Stroke (main): Difference between revisions

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==Background==
==Background==
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment   
*Vascular injury that reduces cerebral blood flow to specific region of brain causing neuro impairment   
*Accurate determination of last known time when pt was at baseline is essential
*Accurate determination of last known time when patient was at baseline is essential
*In-hospital mortality of 5-10% for ischemic stroke and 40-60% for hemorrhagic stroke
*Only 10% of stroke survivors will recover completely
[[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}}
{{Ischemic Stroke Cause}}
{{Hemorrhagic Stroke Cause}}
{{Hemorrhagic Stroke Cause}}
{{Stroke types}}


==Clinical Features==
==Clinical Features==
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==Differential Diagnosis==
==Differential Diagnosis==
===Stroke Types===
*[[Ischemic Stroke]]
**[[Cerebellar Stroke]]
**[[Transient Ischemic Attack (TIA)]]
*[[Hemorrhagic Stroke]]
**[[Intracerebral Hemorrhage]]
**[[Subarachnoid Hemorrhage (SAH)]]
{{Stroke DDX}}
{{Stroke DDX}}
{{Weakness DDX}}


==Diagnosis==
==Evaluation==
[[File:StrokeMCA overlay.png|thumb|[[Ischemic stroke]] with CT showing early signs of a middle cerebral artery stroke with loss of definition of the gyri and grey white boundary.]]
[[File:Intracerebral heamorrage.jpg|thumb|[[Hemorrhagic stroke]] (i.e. spontaneous intracranial hemorrhage).]]
[[File:Posterior fossa hemorrhage.jpg|thumb|[[Hemorrhagic stroke]] in the posterior fossa.]]
[[File:Left MCA Stroke.png|thumb|12-lead ECG of a patient with acute stroke, showing large deeply inverted T-waves.]]
'''Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA)'''
'''Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA)'''
Find out last known normal of affected deficit and write it down in chart
{{Stroke workup}}
{{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)
***'''V'''isual 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
***'''A'''phasia 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
***'''N'''eglect 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==
==Management==
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**[[Ischemic stroke|Ischemic]] vs [[Hemorrhagic stroke|Hemorrhagic]]
**[[Ischemic stroke|Ischemic]] vs [[Hemorrhagic stroke|Hemorrhagic]]
**Acute vs subacute vs old
**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
{{BP Goals in Acute Stroke}}
{{Common Medications for BP Control in Acute Stroke}}


==Disposition==
==Disposition==
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*[[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==

Latest revision as of 19:27, 22 June 2020

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
  • In-hospital mortality of 5-10% for ischemic stroke and 40-60% for hemorrhagic stroke
  • Only 10% of stroke survivors will recover completely
Sensory Homonculus - courtesy AnatomyZone.com

Ischemic stroke causes (87%)

Hemorrhagic stroke causes (13%)

Stroke Types

Clinical Features

Anterior Circulation

  • Blood supply via internal carotid system
  • Includes ACA and MCA

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)

Patient with stroke (forehead sparing).

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

Signs and Symptoms:

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
    • Millard-Gubler syndrome (ventral pontine syndrome) -- ipsilateral CN VI and VII palsy with contralateral hemiplegia of extremities
  • 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)
    • Ipsilateral conjugate gaze towards lesion (PPRF), nystagmus (CN VIII), ataxia, diplopia on lateral gaze (CN VI)
    • Contralateral face/arm/leg paralysis and decreased proprioception
  • Medial midpontine syndrome (paramedian midbasilar artery branch)
    • Ipsilateral ataxia
    • Contralateral face/arm/leg paralysis and decreased proprioception
  • Medial superior pontine syndrome (paramedian upper basilar artery branches)
    • Ipsilateral ataxia, INO, myoclonus of pharynx/vocal cords/face
    • Contralateral face/arm/leg paralysis and decreased proprioception

Superior Cerebellar Artery (SCA)

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)
    • Ipsilateral CN III - eye down and out, pupil dilated
    • Contralateral hemiataxia, tremor, hyperkinesis (red nucleus)
  • Medial midbrain syndrome (upper basilar and proximal PCA)
    • Ipsilateral CN III - eye down and out, pupil dilated
    • Contralateral paralysis of face, arm, leg (corticospinal)

Anterior Inferior Cerebellar Artery (AICA)

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

Weakness

Evaluation

Ischemic stroke with CT showing early signs of a middle cerebral artery stroke with loss of definition of the gyri and grey white boundary.
Hemorrhagic stroke (i.e. spontaneous intracranial hemorrhage).
Hemorrhagic stroke in the posterior fossa.
12-lead ECG of a patient with acute stroke, showing large deeply inverted T-waves.

Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA) Find out last known normal of affected deficit and write it down in chart

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%[7]
    • In acute ICH the sensitivity is 95-100%[8]
    • The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)[9]
  • 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):[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
    • If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA

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

BP Goals in Acute Stroke[15]

Stoke Type Target BP
(mm Hg)
 		Notes
Acute ischemic stroke
IV tPA eligble <185/110
During/after tPA <180/105 Monitor BP every 15 min for 2 hr, then every 30 minfor 6 hr, then hourly until 24 hr.
No tPA <220/120
Mechanical thrombectomy ≤180/105 Maintain during and for 24 h after procedure
Aneurysmal subarachnoid hemorrhage
Unsecured SBP <140-160 Controversy regarding exact number; others recommend <100 MAP
Secured Unclear May depend on ppremorbid BP and presence of vasospasm
Intraparenchymal hemorrhage
Initial SPB 150-220 SBP <140
Initial SPB >220 SBP 140-160

Common Medications for BP Control in Acute Stroke

Agent Typica Dose/Range Onset of Action Cautions/Contraindications
Labetalol 10-20 mg IV push; may repeat x 1 5 min Avoid in COPD, asthma, heart failure, bradycardia, heart block
Nicardipine IV infusion at 5 mg/h; titrate up by 2.5 mh/h q5-15 min; max 15 mg/h 1-5 min Avoid in severe aortic stenosis
Clevidipine 1-2 mg/h IV; titrate by doubling dose q2-5 min; max 21 mg/h 2-4 min; short half-life Avoid in egg/soy allergy
Hydralazine 10-20 mg IV; repeat q4-6 h 10-20 min

Disposition

  • Admit for acute or subacute stroke

See Also

External Links

References

  1. ↑ [Finsterer J. Management of cryptogenic stroke. Acta Neurol Belg. 2010 Jun;110(2):135-47. PMID: 20873443].
  2. ↑ 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.
  3. ↑ Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 18 (5): 849-55.
  4. ↑ 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.
  5. ↑ Rezaee A and Jones J et al. Lacunar stroke syndrome. Radiopaedia. http://radiopaedia.org/articles/lacunar-stroke-syndrome.
  6. ↑ Internal Capsule Stroke. Stanford Medicine Guide. http://stanfordmedicine25.stanford.edu/the25/ics.html
  7. ↑ 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.
  8. ↑ Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
  9. ↑ 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.
  10. ↑ ACEP Clinical Policy: Suspected Transient Ischemic Attack full text
  11. ↑ Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ Cocchi MN, Edlow JA. Managing Hypertention in Patients with Acute Stroke. 2020. Annals of EM 75(6):767771
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