Stroke (main): Difference between revisions
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==Background== | ==Background== | ||
*Vascular injury that reduces | *Vascular injury that reduces cerebral blood flow to specific region of brain causing neuro impairment | ||
*Accurate determination of last known time when | *Accurate determination of last known time when patient was at baseline is essential | ||
[[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]] | [[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]] | ||
{{Ischemic Stroke Cause}} | |||
{{Hemorrhagic Stroke Cause}} | |||
{{Stroke types}} | |||
==Clinical Features== | |||
{{Stroke Syndromes}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{ Stroke DDX}} | {{Stroke DDX}} | ||
{{Weakness DDX}} | |||
==Evaluation== | |||
'''Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA)''' | |||
{{Stroke workup}} | |||
===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 | |||
==Management== | |||
*Depends on type | |||
**[[Ischemic stroke|Ischemic]] vs [[Hemorrhagic stroke|Hemorrhagic]] | |||
**Acute vs subacute vs old | |||
**Due to risk for hemorrhagic transformation, there is no role in acute completed stroke for: | |||
***Dual antiplatelet therapy (as opposed in select cases of [[TIA]]) | |||
***Anticoagulation, with or without atrial fibrillation | |||
==Disposition== | |||
*Admit for acute or subacute stroke | |||
==See Also== | ==See Also== | ||
Line 53: | Line 64: | ||
*[[NIH Stroke Scale]] | *[[NIH Stroke Scale]] | ||
*[[Cerebellar Stroke]] | *[[Cerebellar Stroke]] | ||
*[[Focal neurologic signs]] | |||
==External Links== | ==External Links== | ||
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score] | *[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score] | ||
*[https://emergencymedicinecases.com/ed-stroke-management-endovascular-therapy/ Emergency medicine cases - ED stroke management in the age of endovascular therapy] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Neurology]] |
Revision as of 06:08, 19 February 2019
Background
- Vascular injury that reduces cerebral blood flow to specific region of brain causing neuro impairment
- Accurate determination of last known time when patient was at baseline is essential
Ischemic stroke causes (87%)
- Thrombotic (80% of ischemic CVA)
- Atherosclerosis
- Vasculitis
- Vertebral and carotid artery dissection
- Often preceded by yoga, spinal manipulation, coughing, vomiting
- Polycythemia
- Hypercoagulable state (oral contraceptives, antiphospholipid antibodies, protein S and C deficiencies, sickle cell anemia)
- Infection
- Toxicologic exposure (cocaine, amphetamines, etc.)
- Embolic (20% of ischemic CVA)
- Valvular vegetations
- Mural thrombi
- Arterial-arterial emboli from proximal source (ex. amaurosis fugax -> emboli from a proximal carotid artery plaque embolizes to the ophthalmic artery, causing transient monocular blindness)
- Fat emboli
- Septic emboli
- Hypoperfusion
- Cardiac failure resulting in systemic hypotension
- Cryptogenic
- Cryptogenic Stroke (CS) is defined as an Ischemic stroke of obscure or unknown origin. Its causes are unknown. It is transitory or reversible.[1]
Hemorrhagic stroke causes (13%)
- Intracerebral
- Hypertension
- Cerebral amyloid angiopathy (usually found in elderly, tends to be lobar in nature)[2]
- Anticoagulation
- Vascular malformations (e.g. AVM, moyamoya
- Cocaine use
- Subarachnoid hemorrhage
- Berry aneurysm rupture
- Arteriovenous malformation
Stroke Types
Clinical Features
Anterior Circulation
Internal Carotid Artery
- Tonic gaze deviation towards lesion
- Global aphasia, dysgraphia, dyslexia, dyscalculia, disorientation (dominant lesion)
- Spatial or visual neglect (non-dominant lesion)
Anterior Cerebral Artery (ACA)
Signs and Symptoms:
- Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
- Urinary and bowel incontinence
- Left sided lesion: akinetic mutism, transcortical motor aphasia
- Right sided lesion: Confusion, motor hemineglect
- Presence of primitive grasp and suck reflexes
- May manifest gait apraxia
Middle Cerebral Artery (MCA)
Signs and Symptoms:
- 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
- Wernicke's aphasia (receptive aphasia) -> patient unable to process sensory input and does not understand verbal communication
- Broca's aphasia (expressive aphasia) -> patient unable to communicate verbally, even though understanding may be intact
- Nondominant hemisphere involved: dysarthria (motor deficit of the mouth and speech muscles; understanding intact) w/o aphasia, inattention and neglect side opposite to infarct
- Contralateral homonymous hemianopsia
- Gaze preference toward side of infarct
- Agnosia (inability to recognize previously known subjects)
Posterior circulation
- Blood supply via the vertebral artery
- Branches include, AICA, Basilar artery, PCA and PICA
Signs and Symptoms:
- Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
- Multiple, simultaneous complaints are the rule (including loss of consciousness, nausea/vomiting, alexia, visual agnosia)
- 5 Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
- Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)
- Approximately 25% associated with aortic dissection
Basilar artery
Signs and Symptoms:
- Quadriplegia, coma, locked-in syndrome
- "Crossed signs" in which a patient has unilateral cranial nerve deficits but contralateral hemiparesis and hemisensory loss suggest brainstem infarction
- Sparing of vertical eye movements (CN III exits brainstem just above lesion)
- Thus, may also have miosis b/l
- One and a half syndrome (seen in a variety of brainstem infarctions)
- "Half" - INO (internuclear ophthalmoplegia) in one direction
- "One" - inability for conjugate gaze in other direction
- Convergence and vertical EOM intact
- Medial inferior pontine syndrome (paramedian basilar artery branch)
- Medial midpontine syndrome (paramedian midbasilar artery branch)
- Medial superior pontine syndrome (paramedian upper basilar artery branches)
Superior Cerebellar Artery (SCA)
- ~2% of all cerebral infarctions[3]
- May present with nonspecific symptoms - nausea/vomiting, dizziness, ataxia, nystagmus (more commonly horizontal)[4]
- Lateral superior pontine syndrome
- Ipsilateral ataxia, nausea/vomiting, nystagmus, Horner syndrome, conjugate gaze paresis
- Contralateral loss of pain/temperature in face/extremities/trunk, and loss of proprioception/vibration in LE > UE
Posterior Cerebral Artery (PCA)
Signs and Symptoms:
- Common after CPR, as occipital cortex is a watershed area
- Unilateral headache (most common presenting complaint)
- Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
- Visual agnosia - can't recognize objects
- Possible macular sparing if MCA unaffected
- Motor function is typically minimally affected
- Lateral midbrain syndrome (penetrating arteries from PCA)
- Medial midbrain syndrome (upper basilar and proximal PCA)
Anterior Inferior Cerebellar Artery (AICA)
- Lateral inferior pontine syndrome
- Ipsilateral facial paralysis, loss of corneal reflex (CN VII)
- Ipsilateral loss of pain/temperature (CN V)
- Nystagmus, nausea/vomiting, vertigo, ipsilateral hearing loss (CN VIII)
- Ipsilateral limb and gait ataxia
- Ipsilateral Horner syndrome
- Contralateral loss of pain/temperature in trunk and extremities (lateral spinothalamic)
Posterior Inferior Cerebellar Artery (PICA)
Signs and Symptoms:
- Lateral medullary/Wallenberg syndrome
- Ipsilateral cerebellar signs, ipsilateral loss of pain/temperature of face, ipsilateral Horner syndrome, ipsilateral dysphagia and hoarseness, dysarthria, vertigo/nystagmus
- Contralateral loss of pain/temp over body
- Also caused by vertebral artery occlusion (most cases)
Internal Capsule and Lacunar Infarcts
- May present with either lacunar c/l pure motor or c/l pure sensory (of face and body)[5]
- Pure c/l motor - posterior limb of internal capsule infarct
- Pure c/l sensory - thalamic infarct (Dejerine and Roussy syndrome)
- C/l motor plus sensory if large enough
- Clinically to cortical large ACA + MCA stroke - the following signs suggest cortical rather than internal capsule[6]:
- Gaze preference
- Visual field defects
- Aphasia (dominant lesion, MCA)
- Spatial neglect (non-dominant lesion)
- Others
- Ipsilateral ataxic hemiparesis, with legs worse than arms - posterior limb of internal capsule infarct
- Dysarthria/Clumsy Hand Syndrome - basilar pons or anterior limb of internal capsule infarct
Anterior Spinal Artery (ASA)
Superior ASA
- Medial medullary syndrome - displays alternating pattern of sidedness of symptoms below
- Contralateral arm/leg weakness and proprioception/vibration
- Tongue deviation towards lesion
Inferior ASA
- ASA syndrome
- Watershed area of hypoperfusion in T4-T8
- Bilateral pain/temp loss in trunk and extremities (spinothalamic)
- Bilateral weakness in trunk and extremities (corticospinal)
- Preservation of dorsal columns
Differential Diagnosis
Stroke-like Symptoms
- Stroke
- Seizures/postictal paralysis (Todd paralysis)
- Syncope
- Subdural hemorrhage
- Epidural hemorrhage
- Hypoglycemia
- Hyponatremia
- Meningitis/encephalitis
- Hyperosmotic Coma
- Labyrinthitis
- Drug toxicity
- Bell's Palsy
- Complicated migraine
- Meniere Disease
- Demyelinating disease (MS)
- Conversion disorder
- Transient global amnesia
- Giant cell arteritis
- Cerebral sinus thrombosis
Weakness
- Neuromuscular weakness
- Upper motor neuron:
- CVA
- Hemorrhagic stroke
- Multiple sclerosis
- Amyotrophic Lateral Sclerosis (ALS) (upper and lower motor neuron)
- Lower motor neuron:
- Spinal and bulbar muscular atrophy (Kennedy's syndrome)
- Spinal cord disease:
- Infection (Epidural abscess)
- Infarction/ischemia
- Trauma (Spinal Cord Syndromes)
- Inflammation (Transverse Myelitis)
- Degenerative (Spinal muscular atrophy)
- Tumor
- Peripheral nerve disease:
- Neuromuscular junction disease:
- Muscle disease:
- Rhabdomyolysis
- Dermatomyositis
- Polymyositis
- Alcoholic myopathy
- Upper motor neuron:
- Non-neuromuscular weakness
- Can't miss diagnoses:
- ACS
- Arrhythmia/Syncope
- Severe infection/Sepsis
- Hypoglycemia
- Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
- Respiratory failure
- Emergent Diagnoses:
- Symptomatic Anemia
- Severe dehydration
- Hypothyroidism
- Polypharmacy
- Malignancy
- Aortic disease - occlusion, stenosis, dissection
- Other causes of weakness and paralysis
- Acute intermittent porphyria (ascending weakness)
- Can't miss diagnoses:
Evaluation
Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA)
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:
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):[10]
- MRA brain (without contrast) AND
- MRA neck (without contrast)
- May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA)[11] (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[12]
- If CT perfusion unavailable, use ASPECT score[13]
VAN Score
- NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy[14]
- 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
Management
- Depends on type
- Ischemic vs Hemorrhagic
- Acute vs subacute vs old
- Due to risk for hemorrhagic transformation, there is no role in acute completed stroke for:
- Dual antiplatelet therapy (as opposed in select cases of TIA)
- Anticoagulation, with or without atrial fibrillation
Disposition
- Admit for acute or subacute stroke
See Also
- Transient Ischemic Attack (TIA)
- Thrombolysis in Acute Ischemic Stroke (tPA)
- CVA (Post-tPA Hemorrhage)
- Intracerebral Hemorrhage
- Subarachnoid Hemorrhage (SAH)
- Cervical Artery Dissection
- NIH Stroke Scale
- Cerebellar Stroke
- Focal neurologic signs
External Links
- MDCalc - NIH Stroke Scale/Score
- Emergency medicine cases - ED stroke management in the age of endovascular therapy
References
- ↑ [Finsterer J. Management of cryptogenic stroke. Acta Neurol Belg. 2010 Jun;110(2):135-47. PMID: 20873443].
- ↑ Itoh Y, Yamada M, Hayakawa M, Otomo E, Miyatake T. Cerebral amyloid angiopathy: a significant cause of cerebellar as well as lobar cerebral hemorrhage in the elderly. J Neurol Sci. 1993 Jun;116(2):135-41.
- ↑ Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 18 (5): 849-55.
- ↑ Lee H, Kim HA. Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry. 2013 Apr;84(4):446-51.
- ↑ Rezaee A and Jones J et al. Lacunar stroke syndrome. Radiopaedia. http://radiopaedia.org/articles/lacunar-stroke-syndrome.
- ↑ Internal Capsule Stroke. Stanford Medicine Guide. http://stanfordmedicine25.stanford.edu/the25/ics.html
- ↑ 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.