Ischemic Stroke (Paralytic Stroke): Pathophysiology, Recognition, and Acute Management

Ischemic stroke (often called “paralytic stroke” when causing hemiparesis) results from cerebral arterial occlusion, causing infarction of downstream brain tissue. It accounts for ~87% of strokes.

Pathophysiology

• Thrombotic: Atherosclerotic plaque rupture → in-situ clot (large artery: MCA, ICA; small artery: lacunar).
• Embolic: Clot from heart (AFib, valve, thrombus) or proximal artery travels distally.
• Hypoperfusion: Global hypoperfusion (cardiac arrest, severe stenosis) → watershed infarcts.

Core Clinical Syndromes

• MCA territory: Contralateral face/arm > leg weakness, aphasia (dominant), neglect (non-dominant).
• ACA territory: Contralateral leg > arm weakness, abulia, gait apraxia.
• PCA territory: Homonymous hemianopia, alexia, memory deficits.
• Posterior circulation (vertebrobasilar): Vertigo, diplopia, dysarthria, ataxia, crossed deficits, locked-in syndrome.
• Lacunar syndromes: Pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand.

Time-Critical Recognition: BE-FAST

• Balance loss
• Eyes (vision change)
• Face droop
• Arm weakness
• Speech difficulty
• Time to call 911

Acute Management (Within 4.5–24 hrs)

• IV alteplase (tPA): ≤4.5 hrs from last known well; strict inclusion/exclusion.
• Mechanical thrombectomy: Large vessel occlusion (LVO) ≤24 hrs with favorable imaging (ASPECTS, collateral score).
• Antiplatelet: Aspirin 160–325 mg within 24–48 hrs (after tPA exclusion).
• Stroke unit admission: Monitoring, VTE prophylaxis, dysphagia screen, early mobilization.

Secondary Prevention

• Antithrombotic (antiplatelet/anticoagulant per etiology)
• Statin (high-intensity), BP control (<130/80), diabetes management
• Carotid revascularization if ≥50% symptomatic stenosis
• Lifestyle: Mediterranean diet, exercise, smoking cessation

“Time is brain”—every minute of delay loses ~1.9 million neurons. Public education and prehospital stroke protocols are critical.