Stroke (main): Difference between revisions
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###Vascular malformation rupture | ###Vascular malformation rupture | ||
== | ==Clinical Presentation== | ||
{{Stroke Syndromes}} | {{Stroke Syndromes}} | ||
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{{Weakness DDX}} | {{Weakness DDX}} | ||
==Work-Up== | ==Diagnosis== | ||
===Work-Up=== | |||
#Bedside glucose | #Bedside glucose | ||
#Bedside Hb (polycythemia) | #Bedside Hb (polycythemia) | ||
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##Utox (if ingestion suspected | ##Utox (if ingestion suspected | ||
== | ==Management== | ||
===Ischemic=== | ===Ischemic=== | ||
====Both tPA AND non-tPA candidates==== | ====Both tPA AND non-tPA candidates==== | ||
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==Source== | ==Source== | ||
*AHA/ASA Acute Stroke Guidelines | *AHA/ASA Acute Stroke Guidelines | ||
[[Category:Neuro]] | [[Category:Neuro]] |
Revision as of 20:29, 22 April 2015
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
Causes
- Ischemic (87%)
- Thrombotic (80% of ischemic CVA)
- Atherosclerosis
- Vasculitis
- Arterial dissection
- Polycythemia
- Hypercoagulable state
- Infection
- 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
- Thrombotic (80% of ischemic CVA)
- Hemorrhagic (13%)
- Intracerebral
- HTN
- Amyloidosis
- Anticoagulation
- Vascular malformations
- Cocaine use
- SAH
- Berry aneurysm rupture
- Vascular malformation rupture
- Intracerebral
Clinical Presentation
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[1]
- May present with nonspecific symptoms - nausea/vomiting, dizziness, ataxia, nystagmus (more commonly horizontal)[2]
- 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)[3]
- 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[4]:
- 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
- Seizures/postictal paralysis (Todd paralysis)
- Syncope
- Hypoglycemia
- Hyponatremia
- Meningitis/encephalitis
- Hyperosmotic Coma
- Labyrinthitis
- Drug toxicity
- Lithium, phenytoin, carbamazepine
- Bell's Palsy
- Complicated migraine
- Meniere Disease
- Demyelinating disease (MS)
- Conversion disorder
- Transient global amnesia
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:
Diagnosis
Work-Up
- Bedside glucose
- Bedside Hb (polycythemia)
- CBC
- Chemistry
- Coags
- Troponin
- ECG (esp A-fib)
- Head CT
- Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
- Also consider:
- Pregnancy test
- CXR (if infection suspected)
- UA (if infection suspected)
- Utox (if ingestion suspected
Management
Ischemic
Both tPA AND non-tPA candidates
- Prevent dehydration
- Maintain SpO2 >92%
- Maintain blood glucose between 140 and 180 mg/dL
- Prevent fever
- HOB >30°
tPA Candidate
- tPA
- Hypertension
- Lower SBP to <185, DBP to <110
- Options:
- Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
- Nitroglycerin paste, 1–2 in. to skin OR
- Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
- When desired blood pressure attained reduce to 3mg/hr
Non-tPA Candidate
- Hypertension
- Allow permissive HTN
- If SBP >220 or DBP >120, lower by 25% over 24 hrs (drug of choice is Nicardipine)[5]
- Aspirin 325mg (within 24-48hr)
- Anticoagulation not recommended for acute stroke (even for A-fib)
Hemorrhagic
Cerebellar
- Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
- See Cerebellar 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
External Links
Source
- AHA/ASA Acute Stroke Guidelines
- ↑ 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
- ↑ Zha AM, et al. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015; 21(2):91-8.