Stroke (main): Difference between revisions
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==Treatment== | ==Treatment== | ||
===Ischemic=== | ===Ischemic=== | ||
*tPA AND non-tPA candidates: | |||
**Dehydration | |||
***Normalize volume status w/ IVF | |||
**Hypoxia | |||
***Maintain SpO2 >92% | |||
**Hyperpyrexia | |||
***Search for cause | |||
***Antipyretics | |||
**Glycemic control | |||
***Controversial | |||
====tPA Candidate==== | ====tPA Candidate==== | ||
Line 179: | Line 179: | ||
===Hemorrhagic=== | ===Hemorrhagic=== | ||
See [[Intracerebral Hemorrhage (ICH)]] | *See [[Intracerebral Hemorrhage (ICH)]] | ||
===Cerebellar=== | ===Cerebellar=== | ||
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration) | |||
==See Also== | ==See Also== |
Revision as of 05:46, 29 September 2011
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
Stroke Syndromes
- Anterior Circulation (internal carotid system)
- ACA
- 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
- MCA
- 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
- ACA
- Posterior circulation (vertebral system)
- Vertebral artery
- Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
- Multiple, simultaneous complaints are the rule
- Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
- Isolated events are not attributable to vertebral occlusive disease:
- E.g. Isolated lightheadedness, vertigo, transient ALOC, drop attacks
- Basilar artery
- Quadriplegia, coma, locked-in syndrome
- Posterior cerebral
- Unilateral headache (most common presenting complaint)
- Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
- Motor function is typically minimally affected
- Posteroinferior cerebellar
- Vertigo, gait instability, limb ataxia, HA, dysarthria, N/V, CN abnormalities
- Vertebral artery
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
- Thrombotic (80% of ischemic CVA)
- Hemorrhagic (13%)
- Intracerebral
- HTN
- Amyloidosis
- Anticoagulation
- Vascular malformations
- Cocaine use
- SAH
- Berry aneurysm rupture
- Vascular malformation rupture
- Intracerebral
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
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
- Have pt look at your nose w/ their eyes and then cover one eye
- If any of the above are abnormal obtain full CVA w/u (including MRI)
- Head Impulse Testing
DDX
- Seizures/postictal paralysis (Todd paralysis)
- Transient paralysis following a seizure which typically disappears quickly
- Note: seizures can be secondary to a CVA
- Syncope
- No persistent or associated neurologic symptoms
- Brain neoplasm or abscess
- Focal neurologic findings, signs of infection, detectable by imaging
- Epidural/subdural hematoma
- History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
- Hypoglycemia
- Can be detected by bedside glucose measurement, history of DM
- Hyponatremia
- History of diuretic use, neoplasm, excessive free water intake
- Hypertensive encephalopathy
- Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
- Meningitis/encephalitis
- 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
- Labyrinthitis
- 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
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
Treatment
Ischemic
- tPA AND non-tPA candidates:
- Dehydration
- Normalize volume status w/ IVF
- Hypoxia
- Maintain SpO2 >92%
- Hyperpyrexia
- Search for cause
- Antipyretics
- Glycemic control
- Controversial
- Dehydration
tPA Candidate
- 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
- tPA
- See CVA (tPA)
Non-tPA Candidate
- Hypertension
- Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
- Aspirin 325mg (within 24-48hr)
- Anticoagulation not recommended for acute stroke (even for A-fib)
Hemorrhagic
Cerebellar
- Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
See Also
- Transient Ischemic Attack (TIA)
- CVA (tPA)
- CVA (Post-tPA Hemorrhage)
- Intracranial Hemorrhage (ICH)
- Subarachnoid Hemorrhage (SAH)
Source
- Tintinalli
- UpToDate
- AHA/ASA Acute Stroke Guidelines
- EMCrit