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