Stroke resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D., Ayokunle Olubaniyi, M.B,B.S [2]

Synonyms and Keywords: stroke management, stroke workup, stroke approach, approach to stroke, stroke treatment

Overview

Stroke is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013), it is defined as a neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Therefore, by definition, trauma has to be ruled out before stroke can be diagnosed in a patient with a focal neurological deficit.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• All strokes can potentialy lead to death or permanent disability within 24 hours if left untreated.

Common Causes

• Aneurysms

• Atrial fibrillation
• Eclampsia
• Infective endocarditis
• Myocardial infarction
• Pulmonary embolism

• Arteriovenous malformations
• Atherosclerosis
• Atrial fibrillation
• Embolism
• Hypertension
• Subarachnoid hemorrhage
• Thrombosis
• Transient ischemic attack
• Traumatic brain injury
• Warfarin

Diagnosis

Shown below is an algorithm summarizing the diagnosis of stroke according to the American Academy of Neurology guidelines:

Initial Evaluation

Characterize the symptoms: ❑ Sudden weakness/paralysis - face, arm or leg ❑ Speech/visual difficulties ❑ Altered/loss of consciousness ❑ Sudden severe headache

Examine the patient: ❑ Head - trauma, tongue laceration ❑ Neck - bruits, pulses ❑ Limbs - pulses ❑ Heart - murmurs ❑ Skin - color changes ❑ Neurological exam, NIHSS

Consider alternative diagnosis: ❑ Psychogenic ❑ Seizures ❑ Hypoglycemia ❑ Complicated migraine ❑ Hypertensive encephalopathy ❑ Wernicke encephalopathy ❑ Brain abscess ❑ Brain tumor ❑ Drug toxicity

❑ Check vitals ❑ Stabilize ABC ❑ Brief Hx ❑ Activate stroke team ❑ Stat fingerstick ❑ Labs - CBC, serum electrolytes, urea, creatinine, troponin, EKG, PT/PTT/INR ❑ NPO ❑ Obtain stroke protocol

Other labs in selected patients: ❑ Liver function tests ❑ Toxicology screen (drug abuse, stroke in the young) ❑ Blood alcohol level ❑ Arterial blood gas (hypoxia) ❑ Chest radiograph (lung disease) ❑ EEG (seizures) ❑ Lumbar puncture (SAH) ❑ Sepsis profile - urinalysis, blood culture (if fever is present) ❑ Type and cross match FFP (coagulopathy) ❑ Pregnancy test (in women of child-bearing age)

Non-Contrast Enhanced CT (or MRI) to r/o hemorrhage

Bleed Negative

Bleed Positive

Acute Ischemic Stroke

Hemorrhagic Stroke

Intracerebral Hemorrhage

Subarachnoid Hemorrhage

Treatment

The management of stroke will greatly depend on the type of stroke (if it is either hemorrhagic or ischemic).

• To view the specific treatment of hemorrhagic stroke click here.
• To view the specific treatment of ischemic stroke click here.

Do's

• Perform tertiary preventive measure to decrease subsecuent episodes, such as using statins and anticoagulants, controling glucose levels and blood pressure.

Don'ts

• Do not lower blood pressure in hypertensive patients with ischemic stroke when below