User:James Carroll

2012-11-08T17:43:48Z

James Carroll: Added link to Wikipedia user profile

James Carroll DC Student.

National University of Health Sciences.

Same as Wikipedia editor [http://en.wikipedia.org/wiki/User:Jcarroll jcarroll]

Stroke (main)

2012-11-08T17:40:25Z

James Carroll: /* DDX */ Added links to articles

==Background==
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment
*Accurate determination of last known time when pt was at baseline is essential

===Stroke Syndromes===
#Anterior Circulation (internal carotid system)
##ACA
###Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
###Left sided lesion: akinetic mutism, transcortical motor aphasia
###Right sided lesion: Confusion, motor hemineglect
##MCA
###Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
###Motor deficits found more commonly in face and upper extremity than lower extremity
###Dominant hemisphere involved: aphasia
###Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
###Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
#Posterior circulation (vertebral system)
##Vertebral artery
###Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
###Multiple, simultaneous complaints are the rule
####Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
###Isolated events are not attributable to vertebral occlusive disease:
####E.g. Isolated lightheadedness, vertigo, transient ALOC, drop attacks
##Basilar artery
###Quadriplegia, coma, locked-in syndrome
##Posterior cerebral
###Unilateral headache (most common presenting complaint)
###Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
###Motor function is typically minimally affected
##Posteroinferior cerebellar
###Vertigo, gait instability, limb ataxia, HA, dysarthria, N/V, CN abnormalities

===Causes===
#Ischemic (87%)
##Thrombotic (80% of ischemic CVA)
###Atherosclerosis
###Vasculitis
###Arterial dissection
###Polycythemia
###Hypercoagulable state
###Infection
##Embolic (20% of ischemic CVA)
###Valvular vegetations
###Mural thrombi
###Arterial-arterial emboli from proximal source
###Fat emboli
###Septic emboli
##Hypoperfusion
###Cardiac failure resulting in systemic hypotension
#Hemorrhagic (13%)
##Intracerebral
###HTN
###Amyloidosis
###Anticoagulation
###Vascular malformations
###Cocaine use
##SAH
###Berry aneurysm rupture
###Vascular malformation rupture

==Clinical Features==
*Thrombotic
**Stuttering or waxing and waning
**TIA involving same vascular distribution
*Embolic
**Sudden onset of symptoms
**TIAs involving different vascular distributions
**A-fib
**Valvular replacement
**Recent MI
*Hemorrhagic
**Sudden onset of symptoms
**Preceded by severe headache
**Recent neck trauma/manipulation

==Cerebellar Stroke==
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
*HINTS Exam can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==DDX==
#[[Seizures]]/postictal paralysis (Todd paralysis)
##Transient paralysis following a seizure which typically disappears quickly
##Note: seizures can be secondary to a CVA
#[[Syncope]]
##No persistent or associated neurologic symptoms
#Brain [[neoplasm]] or abscess
##Focal neurologic findings, signs of infection, detectable by imaging
#Epidural/subdural [[hematoma]]
##History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
#[[Hypoglycemia]]
##Can be detected by bedside glucose measurement, history of DM
#[[Hyponatremia]]
##History of diuretic use, neoplasm, excessive free water intake
#Hypertensive encephalopathy
##Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
#[[Meningitis]]/[[encephalitis]]
##Fever, immunocompromise may be present, meningismus, detectable on LP
#[[Hyperosmotic coma]]
##Extremely high glucose levels, history of DM
#[[Wernicke encephalopathy]]
##History of ETOH or malnutrition; triad of ataxia, ophthalmoplegia, and confusion
#[[Labyrinthitis]]
##Predominantly vestibular symptoms; pt should have no other focal findings
#[[Drug toxicity]]
##Lithium, phenytoin, carbamazepine
#[[Bell's palsy]]
##Neuro deficit confined to isolated peripheral 7th nerve palsy; often a/w younger age
#Complicated [[migraine]]
##History of similar episodes, preceding aura, HA
#[[Meniere disease]]
##History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness
#Demyelinating disease ([[MS]])
##Gradual onset, may have hx of multiple episodes of findings in multiple distributions
#[[Conversion disorder]]
##No cranial nerve findings, nonanatomic distribution of findings

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
===Ischemic===
*tPA AND non-tPA candidates:
**Prevent dehydration
**Maintain SpO2 >92%
**Prevent fever
**Controversial

====tPA Candidate====
#tPA
##See [[CVA (tPA)]]
#Hypertension
##Lower SBP to <185, DBP to <110
##Options:
###Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
###Nitroglycerin paste, 1–2 in. to skin OR
###Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
####When desired blood pressure attained reduce to 3mg/hr

====Non-tPA Candidate====
#Hypertension
##Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
#Aspirin 325mg (within 24-48hr)
#Anticoagulation not recommended for acute stroke (even for A-fib)

===Hemorrhagic===
*See [[Intracerebral Hemorrhage (ICH)]]

===Cerebellar===
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)

==See Also==
*[[Transient Ischemic Attack (TIA)]]
*[[CVA (tPA)]]
*[[CVA (Post-tPA Hemorrhage)]]
*[[Intracranial Hemorrhage (ICH)]]
*[[Subarachnoid Hemorrhage (SAH)]]
*[[Cervical Artery Dissection]]

==Source==
*Tintinalli
*UpToDate
*AHA/ASA Acute Stroke Guidelines
*EMCrit

[[Category:Neuro]]

WikEM - User contributions [en]

User:James Carroll

Stroke (main)