Stroke (main)

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

Stroke Syndromes

1. Anterior Circulation (internal carotid system)
   1. ACA
      1. Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
      2. Left sided lesion: akinetic mutism, transcortical motor aphasia
      3. Right sided lesion: Confusion, motor hemineglect
   2. MCA
      1. Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
      2. Motor deficits found more commonly in face and upper extremity than lower extremity
      3. Dominant hemisphere involved: aphasia
      4. Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
      5. Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
2. Posterior circulation (vertebral system)
   1. Vertebral artery
      1. Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
      2. Multiple, simultaneous complaints are the rule
         1. Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
      3. Isolated events are not attributable to vertebral occlusive disease:
         1. e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks
   2. Basilar artery
      1. Quadriplegia, coma, locked-in syndrome
   3. Posterior cerebral
      1. Unilateral headache (most common presenting complaint)
      2. Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
      3. Motor function is typically minimally affected
   4. Posteroinferior cerebellar
      1. Vertigo, gait instability, limb ataxia, HA, dysarthria, N/V, CN abnormalities

Causes

1. Ischemic (87%)
   1. Thrombotic (80% of ischemic CVA)
      1. Atherosclerosis
      2. Vasculitis
      3. Arterial dissection
      4. Polycythemia
      5. Hypercoagulable state
      6. Infection
   2. Embolic (20% of ischemic CVA)
      1. Valvular vegetations
      2. Mural thrombi
      3. Arterial-arterial emboli from proximal source
      4. Fat emboli
      5. Septic emboli
   3. Hypoperfusion
      1. Cardiac failure resulting in systemic hypotension
2. Hemorrhagic (13%)
   1. Intracerebral
      1. HTN
      2. Amyloidosis
      3. Anticoagulation
      4. Vascular malformations
      5. Cocaine use
   2. SAH
      1. Berry aneurysm rupture
      2. Vascular malformation rupture

Clinical Features

• Thrombotic
  • Stuttering or waxing and waning
  • TIA involving same vascular distribution
• Embolic
  • Sudden onset of symptoms
  • TIAs involving different vascular distributions
  • A-fib
  • Valvular replacement
  • Recent MI
• Hemorrhagic
  • Sudden onset of symptoms
  • Preceded by severe headache
  • Recent neck trauma/manipulation

Cerebellar Stroke

• Sudden inability to walk is common finding
• Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
• HINTS Exam can reliably distinguish the two (more effective than early DWI MRI)
  • 1. Head Impulse Testing
    • Tests vestibulo-ocular reflex
    • Have pt fix their eyes on your nose
    • Move their head in the horizontal plane to the left and right
    • If reflex is intact their eyes will stay fixed on your nose
    • If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
    • It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
  • 2. Nystagmus
    • Benign nystagmus only beats in one direction no matter which direction their eyes look
    • Bad nystagums beats in every direction their eyes look
      • If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
  • 3. Test of Skew
    • Vertical dysconjugate gaze is bad
    • Alternating cover test
      • Have pt look at your nose w/ their eyes and then cover one eye
        • When rapidly uncover the eye look to see if the eye quickly moves to re-align
  • If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

DDX

1. Seizures/postictal paralysis (Todd paralysis)
   1. Transient paralysis following a seizure which typically disappears quickly
   2. Note: seizures can be secondary to a CVA
2. Syncope
   1. No persistent or associated neurologic symptoms
3. Brain neoplasm or abscess
   1. Focal neurologic findings, signs of infection, detectable by imaging
4. Epidural/subdural hematoma
   1. History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
5. Hypoglycemia
   1. Can be detected by bedside glucose measurement, history of DM
6. Hyponatremia
   1. History of diuretic use, neoplasm, excessive free water intake
7. Hypertensive encephalopathy
   1. Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
8. Meningitis/encephalitis
   1. Fever, immunocompromise may be present, meningismus, detectable on LP
9. Hyperosmotic Coma
   1. Extremely high glucose levels, history of DM
10. Wernicke Encephalopathy
    1. History of ETOH or malnutrition; triad of ataxia, ophthalmoplegia, and confusion
11. Labyrinthitis
    1. Predominantly vestibular symptoms; pt should have no other focal findings
12. Drug toxicity
    1. Lithium, phenytoin, carbamazepine
13. Bell's Palsy
    1. Neuro deficit confined to isolated peripheral 7th nerve palsy; often a/w younger age
14. Complicated migraine
    1. History of similar episodes, preceding aura, HA
15. Meniere Disease
    1. History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness
16. Demyelinating disease (MS)
    1. Gradual onset, may have hx of multiple episodes of findings in multiple distributions
17. Conversion disorder
    1. No cranial nerve findings, nonanatomic distribution of findings

Work-Up

1. Bedside glucose
2. Bedside Hb (polycythemia)
3. CBC
4. Chemistry
5. Coags
6. Troponin
7. ECG (esp A-fib)
8. Head CT
   1. Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
9. Also consider:
   1. Pregnancy test
   2. CXR (if infection suspected)
   3. UA (if infection suspected)
   4. Utox (if ingestion suspected

Treatment

Ischemic

• tPA AND non-tPA candidates:
  • Prevent dehydration
  • Maintain SpO2 >92%
  • Prevent fever
  • Controversial

tPA Candidate

1. tPA
   1. See CVA (tPA)
2. Hypertension
   1. Lower SBP to <185, DBP to <110
   2. Options:
      1. Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
      2. Nitroglycerin paste, 1–2 in. to skin OR
      3. Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
         1. When desired blood pressure attained reduce to 3mg/hr

Non-tPA Candidate

1. Hypertension
   1. Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
2. Aspirin 325mg (within 24-48hr)
3. Anticoagulation not recommended for acute stroke (even for A-fib)

Hemorrhagic

• See Intracerebral Hemorrhage (ICH)

Cerebellar

• Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)

See Also

• Transient Ischemic Attack (TIA)
• CVA (tPA)
• CVA (Post-tPA Hemorrhage)
• Intracranial Hemorrhage (ICH)
• Subarachnoid Hemorrhage (SAH)
• Cervical Artery Dissection
• NIH Stroke Scale

External Links

• MDCalc - NIH Stroke Scale/Score

Source

• Tintinalli
• UpToDate
• AHA/ASA Acute Stroke Guidelines
• EMCrit