Stroke (main): Difference between revisions

Revision as of 15:17, 5 June 2015

Stroke Types

** Hypertension

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

Sensory Homonculus - courtesy AnatomyZone.com

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
  - Hypertension
  - Amyloidosis
  - Anticoagulation
  - Vascular malformations
  - Cocaine use
- SAH
  - Berry aneurysm rupture
  - Vascular malformation rupture

Differential Diagnosis

Stroke-like Symptoms

Stroke
Seizures/postictal paralysis (Todd paralysis)
Syncope
Subdural hemorrhage
Epidural hemorrhage
Hypoglycemia
Hyponatremia
Meningitis/encephalitis
Hyperosmotic Coma
Labyrinthitis
Drug toxicity
- Lithium, phenytoin, carbamazepine
Bell's Palsy
Complicated migraine
Meniere Disease
Demyelinating disease (MS)
Conversion disorder
Transient global amnesia
Giant cell arteritis
Cerebral sinus thrombosis

External Links

MDCalc - NIH Stroke Scale/Score

References

Authors:

@@ Line 1: / Line 1: @@
+==Stroke Types==
+*[[Ischemic Stroke]]
+**[[Cerebellar Stroke]]
+**[[Transient Ischemic Attack (TIA)]]
+*[[Hemorrhagic Stroke]]
+**[[Intracerebral Hemorrhage]]
+**[[Subarachnoid Hemorrhage (SAH)]]
+ ** [[Hypertension]]
 ==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
 [[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]]
 ===Causes===
 *Ischemic (87%)
@@ Line 30: / Line 40: @@
 ***Berry aneurysm rupture
 ***Vascular malformation rupture
-==Clinical Features==
-{{Stroke Syndromes}}
 ==Differential Diagnosis==
-{{Stroke DDX}}
+{{ Stroke DDX}}
-==Diagnosis==
-===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)
-==Management==
-===Ischemic===
-====Both tPA AND non-tPA candidates====
-*Prevent dehydration
-*Maintain SpO2 >92%
-*Maintain blood glucose between 140 and 180 mg/dL
-*Prevent fever
-*HOB >30°
-====tPA Candidate====
-*tPA
-**See [[Thrombolysis in Acute Ischemic Stroke (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
-**If SBP >220 or DBP >120, lower by 25% over 24 hrs (drug of choice is Nicardipine)<ref>Zha AM, et al. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015; 21(2):91-8.</ref>
-*Aspirin 325mg (within 24-48hr)
-*Anticoagulation not recommended for acute stroke (even for A-fib)
-====Endovascular Therapy====
-*Therapy includes endovascular tPA administration or mechanical clot removal
-*Early trials MR RESCUE, SYNTHESIS, and IMSIII showed no benefit and potential harm
-*MR CLEAN Trial show promising outcomes<ref>Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. NEJM. 2015; 372(1):11-20.</ref>
-**Participants had proximal intracranial artery occlusions
-**Intervention was conducted within 6 hrs
-**Functional independence of 32.6% with endovascular treatment and 19.1% with typical therapy
-===Hemorrhagic===
-*See [[Intracerebral Hemorrhage (ICH)]]
-===Cerebellar===
-*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
-*See [[Cerebellar Stroke]]
 ==See Also==