Stroke (main)

Revision as of 04:31, 28 September 2015 by Rossdonaldson1 (talk | contribs) (Diagnosis)

Stroke Types

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

Ischemic stroke causes (87% of all strokes)

  • Thrombotic (80% of ischemic CVA)
  • 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 stroke causes (13% of all strokes)

Clinical Features

Differential Diagnosis

Stroke-like Symptoms

Diagnosis

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%[1]
    • In acute ICH the sensitivity is 95-100%[2]
    • The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)[3]
  • 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):[4]
    • MRA brain (without contrast) AND
    • MRA neck (without contrast)
      • May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA)[5] (ACEP Level C)

Management

Disposition

See Also

External Links

References

  1. 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.
  2. Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
  3. 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.
  4. ACEP Clinical Policy: Suspected Transient Ischemic Attackfull text
  5. Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.