reported in the United States in 2013.
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ETIOLOGY AND CLASSIFICATION
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Strokes can either be ischemic (87% of all strokes) or hemorrhagic (13% of all strokes). 
Ischemic stroke, which may be thrombotic or embolic, is the abrupt development of a focal neurological deficit that occurs due to inadequate blood supply to an area of the brain. A thrombotic occlusion occurs when a thrombus forms inside an artery in the brain. An embolic stroke typically occurs when a piece of thrombus, originating either inside or outside of the cerebral vessels, breaks loose and is carried to the site of occlusion in the cerebral vessels. An extracerebral source of emboli is often ...