Stroke (main)

Revision as of 19:40, 20 July 2011 by Jswartz (talk | contribs) (Treatment)

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
    • 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
    • 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

Source

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

UpToDate

AHA/ASA Acute Stroke Guidelines