Ischemic Stroke, Hemorrhagic Stroke, and Stroke Treatment

Question 1

Algorithm for a new or worsening focal neurological deficit suspected to be a stroke

Answer 1

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.

Question 2

What if imaging shows intracranial bleeding?

Answer 2

If SAH-STAT CTA head +/- catheter angiography

If ICH-CTA or MRA/MRA +/- catheter angiography

and then surgical vs endovascular or medical management

Question 3

What if imaging shows a cardioembolic state, hypercoaguable state, or cerebral venous thrombosis?

Answer 3

initiate anticoagulation

Question 4

What if imaging shows large vessel atherothromobosis, lacunar stroke, or cyrptogenic stroke?

Answer 4

antiplatelet therapy

Question 5

What is this non-contrast CT brain scan showing?

Answer 5

subcortical hypertensive hemorrhage

Question 6

What is this non-contrast CT brain scan showing?

Answer 6

Lobar Hemorrhage due to Cerebral Amyloid Angiopathy

Question 7

What is this non-contrast CT brain scan showing?

Answer 7

intracerebral hemorrhage

Question 8

What is this non-contrast CT brain scan showing?

Answer 8

subarachnoid hemorrhage

Question 9

What is this non-contrast CT brain scan showing?

Answer 9

subdural hemorrhage

Question 10

What is this non-contrast CT brain scan showing?

Answer 10

epidural hemorrhage

Question 11

How is intracranial hemorrhage tx?

Answer 11

aggressive lowering of BP

Question 12

How is subdural hemorrhage, epidural hemorrhage, and ICH or SAH with life-threatening edema, herniation, or hydrocephalus tx?

Answer 12

neurosurgical decompression

Question 13

How is SAH tx?

Answer 13

surgical clipping or endovascular coiling of cerebral aneurysms

Question 14

What are these non-contrast CT scans showing?

Answer 14

left: normal brain
middle: acute infarct
right: acute infarct 4 day follow up

Question 15

What is considered the “gold standard” of diagnostic imaging in patients with stroke symptoms?

Answer 15

•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.

Question 16

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.

Answer 16

25 (45 total)

Question 17

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.

Question 18

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Question 20

What are some early infarct signs on CT?

Answer 20

Hyperdense middle cerebral artery sign

Loss of gray-white differentiation (Cortical ribbon, including “insular ribbon sign”; Lentiform nuclei)

Sulcal effacement

Hypodensity (hypoattenuation)

Question 21

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Question 24

What are the tx options for ischemic stroke?

Answer 24

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

Question 25

Answer 25

Question 26

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%).

Answer 26

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

Question 27

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Question 30

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