The aim of this review is to present the current knowledge regarding stroke. It will appear in three parts (in part I the epidemiology, clinical picture, and risk factors were discussed, while part III will consist of the management and rehabilitation). In the present part (II) the pathogenetic and pathophysiologic aspects of stroke are described. Regarding the investigations apart from the history and clinal examination and general investigations, the following specialized investigations and their role are discussed in detail: Computed tomography (CT), magnetic resonance imaging (MRI), xenon-blood-flow, positron emission tomography (PET), cerebral angiography, magnetic resonance angiography (MRA), ultrasonography, transcranial Doppler (TCD), echocardiography, Holter moni toring, and biopsies. In addition, taking into account the information from the above-cited modalities a prognosis for the final outcome is presented.
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References
1.
Hollenhorst RW: Significance of bright plaques in the retinal arterioles. JAMA178:23-29, 1961.
2.
Ross Russell RW: Observations on the retinal blood vessels in monocular blindness. Lancet30:1422-1428, 1961.
3.
Ashby M., Oakley N., Lorentz I., et al: Recurrent transient monocular blindness. Br Med J12:894-897, 1963.
4.
Ross Russell RW: Atheromatous retinal embolism. Lancet28:1354-1356, 1963.
5.
McBrien DJ, Bradley RD: The nature of retinal emboli in stenosis of the internal carotid artery . Lancet30:697-699, 1963.
6.
Hollenhorst RW: Vascular status of patients who have cholesterol emboli in the retina. Am J Ophthalmol61:1159-1165, 1966.
7.
Dyll LM, Margolis M., David NJ: Amaurosis fugax. Neurology16:135-138, 1966.
8.
Furlan AJ, Whisnant JP, Kearns TP: Unilateral visual loss in bright light. Arch Neurol36:675-676, 1979.
Ross Russell RW, Page Ngr: Critical perfusion of brain and retina . Brain106:419-434, 1983.
11.
Ross RT, Morrow IM: Ocular and cerebral ischemic mechanisms in disease of internal carotid artery . Can J Neurol Sci11:262-268, 1984.
12.
Wiebers DO, Swanson JW, Cascino TL, et al: Bilateral loss of vision in bright light. Stroke20:554-558, 1989.
13.
Harrison Mjg , Marshall J.: TIA finding of thrombus at carotid endarterectomy and its relationship to the timing of surgery. Br J Surg64:511-512, 1977.
14.
Barnett Hjm , Peerless SJ, Kaufmann Jce: Stump of internal carotid artery—a source for further cerebral embolic ischemia. Stroke9:448-456, 1978.
15.
Beal MF, Williams RF, Richardson EP, et al : Cholesterol embolism as a cause of transient ischemic attacks and cerebral infarction. Neurology31:860-865, 1981.
Ruff RL, Talman WT, Petito F.: Transient ischemic attacks associated with hypotension in hypertensive patients with carotid artery stenosis. Stroke12:353-355, 1981.
18.
Somerville ER: Orthostatic transient ischemic attacks : A symptom of large vessel occlusion. Stroke15:1066-1067, 1984.
19.
Yanagihara T., Piepgras DG, Klass DW: Repetitive involuntary movement associated with cerebral ischemia. Ann Neurol18:244-250, 1985.
20.
Baquis GD, Pessin MS, Scott RM: Limb shaking: A carotid TIA. Stroke16:444-448, 1985.
21.
Dobkin BH: Orthostatic hypotension as a risk factor for symptomatic occlusive cerebrovascular disease. Neurology39:30-34, 1989.
22.
Tatemichi TK , Young WL, Prohovnik I., et al: Perfusion insufficiency in limb shaking transient ischemic attacks. Stroke21:341-347, 1990.
23.
Kamata T., Yokota T., Furukawa T., et al: Cerebral ischemic attacks caused by postprandial hypotension. Stroke25:511-513, 1994.
24.
Foulkes MA, Wolf PA, Price TR, et al: The Stroke Data Bank: Design, methods and baseline characteristics . Stroke1988; 19:547-554, 1988.
25.
Special report from the National Institute of the Neurological Disorders and Stroke: Classification of Cerebrovascular Disease III. Stroke21:637-676, 1990.
26.
Chamorro A. , Sacco RL, Mohr JP, et al: Clinical-computed tomographic correlations of lacunar infarction in the Stroke Data Bank. Stroke22:175-181, 1991.
27.
Donnan GA: Investigation of patients with stroke and transient ischaemic attacks . Lancet339:473-477, 1992.
28.
Culebras A. , Kase CS, Masdeu JC, et al: Practice guidelines for the use of imaging in transient ischemic attacks and acute stroke. A report of the Stroke Council, American Heart Association. Stroke28:1480-1497, 1997.
29.
Davis KR, Ackerman RH, Kistler JP, et al: Computed tomography of cerebral infarction: Hemorrhagic, contrast enhancement, and time of appearance. Comput Tomogr11:71-86, 1977.
30.
Stevens JM, Barber CJ, Kerslake R., et al: Extended use of cranial CT in the evaluation of patients with stroke and transient ischaemic attacks. Neuroradiology33:200-206, 1991.
31.
Bogousslavsky J., Regli F.: Centrum ovale infarcts: Subcortical infarction in the superficial territory of the middle cerebral artery. Neurology42:1992-1998, 1992 .
32.
Tegeler CH, Shi F., Morgan T.: Carotid stenosis in lacunar stroke. Stroke22:1124-1128, 1991.
33.
Boiten J., Lodder J.: Lacunar infarcts: Pathogenesis and validity of the clinical syndromes . Stroke22:1374-1378, 1991 .
34.
Weiller C., Ringelstein EB, Reiche W., et al.Clinical and hemodynamic aspects of low flow infarcts. Stroke22:1117-1123, 1991.
35.
Meagher E., Grace PA, Bouchier-Hayes D.: Are CT infarcts a separate risk factor in patients with transient cerebral ischaemic episodes?Eur J Vasc Surg5:165-167, 1991.
36.
Bogousslavsky J., Regli F.: Borderzone infarctions distal to internal carotid artery occlusion: Prognostic implications. Ann Neurol20:346-350, 1986.
Ringelstein EB, Sievers C., Ecker S., et al: Noninvasive assessment of CO2 induced vasomotor response in normal individuals and patients with internal carotid artery occlusions. Stroke19:963-969, 1988.
39.
Mull M., Schwarz M., Thron A.: Cerebral haemispheric low flow infarcts in the arterial occlusive disease: Lesion patterns and angiomorphological conditions. Stroke28:118-123, 1997.
40.
Beal MF, Williams RS, Richardson P., et al : Cholesterol embolism as a cause of transient ischemic attacks and cerebral infarction. Neurology31:860-865, 1981.
41.
Torvik A.: The pathogenesis of watershed infarcts in the brain. Stroke15:221-223, 1984.
42.
Pollanen MS , Deck Jhn: Directed embolization is an alternate cause of cerebral watershed infarctions. Arch Pathol Lab Med113:1139-1141, 1989.
43.
Graeber MC, Jordan JE, Mishra SK, et al: Watershed infarction on computer tomographic scan: An unreliable sign of hemodynamic stroke. Arch Neurol49:311-313, 1992.
44.
Weiller C., Ringelstein B., Reiche W., et al: The large striatocapsular infarctions: A clinical and pathophysiological entity. Arch Neurol47:1085-1091, 1990 .
45.
Adams HP, Damasio H., Putman S., et al: Middle cerebral artery occlusion as a cause of isolated subcortical infarction . Stroke14:948-952, 1983.
46.
Ringelstein EB , Biniek R., Weiler C., et al: Type and extent of hemispheric brain infarctions and clinical outcome in early and delayed middle cerebral artery recanalization. Neurology42:289-298, 1992.
47.
Caplan L., Babikian V., Helgason C., et al: Occlusive disease of the middle cerebral artery. Neurology35:975-982, 1985.
48.
Araki G., Mihara H., Shizuka M., et al: CT and arteriographic comparison of patients with transient ischemic attacks—correlation with small infarction of basal ganglia. Stroke14:276-280, 1983.
49.
Pantoni L., Garcia JH: Pathogenesis of leukoareosis. Stroke28:652-659, 1997.
50.
Norrving B. , Cronqvist S.: Clinical and radiologic features of lacunar versus nonlacunar minor stroke. Stroke20:59-64, 1989.
51.
Baron JC: Positron tomography in cerebral ischemia. A review. Neuroradiology27:509-516, 1985.
52.
Lownie SP: Cerebral angiography: Conventional angiography. In Stroke: Pathophysiology, Diagnosis and Management, ed. 2, ed. by Bamett HJM, Mohr JP, Stein BM, et al. New York : Churchill Livingstone, 1992, p 215.
53.
North American Symptomatic Carotid Endarterectomy Trial Collaborators.Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med325:445-453, 1991.
54.
European Carotid Surgery Trialists' Collaborative Group.MRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet337:1235-1243, 1991 .
55.
Anderson CM , Lee RE, Levin DL, et al: Measurement of internal carotid artery stenosis from source MR angiograms. Radiology193:219-226, 1994.
56.
Saouaf R., Grassi CJ, Hartnell GG, et al: Complete MR angiography and Doppler ultrasound as the sole imaging modalities prior to carotid endarterectomy. Clin Radiol53:579-586, 1998.
57.
Robinson ML , Sacks D., Perlmutter GS, et al: Diagnostic criteria for carotid duplex sonography. Am J Roentgenol151:1045-1048, 1988.
58.
Polak JF, Dopkin GR, O'Leary DH, et al: Internal carotid artery stenosis: Accuracy and reproducibility of color-Doppler-assisted imaging. Radiology173:793-798, 1989.
59.
Moneta GL, Taylor DC, Zierler RE, et al: Asymptomatic high grade internal carotid artery stenosis : Is stratification according to risk factors or duplex spectral analysis possible. J Vasc Surg10:475-483, 1989.
60.
Withers CE, Gosink BB, Keighhtley AM, et al : Duplex carotid sonography. Peak systolic velocity in quantifying internal carotid artery stenosis. J Ultrasound Med9:345-349, 1990.
61.
Moneta GL, Edwards JM, Papanicolaou G., et al: Screening for asymptomatic carotid artery stenosis: Duplex criteria for discriminating 60% to 99% stenosis. J Vasc Surg21:989-994, 1995.
62.
Hood DB, Mattos MA, Mansour A., et al: Prospective evaluation of new duplex criteria to identify 70% internal carotid artery stenosis. J Vasc Surg23:254-262, 1996.
63.
Dhanjil S., Jameel M., Nicolades A., et al : Ratio of peak systolic velocity of internal carotid to end diastolic velocity of common carotid: new duplex criteria for grading internal carotid stenosis. J Vasc Techn21:237-240, 1997.
64.
Geroulakos G., Ramaswami G., Nicolaides A., et al: Characterisation of symptomatic and asymptomatic carotid plaques using high-resolution real-time ultrasonography . Br J Surg80:1274-1277, 1993 .
65.
Picano E., Landini L., Distante A., et al: Fibrosis, lipids and calcium in human atherosclerotic plaque. Circ Res56:556-562, 1985.
66.
Picano E., Landini L., Distante A., et al: Angle dependence of ultrasonic backscatter in arterial tissues: A study in vitro. Circulation72:572-576, 1985.
67.
Aldoori MI, Baird RN, Al-Sam SZ, et al: Duplex scanning and plaque histology in cerebral ischaemia. Eur J Vasc Surg1:159-164, 1987.
68.
Bendick PJ, Glover JL, Hankin R., et al: Carotid plaque morphology: Correlation of duplex sonography with histology . Ann Vasc Surg2:6-13, 1988.
69.
Picano E., Landini L., Lattanzi F., et al: Time domain echo pattern evaluations from normal and atherosclerotic arterial walls: A study in vitro. Circulation77:654-659, 1988.
70.
Urbani MP, Picano E., Parenti G., et al: In vivo radiofrequency-based ultrasonic tissue characterization of the atherosclerotic plaque. Stroke24:1507-1512, 1993 .
71.
Beletsky VY , Kelley RE, Fowler M., et al: Ultrasonic densitometric analysis of carotid plaque composition. Stroke27:2173-2177, 1996.
72.
Aaslid R., Markwalder TM, Nornes H.: Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg57:769-774, 1982.
73.
Fox JF: How to measure carotid stenosis. Radiology186:316-318, 1993.
74.
Eliasziw M. , Fox AJ, Sharpe BL, et al: Carotid artery stenosis: External validity of the North American Carotid Endarterectomy Trial Measurement Method. Radiology204:229-233, 1997.
Kleiser B., Widder B.: Course of carotid artery occlusions with impaired cerebrovascular reactivity . Stroke23:171-174, 1992.
77.
Eicke BM, von Lorentz J., Paulus W.: Embolus detection in different degrees of carotid disease. Neurol Res17:181-184, 1995.
78.
Consensus on microembolus detection by TCD. Stroke29:725-729, 1998.
79.
Markus HS, Brown MM: Differentiation between different pathological cerebral embolic materials using transcranial Doppler in an in vitro model. Stroke24:1-5, 1993.
80.
Droste DW, Markus HS, Nassiri D., et al: The effect of velocity on the appearance of embolic signals studied in transcranial Doppler models. Stroke25:986-991, 1994.
81.
Babikian VL , Hyde C., Pochay V., et al: Clinical correlates of high-intensity transient signals detected on transcranial Doppler sonography in patients with cerebrovascular disease. Stroke25:1570-1573, 1994.
82.
Georgiadis D., Grosset DG, Quin RO, et al: Detection of intracranial emboli in patients with carotid disease. Eur J Vasc Surg8:309-314, 1994.
83.
Sitzer M., Siebler M., Steinmetz H.: Silent emboli and their relation to clinical symptoms in extracranial carotid artery disease. Cerebrovasc Dis5:121-123, 1995.
84.
Sitzer M.Muller W., Siebler M., et al: Plaque ulceration and lumen thrombus are the main sources of cerebral microemboli in high-grade internal carotid artery stenosis. Stroke26:1231-1233, 1995.
85.
Markus HS, Thomson ND, Brown MM: Asymptomatic cerebral embolic signals in symptomatic and asymptomatic carotid artery disease. Brain118: 1005-1011, 1995.
86.
Orlandi G., Parenti G., Bertolucci A., et al : Silent cerebral microembolism in symptomatic and asymptomatic carotid artery stenoses of low and high degree. Eur Neurol38:39-43, 1997.
87.
Babikian VL , Wijman Cac, Hyde C., et al: Cerebral microembolism and early recurrent cerebral or retinal ischemic events. Stroke28:1314-1318, 1997.
88.
Georgiadis D., Lindner A., Manz M., et al: Intracranial microembolic signal in 500 patients with potential cardiac or carotid embolic source and normal controls. Stroke28:1203-1207, 1997 .
89.
Wijman Cac, Babikian VL, Matjucha Ica, et al : Cerebral microembolism in patients with retinal ischemia . Stroke29:1139-1143, 1998 .
90.
Molloy J., Khan N., Markus HS: Temporal variability of asymptomatic embolization in carotid artery stenosis and optimal recording protocols. Stroke29:1129-1132, 1998.
91.
Molloy J., Markus HS: Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis. Stroke30:1440-1443, 1999 .
92.
Forteza AM, Babikian VL, Hyde C., et al: Effect of time and cerebrovascular symptoms on the prevalence of microembolic signals in patients with cervical carotid stenosis. Stroke27:687-690, 1996.
93.
Sliwka U., Lingnau A., Stohlmann WD, et al : Prevalence and time course of microembolic signals in patients with acute stroke. Stroke28:358-363, 1997.
94.
Valton L., Larrue V., Arrue P., et al: Asymptomatic cerebral embolic signals in patients with carotid stenosis . Stroke26:813-815, 1995.
95.
Spencer MP: Doppler microembolic signals for diagnosis of ulcerated carotid artery plaques . Echocardiography13:1-4, 1996.
96.
Orlandi G., Parenti G., Bertolucci A., et al : Carotid plaque features on angiography and asymptomatic cerebral microembolism. Acta Neurol Scand96:183-186, 1997.
97.
Greenland P. , Knopman DS, Mikell FL, et al: Echocardiography in diagnostic assessment of stroke. Ann Intern Med95:51-53, 1981.
98.
Cujec B., Polasek P., Voll C., et al: Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients. Stroke22:727-733, 1991.
99.
Rem JA, Hachinski VC, Boughner DR, et al: Value of cardiac monitoring and echocardiography in TIA and stroke patients . Stroke16:950-956, 1985.
100.
Burger PC, Burch JG, Vogel FS: Granulomatous angiitis. An unusual etiology of stroke. Stroke8:29-35, 1977.
101.
Howard GF III, Ho SU, Kim KS, et al: Bilateral carotid artery occlusion resulting from giant cell arteritis. Ann Neurol15:204-207, 1984.
102.
Greenfield's Neuropathology, ed. 4, ed. by Adams JH, Corsellis JAN, Duchen LW. New York : Wiley Medical, 1984, p 185.
103.
Gudmundsson G., Hallgrimsson J., Jonasson TA, etal: Hereditary cerebral haemorrhage with amyloidosis. Brain95:387-404, 1972.
104.
Lammie GA, Rakshi J., Rossor MN, et al: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) — confirmation by cerebral biopsy in 2 cases. Clin Neuropathol14:201-206, 1995.
105.
Chambers BR , Norris JW, Shurvell BL, et al: Prognosis of acute stroke. Neurology37:221-225, 1987.
