Difference between revisions of "Stroke (main)"

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==Stroke Types==
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*[[Ischemic Stroke]]
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**[[Cerebellar Stroke]]
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**[[Transient Ischemic Attack (TIA)]]
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*[[Hemorrhagic Stroke]]
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**[[Intracerebral Hemorrhage]]
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**[[Subarachnoid Hemorrhage (SAH)]]
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** [[Hypertension]]
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==Background==
 
==Background==
 
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment   
 
*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
 
*Accurate determination of last known time when pt was at baseline is essential
 
[[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]]
 
[[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]]
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===Causes===
 
===Causes===
 
*Ischemic (87%)
 
*Ischemic (87%)
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***Berry aneurysm rupture
 
***Berry aneurysm rupture
 
***Vascular malformation rupture
 
***Vascular malformation rupture
 
==Clinical Features==
 
{{Stroke Syndromes}}
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
{{Stroke DDX}}
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{{ 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==
 
==See Also==

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

See Also

External Links

References