Difference between revisions of "Stroke (main)"

(Created page with "==ER Work-Up== 0) Icon/Glu check 1) Head CT (non-con) 2) ECG (a. fib) 3) UA/Utox 4) CBC, Chem 7, LFTs, PT/PTT 4+) Trop (in elderly; poss silent MI) ==DDX Ischemi...")
 
(VAN Score)
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==ER Work-Up==
+
==Background==
 +
*Vascular injury that reduces cerebral blood flow to specific region of brain causing neuro impairment 
 +
*Accurate determination of last known time when patient was at baseline is essential
 +
[[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]]
  
 +
{{Ischemic Stroke Cause}}
 +
{{Hemorrhagic Stroke Cause}}
 +
{{Stroke types}}
  
0)  Icon/Glu check
+
==Clinical Features==
 +
{{Stroke Syndromes}}
  
1)  Head CT (non-con)
+
==Differential Diagnosis==
 +
{{Stroke DDX}}
 +
{{Weakness DDX}}
  
2) ECG (a. fib)
+
==Evaluation==
 +
'''Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA)'''
 +
Find out last known normal of affected deficit and write it down in chart
 +
{{Stroke workup}}
 +
===Large Vessel Occlusion - Thrombectomy===
 +
*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
 +
*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours<ref>Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.</ref>
 +
*If CT perfusion unavailable, use ASPECT score<ref>Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670-4.</ref>
 +
====VAN Score====
 +
*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>
 +
*'''VAN''' score is just as sensitive, but also may be more specific (~90%)
 +
**Weakness must be present, plus one or all of the VAN to be VAN positive
 +
***Weakness qualifying findings -- if no weakness, the pt is VAN negative
 +
****Mild (minor drift)
 +
****Moderate (severe drift—touches or nearly touches ground)
 +
****Severe (flaccid or no antigravity)
 +
***'''V'''isual disturbance qualifying findings
 +
****Field cut (which side) (4 quadrants)
 +
****Double vision (ask patient to look to right then left; evaluate for uneven eyes)
 +
****Blind new onset
 +
***'''A'''phasia qualifying findings
 +
****Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
 +
****Receptive (not understanding or following commands) (close eyes, make fist)
 +
****Mixed
 +
***'''N'''eglect qualifying findings
 +
****Forced gaze or inability to track to one side
 +
****Unable to feel both sides at the same time, or unable to identify own arm
 +
****Ignoring one side
 +
**If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA
  
3) UA/Utox
+
==Management==
 +
*Depends on type
 +
**[[Ischemic stroke|Ischemic]] vs [[Hemorrhagic stroke|Hemorrhagic]]
 +
**Acute vs subacute vs old
 +
**Due to risk for hemorrhagic transformation, there is no role in acute completed stroke for:
 +
***Dual antiplatelet therapy (as opposed in select cases of [[TIA]])
 +
***Anticoagulation, with or without atrial fibrillation
  
4)  CBC, Chem 7, LFTs, PT/PTT
+
==Disposition==
 +
*Admit for acute or subacute stroke
  
4+) Trop (in elderly; poss silent MI)
+
==See Also==
 +
*[[Transient Ischemic Attack (TIA)]]
 +
*[[Thrombolysis in Acute Ischemic Stroke (tPA)]]
 +
*[[CVA (Post-tPA Hemorrhage)]]
 +
*[[Intracerebral Hemorrhage]]
 +
*[[Subarachnoid Hemorrhage (SAH)]]
 +
*[[Cervical Artery Dissection]]
 +
*[[NIH Stroke Scale]]
 +
*[[Cerebellar Stroke]]
 +
*[[Focal neurologic signs]]
  
+
==External Links==
 +
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score]
 +
*[https://emergencymedicinecases.com/ed-stroke-management-endovascular-therapy/ Emergency medicine cases - ED stroke management in the age of endovascular therapy]
  
==DDX Ischemic==
+
==References==
 +
<references/>
  
 
+
[[Category:Neurology]]
1) Thrombosis (atherosclerosis, vasculitis, dissection)
 
 
 
2)  Embolic  (cardiac -a.fib, valve, septic- CAS, hypercoagulable)
 
 
 
3)  Vasospasm
 
 
 
4)  Hypotension/watershed
 
 
 
 
 
 
==Treatment==
 
 
 
 
 
A) Ischemic
 
 
 
    1) <3 hrs -->  see Neuro: CVA (tPA Criteria)
 
 
 
    2) >3 hrs
 
 
 
          a) ASA (if ASA intolerant or failure, then Ticlopidine, Plavix, or Coumadin)
 
 
 
          b) HTN Control (no rx unless >220/120 -- labetolol, nitro, or esmolol gtt)
 
 
 
              -e.g. labetolol 5mg IV Q15min (max =300mg)
 
 
 
          c) Heparin only if cardiac embolic source/a-fib.
 
 
 
B) Hemorrhagic --> see Neuro: Intracranial Hemorrhage (ICH)
 
 
 
 
 
 
==Neuro Work-Up==
 
 
 
 
 
5)  ESR, ANA, RPR, TSH
 
 
 
6)  Guiac
 
 
 
7)  Fasting lipids
 
 
 
8)  Carotic US or MRA carotids
 
 
 
9)  Echo w/double bubble
 
 
 
 
 
 
(YOUNG ONLY)
 
 
 
10)  HIV
 
 
 
11)  Factor V Leiden, homocystein, protein C&S
 
 
 
12)  Lupus anticoagulant, anticardiolipin Ab
 
 
 
13)  AT III, RF, sickle cell
 
 
 
 
 
 
==Source==
 
 
 
 
 
8/12/07 DONALDSON (adapted from Smith, Lampe, NEJM '07)
 
 
 
 
 
 
 
 
 
[[Category:Neuro]]
 

Revision as of 16:39, 21 April 2019

Background

  • Vascular injury that reduces cerebral blood flow to specific region of brain causing neuro impairment
  • Accurate determination of last known time when patient was at baseline is essential
Sensory Homonculus - courtesy AnatomyZone.com

Ischemic stroke causes (87% of all strokes)

Hemorrhagic stroke causes (13% of all strokes)

Stroke Types

Clinical Features

Anterior Circulation

  • Blood supply via internal carotid system
  • Includes ACA and MCA

Internal Carotid Artery

  • Tonic gaze deviation towards lesion
  • Global aphasia, dysgraphia, dyslexia, dyscalculia, disorientation (dominant lesion)
  • Spatial or visual neglect (non-dominant lesion)

Anterior Cerebral Artery (ACA)

Signs and Symptoms:

  • Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
  • Urinary and bowel incontinence
  • Left sided lesion: akinetic mutism, transcortical motor aphasia
  • Right sided lesion: Confusion, motor hemineglect
  • Presence of primitive grasp and suck reflexes
  • May manifest gait apraxia

Middle Cerebral Artery (MCA)

Signs and Symptoms:

  • 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
    • Wernicke's aphasia (receptive aphasia) -> patient unable to process sensory input and don't understand verbal communication
    • Broca's aphasia (expressive aphasia) -> patient unable to communicate verbally, even though understanding may be intact
  • Nondominant hemisphere involved: dysarthria (motor deficit of the mouth and speech muscles; understanding intact) w/o aphasia, inattention and neglect side opposite to infarct
  • Contralateral homonymous hemianopsia
  • Gaze preference toward side of infarct
  • Agnosia (inability to recognize previously known subjects)

Posterior circulation

Signs and Symptoms:

  • Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
  • Multiple, simultaneous complaints are the rule (including loss of consciousness, nausea and vomiting, alexia, visual agnosia)
  • 5 Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
  • Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)

Basilar artery

Signs and Symptoms:

  • Quadriplegia, coma, locked-in syndrome
  • "Crossed signs" in which a patient has unilateral cranial nerve deficits but contralateral hemiparesis and hemisensory loss suggest brainstem infarction
    • Millard-Gubler syndrome (ventral pontine syndrome) -- ipsilateral CN VI and VII palsy with contralateral hemiplegia of extremities
  • Sparing of vertical eye movements (CN III exits brainstem just above lesion)
    • Thus, may also have miosis b/l
  • One and a half syndrome (seen in a variety of brainstem infarctions)
    • "Half" - INO (internuclear opthalmoplegia) in one direction
    • "One" - inability for conjugate gaze in other direction
    • Convergence and vertical EOM intact
  • Medial inferior pontine syndrome (paramedian basilar artery branch)
    • Ipsilateral conjugate gaze towards lesion (PPRF), nystagmus (CN VIII), ataxia, diplopia on lateral gaze (CN VI)
    • Contralateral face/arm/leg paralysis and decreased proprioception
  • Medial midpontine syndrome (paramedian midbasilar artery branch)
    • Ipsilateral ataxia
    • Contralateral face/arm/leg paralysis and decreased proprioception
  • Medial superior pontine syndrome (paramedian upper basilar artery branches)
    • Ipsilateral ataxia, INO, myoclonus of pharynx/vocal cords/face
    • Contralateral face/arm/leg paralysis and decreased proprioception

Superior Cerebellar Artery (SCA)

  • ~2% of all cerebral infarctions[2]
  • May present with nonspecific symptoms - N/V, dizziness, ataxia, nystagmus (more commonly horizontal)[3]
  • Lateral superior pontine syndrome
    • Ipsilateral ataxia, n/v, nystagmus, Horner's syndrome, conjugate gaze paresis
    • Contralateral loss of pain/temperature in face/extremities/trunk, and loss of proprioception/vibration in LE > UE

Posterior Cerebral Artery (PCA)

Signs and Symptoms:

  • Common after CPR, as occiptal cortex is a watershed area
  • Unilateral headache (most common presenting complaint)
  • Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
  • Visual agnosia - can't recognize objects
  • Possible macular sparing if MCA unaffected
  • Motor function is typically minimally affected
  • Lateral midbrain syndrome (penetrating arteries from PCA)
    • Ipsilateral CN III - eye down and out, pupil dilated
    • Contralateral hemiataxia, tremor, hyperkinesis (red nucleus)
  • Medial midbrain syndrome (upper basilar and proximal PCA)
    • Ipsilateral CN III - eye down and out, pupil dilated
    • Contralateral paralysis of face, arm, leg (corticospinal)

Anterior Inferior Cerebellar Artery (AICA)

  • Lateral inferior pontine syndrome
  • Ipsilateral facial paralysis, loss of corneal reflex (CN VII)
  • Ipsilateral loss of pain/temp (CN V)
  • Nystagmus, N/V, vertigo, ipsilateral hearing loss (CN VIII)
  • Ipsilateral limb and gait ataxia
  • Ipsilateral Horner syndrome
  • Contralateral loss of pain/temp in trunk and extremities (lateral spinothalamic)

Posterior Inferior Cerebellar Artery (PICA)

Signs and Symptoms:

  • Lateral medullary/Wallenberg syndrome
  • Ipsilateral cerebellar signs, ipsilateral loss of pain/temp of face, ipsilateral Horner's syndrome, ipsilateral dysphagia and hoarseness, dysarthria, vertigo/nystagmus
  • Contralateral loss of pain/temp over body
  • Also caused by vertebral artery occlusion (most cases)

Internal Capsule and Lacunar Infarcts

  • May present with either lacunar c/l pure motor or c/l pure sensory (of face and body)[4]
    • Pure c/l motor - posterior limb of internal capsule infarct
    • Pure c/l sensory - thalamic infarct (Dejerine and Roussy syndrome)
  • C/l motor plus sensory if large enough
  • Clinically to cortical large ACA + MCA stroke - the following signs suggest cortical rather than internal capsule[5]:
    • Gaze preference
    • Visual field defects
    • Aphasia (dominant lesion, MCA)
    • Spatial neglect (non-dominant lesion)
  • Others
    • I/l ataxic hemiparesis, with legs worse than arms - posterior limb of internal capsule infarct
    • Dysarthria/Clumsy Hand Syndrome - basilar pons or anterior limb of internal capsule infarct

Anterior Spinal Artery (ASA)

Superior ASA

  • Medial medullary syndrome - displays alternating pattern of sidedness of symptoms below
  • Contralateral arm/leg weakness and proprioception/vibration
  • Tongue deviation towards lesion

Inferior ASA

  • ASA syndrome
  • Watershed area of hypoperfusion in T4-T8
  • B/l pain/temp loss in trunk and extremities (spinothalamic)
  • B/l weakness in trunk and extremities (corticospinal)
  • Preservation of dorsal columns

Differential Diagnosis

Stroke-like Symptoms

Weakness

Evaluation

Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA) Find out last known normal of affected deficit and write it down in chart

Stroke Work-Up

  • Labs
    • POC glucose
    • CBC
    • Chemistry
    • Coags
    • Troponin
    • T&S
  • ECG
    • In large ICH or stroke, may see deep TWI and prolong QT, occ ST changes
  • Head CT (non-contrast)
    • In ischemia stroke CT has sensitivity 42%, specificity 91%[6]
    • In acute ICH the sensitivity is 95-100%[7]
    • The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)[8]
  • Also consider:
    • CTA brain and neck
      • To check for large vessel occlusion for potential thrombectomy
      • Determine if there is carotid stenosis that warrants endarterectomy urgently
    • Pregnancy test
    • CXR (if infection suspected)
    • UA (if infection suspected)
    • Utox (if ingestion suspected)

MR Imaging (for Rule-Out CVA or TIA)

  • MRI Brain with DWI, ADC (without contrast) AND
  • Cervical vascular imaging (ACEP Level B in patients with high short-term risk for stroke):[9]
    • MRA brain (without contrast) AND
    • MRA neck (without contrast)
      • May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA)[10] (ACEP Level C)

Large Vessel Occlusion - Thrombectomy

  • "Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
  • CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours[11]
  • If CT perfusion unavailable, use ASPECT score[12]

VAN Score

  • NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy[13]
  • VAN score is just as sensitive, but also may be more specific (~90%)
    • Weakness must be present, plus one or all of the VAN to be VAN positive
      • Weakness qualifying findings -- if no weakness, the pt is VAN negative
        • Mild (minor drift)
        • Moderate (severe drift—touches or nearly touches ground)
        • Severe (flaccid or no antigravity)
      • Visual disturbance qualifying findings
        • Field cut (which side) (4 quadrants)
        • Double vision (ask patient to look to right then left; evaluate for uneven eyes)
        • Blind new onset
      • Aphasia qualifying findings
        • Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
        • Receptive (not understanding or following commands) (close eyes, make fist)
        • Mixed
      • Neglect qualifying findings
        • Forced gaze or inability to track to one side
        • Unable to feel both sides at the same time, or unable to identify own arm
        • Ignoring one side
    • If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA

Management

  • Depends on type
    • Ischemic vs Hemorrhagic
    • Acute vs subacute vs old
    • Due to risk for hemorrhagic transformation, there is no role in acute completed stroke for:
      • Dual antiplatelet therapy (as opposed in select cases of TIA)
      • Anticoagulation, with or without atrial fibrillation

Disposition

  • Admit for acute or subacute stroke

See Also

External Links

References

  1. Itoh Y, Yamada M, Hayakawa M, Otomo E, Miyatake T. Cerebral amyloid angiopathy: a significant cause of cerebellar as well as lobar cerebral hemorrhage in the elderly. J Neurol Sci. 1993 Jun;116(2):135-41.
  2. Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 18 (5): 849-55.
  3. Lee H, Kim HA. Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry. 2013 Apr;84(4):446-51.
  4. Rezaee A and Jones J et al. Lacunar stroke syndrome. Radiopaedia. http://radiopaedia.org/articles/lacunar-stroke-syndrome.
  5. Internal Capsule Stroke. Stanford Medicine Guide. http://stanfordmedicine25.stanford.edu/the25/ics.html
  6. Mullins ME, Schaefer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology. 2002 Aug;224(2):353-60.
  7. Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
  8. Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.
  9. ACEP Clinical Policy: Suspected Transient Ischemic Attackfull text
  10. Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.
  11. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.
  12. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670-4.
  13. Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.