Template:Stroke workup: Difference between revisions
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**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>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.</ref>
**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>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.</ref>
*Also consider:
*Also consider:
**CTA brain and neck (to check for large vessel occlusion for potential thrombectomy)
**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
**Pregnancy test
**CXR (if infection suspected)
**[[CXR]] (if infection suspected)
**UA (if infection suspected)
**[[UA]] (if infection suspected)
**Utox (if ingestion suspected)
**[[Utox]] (if ingestion suspected)


{{MR studies CVA/TIA}}
{{MR studies CVA/TIA}}
===Large Vessel Occlusion - Thrombectomy===
*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours<ref>Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.</ref>
*If CT perfusion unavailable, use ASPECT score<ref>Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670-4.</ref>
====VAN Score====
*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>
*VAN score is just as sensitive, but also may be more specific (~90%)
**Weakness must be present, plus one or all of the VAN to be VAN positive
***Weakness qualifying findings -- if no weakness, the pt is VAN negative
****Mild (minor drift)
****Moderate (severe drift—touches or nearly touches ground)
****Severe (flaccid or no antigravity)
***Visual disturbance qualifying findings
****Field cut (which side) (4 quadrants)
****Double vision (ask patient to look to right then left; evaluate for uneven eyes)
****Blind new onset
***Aphasia qualifying findings
****Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
****Receptive (not understanding or following commands) (close eyes, make fist)
****Mixed
***Neglect qualifying findings
****Forced gaze or inability to track to one side
****Unable to feel both sides at the same time, or unable to identify own arm
****Ignoring one side
**If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA

Latest revision as of 01:13, 2 October 2019

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)
  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 Attack full 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.
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