Template:Stroke workup: Difference between revisions
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{{MR studies CVA/TIA}} | {{MR studies CVA/TIA}} | ||
===Large Vessel Occlusion | ===Large Vessel Occlusion - Thrombectomy=== | ||
*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from 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> | *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> | ||
Revision as of 05:57, 19 February 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)
- Also consider:
- CTA brain and neck (to check for large vessel occlusion for potential thrombectomy)
- 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)
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[6]
- If CT perfusion unavailable, use ASPECT score[7]
VAN Score
- NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy[8]
- 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
- Weakness qualifying findings -- if no weakness, the pt is VAN negative
- If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA
- Weakness must be present, plus one or all of the VAN to be VAN positive
- ↑ 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.
- ↑ Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
- ↑ 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.
- ↑ ACEP Clinical Policy: Suspected Transient Ischemic Attack full text
- ↑ Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.
- ↑ 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.
- ↑ 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.
- ↑ 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.