Ischemic brain injury results from a cascade of events running from energy depletion to necrosis or apoptosis. Intermediate factors include exci-totoxicity, free radical formation, and inflammation. Initially after arterial occlusion, a central core of very low perfusion is surrounded by an area with a less severe reduction in perfusion. In this so-called ischemic penumbra,

Table 1

Common and some unusual causes of ischemic stroke

Common causes

Atherothromboembolism Embolism from the heart Small vessel disease

Unusual causes

Arterial dissection Fibromuscular dysplasia Cerebral venous thrombosis Vasculitis Migraine Cocaine use Moyamoya syndrome Hematological disorders CADASIL*

Mitochondrial cytopathy Fabry disease

*CADASIL: cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.

there is dysfunction from metabolic and ionic disturbances, but structural integrity is still preserved. In the first minutes to hours, clinical deficits therefore do not necessarily reflect irreversible damage. Depending on residual blood flow and duration of ischemia, the penumbra will eventually be incorporated into the infarct if reperfusion is not achieved (9,10).

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