Stroke (main)

Work-Up

1. Glucose check
2. CBC, chemistry, coags, troponin
3. Lipid profile
4. Head CT
5. ECG (a. fib)
6. Also consider:
   1. Pregnancy test
   2. Utox
   3. TTE with bubble study

DDX Ischemic

1. Thrombosis (atherosclerosis, vasculitis, dissection)
2. Embolic (cardiac -a.fib, valve, septic- CAS, hypercoagulable)
3. Vasospasm
4. Hypotension/watershed

Treatment

Ischemic

1. Glycemic control
   1. Use insulin to maintain blood sugar < 185
2. Temperature control
   1. Treat fever > 37.5 (99.5)
3. If pt is tPA candidate go to --> CVA (tPA Criteria)
   1. Consider tPA
      1. If give tPA DO NOT give antiplatelets/anticoagulants for at least 24 hours
   2. BP Control
      1. If potential candidate for tPA but BP > 185/110:
         1. Labetalol 10-20mg IV over 1-2min, may repeat x 1, OR
         2. Nicardipine IV 5mg/hr, titrate up by 2.5mg/hr q5-15min, max 15mg/hr; when desired BP reached lower to 3mg/hr OR
         3. other agents (hydralazine, enalaprit, etc) may be considered when appropriate
4. If pt is NOT a tPA candidate:
   1. Aspirin
   2. BP control
      1. Only tx BP if > 220/120
   3. Anticoagulation
      1. Heparin only if cardiac embolic source/ a-fib

Hemorrhagic

See Intracranial Hemorrhage (ICH)

Cerebellar Stroke

• Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
• HINTS Exam can reliably distinguish the two (more effective than early DWI MRI)
  • 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 their head will move 1st and then their eyes will "catch up"
    • It is reassuring if the reflex is abnormal (due to dysfunction of the nerve)
  • 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
  • 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 are abnormal obtain full CVA w/u (including MRI)

See Also

• CVA (tPA Criteria)
• Transient Ischemic Attack (TIA)

Source

8/12/07 DONALDSON (adapted from Smith, Lampe, NEJM '07)

UpToDate

AHA/ASA Acute Stroke Guidelines