CVA – ED

Cerebrovascular Accident (CVA)

• Ischemic – thrombotic vs embolic, vasculitis, connective tissue disease, IVDU
• Hemorrhagic – intracerebral / SAH (majority of trauma) – 90% internal capsule, AVM (h/a and Sz if unruptured & coma/ICB if ruptured), mycotic (septic embolus)
  • Epidural hematoma (middle meningeal artery), SDH (bridging veins) – elderly, alcoholic, NOAC, Contusion – intraparenchymal blood
• 80% in anterior circulation and 20% in posterior

1. In a patient with acute neurologic signs or symptoms, consider diagnoses other than a CVA when establishing the differential diagnosis (e.g., migraine, hypoglycemia, Todd’s paralysis, tumour)

2. When a patient presents with symptoms secondary to non-MCA (middle cerebral artery) distributions (e.g., posterior circulation deficits, confusion), recognize CVA in subtle patient presentations.

3. In a patient with new but persistent acute neurological deficit of likely vascular origin, determine the pertinence of attempting urgent reperfusion by:

• Identifying the anatomic territory of injury

MCA

• contralateral motor/sensory loss, upper > lower deficit
  • ddx: central cord syndrome, putamen bleed
• Homonymous hemianopsia
• dominent (L) – aphasia (wernicke – receptive, brocca – expressive); nondominent – neglect

ACA

• contralateral motor/sensory loss, lower > upper deficits

PCA

• contralateral homonymous hemianopsia, +/- ipsilateral CN 3 palsy

Vertebrobasilar (brainstem + cerebellum)

• ipsilateral cerebellar & CN deficits & contralateral motor/sensory deficits
• Brainstem signs: vertigo, nystagmus, diplopia, dysphagia, bilateral vision loss, dysarthria; Gaze preference suggests brainstem infarct

1. Basilar artery
   1. bilateral deficits – “lock-in syndrome”: quadriplegia
   2. preserved pupils and upper gaze
2. Vertebral artery / PICA – lateral medulla infarct of brainstem = Wallenberg’s syndrome:
   1. vertigo, ipsilateral facial numbness, loss of corneal reflex, horner’s syndrome;
   2. contralateral loss of pain and temperature in trunk & limbs

Hemorrhagic stroke

• Putamen – more lethargic than MCA infarct
  • contralateral hemiparesis/hemiplegia, sensory deficit, conjugate gaze paresis
  • Homonymous hemianopsia
  • Aphasia, neglect, apraxis
• Cerebellar
  • severe ataxia, vertigo, nystagmus
  • dysarthria, ipsilateral gaze palsy, facial weakness/sensory loss
  • dec LOC
  • No hemiparesis
• Thalamic
  • contralateral hemiparesis/hemiplegia, sensory deficits; sensory > motor loss
  • may cause isolated sensory symptoms
• Pontine
  • severe headache, pinpoint pupils
  • Decerebrate posturing and abscence of oculovestibular reflexes

• Looking for precipitating causes (e.g., arrhythmia, embolus secondary to ACS)

• 1/3 pt with A Fib develop a stroke
• 80% lacunar infarct have HTN

• Selecting the appropriate imaging modality (non-contrast CT versus CT angiogram versus triphasic contrast CT)

• Noncontrast CT produce false negative result for ICH if Hct<30%
• MRI better for early edema, mass effect, posterior fossa / brainstem otherwise CT better for stroke work up

• Assessing the patient’s eligibility for, and the risks of, thrombolysis.

Stroke Tx

• HTN in acute stroke – treat if >220/115 or MAP >130
  • treat for BP >185/110 if considering thrombolytics
  • Labetalol, incardipine, nitroprusside (for intractable HTN)
• HoTN – Tx aggressively with IVF, vasopressors prn
• ASA 160-325mg within 48hr (unless thrombolysis candidate)
• worse prognosis with hyperglycemia, fever, hypoxia, HoTN

TPA

• inclusion
  • acute ischemic stroke with clear onset within 4.5 hr
  • Age >18 (no upper limit)
  • stroke symptoms >30min w/o significant improvement prior to Tx
  • CT head showed no ICH
• Exclusion
  • Severe stroke NIH>25 or >1/3 of MCA territory or minor stroke symptoms
  • oral anticoagulant use regardless of INR/PT
• contraindications: onset >4.5hr or unknown
  • ICH on CT or hx of ICH
  • Within 3mo of intracranial surgery, serious head trauma, previous stroke
  • Active internal bleeding,
  • GI or GU hemorrhage in prev 21 days or GI malignancy
  • Known AVM or aneurysm or intracranial neoplasm
  • presentation consistent with SAH (even neg CT)
  • Arterial puncture at a noncompressible site within 7 days
  • Seizure at onset of stroke
  • Known bleeding diathesis: platelet <100k, PT>15sec, INR>1.7, current use of NoAC or prolonged PPT and heparin within 48hr
  • BP >185/110 on repeated measurement
  • Major surgery within 14 days
  • Glucose <50 or >400
  • Rapid improving or minor symptoms
• Relative contraindications
  • minor or rapidly improving stroke symptoms
  • Major surgery / serious trauma within 14 days
  • Recent GI/GU hemorrhage <21days
  • Abnormal blood glucose despite Tx
  • post AMI pericarditis
  • Recent acute MI <3mo
  • Recent LP
  • NIH >22

intra-arterial tPA

• brainstem stroke even in delayed presentation
• large MCA between 3-6hr presentation
• vertebral/vasilar artery occlusion
• use when IV TPA contraidicated

If <6hr and large vessel occlusion

• CTA to determine if amenable to thrombectomy

4. In a patient with a transient neurological deficit, stratify risk of a recurrent event (e.g., ABCD2 ) and arrange for ancillary evaluation (e.g., carotid Doppler, Holter monitor, ECG) in a timely fashion.

TIA

• complete recovery within 24hr; new definition: transient neurologic dysfunction w/o infarct on MRI
• Evaluation: ECG, carotid us, echo
• Admit if known internal carotid stenosis >50%, hx of A Fib, hypercoagulable state,
• Crescendo TIAs – >2 TIA within 72 hr – higher risk of stroke
• ASA dec risk of subsequent stroke – 1st line
  • plavix better; plavix + ASA not better than either one alone
  • add plavix if pt already on ASA
• ABCD2 score to predict % stroke in 2d: Low 0-3; Moderate 4-5; High 6-7pt
  • Age >60 = 1
  • BP >=140/90 = 1
  • Clinical features: unilateral weakness= 2; speech disturbance w/o weakness= 1
  • Duration >=60min = 2; 10-59min = 1
  • DM = 1