Evaluation and management of stroke

In contrast to myocardial infarction, stroke is a heterogeneous disease with multiple different causes. Determination of stroke mechanism is critical to choosing optimal therapy to prevent recurrence. This article reviews the diagnostic approach to stroke and prognostic and treatment implications of specific stroke mechanisms. Data on the role of antiplatelet and anticoagulant therapy in secondary stroke pre-vention, as well as the role of these agents and thrombolytic therapy in acute stroke treatment are re-viewed. Situations of particular relevance to the practicing hematologist—stroke in the young, patients with multiple recurrent strokes, patients with abnormal hypercoagulable laboratory testing, and treatment of intracerebral hemorrhage following thrombolytic therapy—are discussed. Unlike myocardial infarction, which uniformlyoccurs due to plaque rupture and local thrombosisof a coronary artery, ischemic stroke is a heteroge-neous condition. Embolism to an intracranial artery may come from thrombus on an ulcerated plaque in the carotid artery or may be due to cardioembolism from atrial fibrilla-tion. Large vessel atherosclerosis may progress to occlusion causing perfusion failure. Occlusion of the small perforating vessels deep in the brain may cause lacunar stroke. Les