Brain (CNS)
Ischemic Stroke
허혈성뇌졸중
Focal cerebral ischemia and neurologic deficit from arterial occlusion
- How common
- 80% of all strokes
- Typical age
- Mostly 60+
What is it?
Arterial occlusion (thrombus/embolus) reduces CBF → infarct core plus salvageable penumbra → time-dependent expansion of irreversible injury.
Commonly affected: Territory of occluded artery (MCA most common)
How it develops
- Arterial occlusionThrombus (atherosclerosis) or cardioembolism (AFib)
- Reduced CBF<10mL/100g/min → infarct core forms
- PenumbraSurrounding salvageable ischemic tissue – reperfusion target
- Time-dependent expansion"Time is brain": ~1.9 million neurons lost per minute
Symptoms
- HemiparesisUnilateral face/arm/leg weakness
- Aphasia/dysarthriaBroca/Wernicke aphasia in dominant MCA
- Facial droopCentral VII palsy with forehead sparing
- Visual field deficitHomonymous hemianopia
- ImbalanceVertigo/diplopia in posterior circulation strokes
How it is examined
- NIHSS scoring (0-42)11 items: LOC, gaze, vision, motor, sensation, language
- FAST screenFace, Arm, Speech, Time
- ECG/echoIdentify AFib or cardioembolic source
Imaging
Non-contrast head CT first to rule out hemorrhage.
- Often normal early or subtle hypodensity
- Hyperdense MCA sign
- Loss of insular ribbon
MRI DWI is most sensitive for early ischemia.
- DWI hyperintensity within minutes
- ADC drop
- CTA/MRA shows large vessel occlusion
Non-surgical care
- IV thrombolysis (tPA)Alteplase 0.9 mg/kg within 4.5 h (or tenecteplase)
- Mechanical thrombectomyStent retriever/aspiration up to 24 h for LVO
- Antiplatelet therapyAspirin 162-325 mg (24 h post-tPA); DAPT 21 d (minor stroke)
- BP controlKeep <185/110 pre-tPA, <180/105 post-tPA
- Anticoagulation (cardioembolic)Initiate DOAC after stabilization in AFib patients
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Malignant MCA infarct, cerebellar infarct with mass effect
Procedures that may be discussed
- Decompressive hemicraniectomy (within 48 h)
- Suboccipital decompression + EVD
- Carotid endarterectomy/stenting (secondary prevention)
Outlook
With rapid reperfusion, 50% achieve mRS 0-2 at 90 days. Targets: door-to-needle <60 min, door-to-puncture <90 min.