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


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


  • contralateral motor/sensory loss, lower > upper deficits


  • 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


  • 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.


  • 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


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CCFP ExamApril 30, 2015
The big day is here.
August 2020
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