Difference between revisions of "Stroke (main)"

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#[[Seizures]]/postictal paralysis (Todd paralysis)
*[[Seizures]]/postictal paralysis (Todd paralysis)
##Transient paralysis following a seizure which typically disappears quickly
##Note: seizures can be secondary to a CVA
##No persistent or associated neurologic symptoms
#Brain neoplasm or abscess
*[[Hyperosmotic Coma]]
##Focal neurologic findings, signs of infection, detectable by imaging
#Epidural/subdural hematoma
*[[Drug toxicity]]
##History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
**Lithium, phenytoin, carbamazepine
*[[Bell's Palsy]]
##Can be detected by bedside glucose measurement, history of DM
*Complicated [[migraine]]
*[[Meniere Disease]]
##History of diuretic use, neoplasm, excessive free water intake
*Demyelinating disease ([[MS]])
#Hypertensive encephalopathy
*Conversion disorder
##Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
##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
##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

Revision as of 19:30, 25 September 2014


  • 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


  1. Ischemic (87%)
    1. Thrombotic (80% of ischemic CVA)
      1. Atherosclerosis
      2. Vasculitis
      3. Arterial dissection
      4. Polycythemia
      5. Hypercoagulable state
      6. Infection
    2. Embolic (20% of ischemic CVA)
      1. Valvular vegetations
      2. Mural thrombi
      3. Arterial-arterial emboli from proximal source
      4. Fat emboli
      5. Septic emboli
    3. Hypoperfusion
      1. Cardiac failure resulting in systemic hypotension
  2. Hemorrhagic (13%)
    1. Intracerebral
      1. HTN
      2. Amyloidosis
      3. Anticoagulation
      4. Vascular malformations
      5. Cocaine use
    2. SAH
      1. Berry aneurysm rupture
      2. 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


Anterior Circulation

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

Anterior Cerebral Artery (ACA)

Signs and Symptoms:

  • 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

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
  • Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
  • Homonymous hemianopsia and gaze preference toward side of infarct may also be seen

Posterior circulation

Signs and Symptoms:

  • Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
  • Multiple, simultaneous complaints are the rule
  • 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

Posterior Cerebral Artery (PCA)

Signs and Symptoms:

  • Unilateral headache (most common presenting complaint)
  • Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
  • Motor function is typically minimally affected

Posteroinferior Cerebellar Artery (PICA)

Signs and Symptoms:

  • Vertigo, gait instability, limb ataxia, Headache, dysarthria, Nausea and Vomitting, Cranial Nerve abnormalities



  1. Bedside glucose
  2. Bedside Hb (polycythemia)
  3. CBC
  4. Chemistry
  5. Coags
  6. Troponin
  7. ECG (esp A-fib)
  8. Head CT
    1. Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
  9. Also consider:
    1. Pregnancy test
    2. CXR (if infection suspected)
    3. UA (if infection suspected)
    4. Utox (if ingestion suspected



  • tPA AND non-tPA candidates:
    • Prevent dehydration
    • Maintain SpO2 >92%
    • Prevent fever
    • Controversial

tPA Candidate

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

Non-tPA Candidate

  1. Hypertension
    1. Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
  2. Aspirin 325mg (within 24-48hr)
  3. Anticoagulation not recommended for acute stroke (even for A-fib)



  • Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
  • See Cerebellar Stroke

See Also

External Links


  • Tintinalli
  • UpToDate
  • AHA/ASA Acute Stroke Guidelines
  • EMCrit