Clinical Stroke Flashcards
What is a stroke
Clinical def
A sudden focal neurological deficit due to an interruption of the blood supply to the brain
What is a stroke
Ischemic or hemorrhagic
Ischemic: obstruction of a feeding blood vessel or a significant reduction in blood flow
Hemorrhagic: rupture of a blood vessel into or around the brain
Stroke
mechanisms
- Artery to artery embolism – Atherosclerotic damage to an artery (aorta, carotids, intracranial vessels) that produces local thrombosis and distal embolization of the clot
- Small artery thrombosis –Atherosclerosis, lipohyalinosis, vasculitis
- Cardiac embolism –Intracardiac thrombus with distal clot embolization
- Hypotension / hypovolemia / hypoxemia - Generalized brain ischemia; usually occur in combination
TIA prognosis
- 1 in 15 individuals over age 65 with TIA history
- Average duration at ED visit: 3 hr. 27 min.
- Alternative dx to TIA likely in 5.6% (syncope, vestibulopathy, anxiety, migraine, seizure, meds)
- 5% have stroke within 2 days; 10.5% stroke within 90 days
- 14% hospitalized
ABCD2 score
What does it do?
A simple score (ABCD2) to identify individuals at high early risk of stroke after transient ischemic attack
ABCD2
How is it calculated
A (Age); 1 point for age >60 years,
B (Blood pressure > 140/90 mmHg); 1 point for hypertension at the acute evaluation,
C (Clinical features); 2 points for unilateral weakness, 1 for speech disturbance without weakness, and
D (symptom Duration); 1 point for 10–59 minutes, 2 points for >60 minutes.
D (Diabetes); 1 point
Total scores ranged from 0 (lowest risk) to 7 (highest risk). An ABCD2 score of 4 or greater can justify 24-48 hour admission in the USA solely on the basis of a greater opportunity to administer thrombolysis early if a subsequent stroke occurs
Stroke
Signs/sx
- Sudden onset (usually maximum within 10 seconds)
- Weakness of one side of the body / face
- Numbness / tingling of one side of the body or face
- Incoordination / clumsiness of one side of the body, falling to one side, spinning sensation
- Sudden change in speech or language
- Loss of vision, especially in one eye on or one side
- Double vision
- Acute confusion
- Sudden, severe headache
Stroke
Focused history
What should you ask about
Risk factors
High blood pressure (hypertension) "High sugar" (diabetes) Heart disease, heart attacks, irregular heart beats High cholesterol Smoking, alcohol use, illegal drugs No regular physical exercise Family history of stroke Previous stroke Sickle-cell disease
Stroke
Focused history
What should you ask about
Focal sx
Numbness, tingling, weakness, clumsiness, heaviness of one side of the body
Change or loss of language (understanding, comprehension, reading, writing)
Change or loss of steady walking, imbalance, falling
Headache (location, type, severity, duration)
Change or loss of vision (one eye? Both eyes?)
Stroke
Physical examination
general
ABCS
Vitals
Cardiac Auscultation
Presence of bruits
Stroke
Physical examination
Focused neurological examination
Level of consciousness (alert, lethargic / drowsy, stupor, coma)
Language (comprehension, fluency, repetition, naming, reading, writing)
Visual fields and eye movements (other CN)
Strength (face, arms, legs, drift) and reflexes
Coordination (gait, finger to nose, heel to shin)
Sensation (pinprick, temperature, joint position sense / vibration)
Stroke
Initial testing
Labs: CBC, chemistry, PT / INR / PTT, troponins, SaO2, type and screen
EKG
CT head without contrast
– IMPORTANT: Remember that we can’t tell the difference between ischemic and hemorrhagic stroke based on clinical features alone
Acute stroke management
- Evaluation and stabilization of patient – Vitals, cardiovascular, neurological assessment, O2 NC, HLIV x2
- Diagnostic work-up begun – Labs, brain imaging (CT, MRI)
- Consider “clot-buster”: t-PA therapy (call Stroke Team)
Acute stroke management
Other therapies
– Antiplatelet agent
– Manage / prevent stroke complications (seizures, pneumonia, aspiration, DVT)
Admit to Stroke Unit
NINDS targets for thrombolytics
Time target
Door to Doctor 10 minutes Door to CT completion 25 minutes Door to CT read 45 minutes Door to tx 60 minutes Access to neurological expertise 15 minutes Access to neurosurgical expertise 2 hours Admit to monitored food 3 hours
T-PA criteria
Inclusion criteria: Age > 18 Ischemic stroke with measurable deficit 80 years of age Taking oral anticoagulants (even if INR 25 Hx of diabetes and stroke
Inpatient evaluation and tx
If not tPA or other intervention: ASA 325mg (or other antiplatelet daily)
NPO if unable to swallow: feed w/in 72 hours, many need tube feeds
SQ heparin or compression device to prevent DVT
Control serum glucose
Echocardiogram
Cardiac telemetry
MRI brain (with DWI/ADC)
Carotid duplex ultrasound/MRA
Labs: RPR, fasting lipids
Begin rehabilitation