Ischemic Stroke, Hemorrhagic Stroke, and Stroke Treatment Flashcards
Algorithm for a new or worsening focal neurological deficit suspected to be a stroke
STAT head CT to rule out hemorrhage (MRI if symptoms resolved spontaneously) or Multi-modal CT or MRI imaging for ischemic stroke (if reperfusion is thought after the timeframe for IV TPA) + Catheter Angiography, Labs, etc.
What if imaging shows intracranial bleeding?
If SAH-STAT CTA head +/- catheter angiography
If ICH-CTA or MRA/MRA +/- catheter angiography
and then surgical vs endovascular or medical management
What if imaging shows a cardioembolic state, hypercoaguable state, or cerebral venous thrombosis?
initiate anticoagulation
What if imaging shows large vessel atherothromobosis, lacunar stroke, or cyrptogenic stroke?
antiplatelet therapy
What is this non-contrast CT brain scan showing?
subcortical hypertensive hemorrhage
What is this non-contrast CT brain scan showing?
Lobar Hemorrhage due to Cerebral Amyloid Angiopathy
What is this non-contrast CT brain scan showing?
intracerebral hemorrhage
What is this non-contrast CT brain scan showing?
subarachnoid hemorrhage
What is this non-contrast CT brain scan showing?
subdural hemorrhage
What is this non-contrast CT brain scan showing?
epidural hemorrhage
How is intracranial hemorrhage tx?
aggressive lowering of BP
How is subdural hemorrhage, epidural hemorrhage, and ICH or SAH with life-threatening edema, herniation, or hydrocephalus tx?
neurosurgical decompression
How is SAH tx?
surgical clipping or endovascular coiling of cerebral aneurysms
What are these non-contrast CT scans showing?
left: normal brain
middle: acute infarct
right: acute infarct 4 day follow up
What is considered the “gold standard” of diagnostic imaging in patients with stroke symptoms?
•A noncontrast CT scan
It should be performed quickly to differentiate between a hemorrhagic and ischemic stroke. Useful information regarding the stage of the stroke can also be obtained.
For patients being considered for tPA treatment, the goal is for a CT scan to be completed within __ minutes of arrival in the Emergency Department (ED) and for interpretation to be completed within another 20 minutes.
25 (45 total)
Note that with intracranial hemorrhages (thalamic and subarachnoid), these indicate that these patients are not eligible for thrombolytic therapy.
Also note that during the first few hours of an ischemic stroke, noncontrast CT scans may not reveal signs of brain ischemia. However, if the scan shows no evidence of hemorrhage, patients may be considered candidates for tPA.
What are some early infarct signs on CT?
Hyperdense middle cerebral artery sign
Loss of gray-white differentiation (Cortical ribbon, including “insular ribbon sign”; Lentiform nuclei)
Sulcal effacement
Hypodensity (hypoattenuation)
What are the tx options for ischemic stroke?
Within 4.5 hours from last seen well: iv alteplase
ELVO within 6 hrs: mechanical thrombectomy
In-eligible for reperfusion within 24 hrs: ASA
After 24 hrs: initiate secondary stroke prevention
Talking Points
•This study investigated the short-term risk of stroke and other adverse events in 1,707
patients after emergency department diagnosis of transient ischemic attack (TIA).
•During the 90 days after an index TIA, a total of 428 patients (25.1%) experienced a stroke or other adverse events. This included strokes (10.5%), recurrent TIAs (12.7%), cardiovascular events (2.6%) and deaths (2.6%).
Background
The study results indicate that the short-term risk of stroke, other adverse events and deaths among patients who present to an emergency department with a TIA is substantial. Half of the strokes occurred within 2 days of the TIA. Short-term risks of cardiovascular events, death and recurrent TIA were also high.
This study identified 5 independent risk factors for stroke within 90 days after TIA: age older than 60 years, diabetes mellitus, duration of episode greater than 10 minutes, and weakness and speech impairment with the episode
