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Dr Farzadfard
Stroke types
Infarcts
Artery
Vein
Hemorrhages
ICH
IVH
SAH
Presentation
Abrupt Onset
Fit the distribution of a single vascular territory
early decrease in level of consciousness, nausea and vomiting, headache, and accelerated hypertension are more common with hemorrhages.
Subarachnoid hemorrhages classically present as a bursting very severe headache (‘‘the worst headache of my life’’), and are often accompanied by stiff neck, decreased consciousness, nausea and vomiting
Signs and symptoms characteristic of the various arterial territories
Middle cerebral – contralateral loss of strength and sensation in the face, arm, and to a lesser extent leg. Aphasia if dominant hemisphere, neglect if non-dominant.
Anterior cerebral – contralateral loss of strength and sensation in the leg and to a lesser extent arm.
Posterior cerebral – contralateral visual field deficit. Possibly confusion and aphasia if dominant hemisphere.
Penetrating (lacunar syndrome) – contralateral weakness or sensory loss (usually not both) in face, arm, and leg. No aphasia, neglect, or visual loss. Possibly ataxia, dysarthria.
Vertebral (or posterior inferior cerebellar) – truncal ataxia, dysarthria, dysphagia, ipsilateral sensory loss on the face, and contralateral sensory loss below the neck.
Basilar – various combinations of limb ataxia, dysarthria, dysphagia, facial and limb weakness and sensory loss (may be bilateral), pupillary asymmetry, disconjugate gaze, visual field loss, decreased responsiveness
DIAGNOSIS
History
Exam
presence of comorbidities
Absence of seizures or other stroke mimics
Imaging
Differential diagnosis
Seizures
Migraine
Syncope
Hypoglycemia
Metabolic encephalopathy
Drug overdose
Central nervous system tumor
Herpes simplex encephalitis (HSE)
Subdural hematoma
O2 via nasal cannula
Intubation may be necessary
Consider putting the head of the bed flat
Consider normal saline bolus
All patients
brain CT (brain MRI could be considered at qualified centers)
electrocardiogram
blood glucose
serum electrolytes
renal function tests
complete blood count, including platelet count
PT, INR,PTT
Selected patients
hepatic function tests
toxicology screen
blood alcohol determination
pregnancy test
oxygen saturation or arterial blood gas tests (if hypoxia is suspected)
chest radiography (if lung disease or aortic dissection are suspected)
lumbar puncture (if subarachnoid hemorrhage is suspected and CT is negative for blood)
electroencephalogram (if seizures are suspected)
Do not treat hypertension acutely unless:
(1) the patient was treated with TPA
(2) the patient has acute hypertensive end organ damage (congestive heart failure, myocardial infarction, hypertensive encephalopathy, dissecting aortic aneurysm, etc.)
(3) systolic or diastolic pressures are above 220 or 120 mm Hg
Proven acute medical treatment for ischemic stroke
tissue plasminogen activator (rt-PA)
Age 18 or older
Clinical diagnosis of ischemic stroke causing a measurable neurological deficit
Onset of stroke symptoms well established to be less than 180 minutes (3 hours) before treatment would begin
aspirin with 48 hours of stroke onset
Clopidogrel (Plavix) 375 mg, and then aspirin 81mg and clopidogrel 75mg once daily for the first few days
In patients who :
while already on antiplatelet therapy
have a fluctuating neurological course
have a heavy burden of atherosclerotic risk factors or atherosclerotic lesions
Based on the NINDS rt-PA study, the requirements for administering rt-PA include
a CT scan of the head, which is negative for hemorrhage
a serum glucose level between 50 and 400 mg/dL
INR less than 1.7
platelet count more than 100,000 per cubic mL
systolic blood pressure less than 185 mmHg systolic
no recent major procedures, traumas, or stroke
Later head CT (day 2) revealing hypodensity within the left MCA distribution
Acute anticoagulant therapy
patients with a cardioembolic condition at high risk for recurrence (thrombus on valves, or mural thrombus),
documented large-artery (ICA, MCA, or basilar artery ) occlusive clot at risk for distal embolism
arterial dissection
venous thrombosis
Treat
HYPERGLYCEMIA
HYPERTHERMIA
DVT prophylaxis
Heparin 5000 units SC every 12 hours
Enoxaparin (Lovenox, Clexane) 40 mg SC once daily
Dalteparin (Fragmin) 5000 units SC once daily
Sequential compression devices (non-drug)
Compression (TED) stockings
TIA
brief episode of neurologic dysfunction caused by focal brain or retinal ischemia
The causes are the same as for ischemic stroke
the management is similar to that for acute ischemic stroke
Observe the patient for 24 hours
Start daily antiplatelets
EKG
Cardiovascular risk-factor evaluation of blood pressure, lipids, and fasting glucose
Intracerebral hemorrhage
Spontaneous bleeding into the brain parenchyma or ventricles from a ruptured artery, vein, or other vascular structure
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