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| __NOTOC__ | | __NOTOC__ |
| {{CMG}}; {{AE}} {{AO}} | | {{CMG}}; {{AE}} {{AO}} |
| ==Definitions== | | ==Overview== |
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| The term 'stroke' is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013),<ref name="Sacco-2013">{{Cite journal | last1 = Sacco | first1 = RL. | last2 = Kasner | first2 = SE. | last3 = Broderick | first3 = JP. | last4 = Caplan | first4 = LR. | last5 = Connors | first5 = JJ. | last6 = Culebras | first6 = A. |last7 = Elkind | first7 = MS. | last8 = George | first8 = MG. | last9 = Hamdan | first9 = AD. | title = An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. | journal = Stroke | volume = 44 | issue = 7 | pages = 2064-89 | month = Jul | year = 2013 | doi = 10.1161/STR.0b013e318296aeca | PMID = 23652265 }}</ref> the updated definitions are: | | The term 'stroke' is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013),<ref name="Sacco-2013">{{Cite journal | last1 = Sacco | first1 = RL. | last2 = Kasner | first2 = SE. | last3 = Broderick | first3 = JP. | last4 = Caplan | first4 = LR. | last5 = Connors | first5 = JJ. | last6 = Culebras | first6 = A. |last7 = Elkind | first7 = MS. | last8 = George | first8 = MG. | last9 = Hamdan | first9 = AD. | title = An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. | journal = Stroke | volume = 44 | issue = 7 | pages = 2064-89 | month = Jul | year = 2013 | doi = 10.1161/STR.0b013e318296aeca | PMID = 23652265 }}</ref> the updated definitions are: |
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| ===Ischemic Stroke===
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| Ischemic stroke is defined as an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction.
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| ====CNS Infarction====
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| CNS infarction is brain, spinal cord, or retinal cell death attributable to ischemia, based on:
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| 1. Pathological, imaging, or other objective evidence of cerebral, spinal cord, or retinal focal ischemic injury in a defined vascular distribution; or
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| 2. Clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting ≥24 hours or until death, and other etiologies excluded.
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| CNS infarction also include:
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| * '''Hemorrhagic infarction ("hemorrhagic transformation of infarction"''', '''"hemorrhagic conversion of infarction"''')<ref name="Trouillas-2006">{{Cite journal | last1 = Trouillas | first1 = P. | last2 = von Kummer | first2 = R. | title = Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke. | journal = Stroke | volume = 37 | issue = 2 | pages = 556-61 | month = Feb | year = 2006 | doi = 10.1161/01.STR.0000196942.84707.71 | PMID = 16397182 }}</ref> - This may occur spontaneously or due to antithrombotic or thrombolytic treatment. They generally lack a mass effect, and are managed according to ischemic stroke recommendations. There are two types:
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| ::Type I - petechiae of blood along the margins of the infarction.
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| ::Type II - confluent petechiae within the infarction but without a space-occupying effect.
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|
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| ===Hemorrhagic Stroke===
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| Hemorrhagic stroke is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. It is important to note that only '''non-traumatic causes''' of CNS hemorrhages are classified as stroke. Hemorrhagic stroke consists of:
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| ====Intracerebral Hemorrhage (ICH)====
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| This is defined as a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. Therefore, it consists of:
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| * [[Intraparenchymal hemorrhage]]
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| * [[Intraventricular hemorrhage]]
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| * Parenchymal hemorrhages following CNS infarction<ref name="Trouillas-2006">{{Cite journal | last1 = Trouillas | first1 = P. | last2 = von Kummer | first2 = R. | title = Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke. | journal = Stroke | volume = 37 | issue = 2 | pages = 556-61 | month = Feb | year = 2006 | doi = 10.1161/01.STR.0000196942.84707.71 | PMID = 16397182 }}</ref>
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| ::Type I - confluent hemorrhage limited to ≤30% of the infarcted area with only mild space-occupying effect.
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| ::Type II - >30% of the infarcted area and/or exerts a significant space-occupying effect.
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|
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| ====Subarachnoid Hemorrhage (SAH)====
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| This is defined as bleeding into the [[subarachnoid space]] (the space between the arachnoid membrane and the pia mater of the brain or spinal cord). This consists of:
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| * Aneurysmal SAH
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| * Non-aneurysmal SAH
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| ===Stroke in the Young=== | | ===Stroke in the Young=== |
| This is a term used to describe stroke seen in individuals between 18 and 45 years of age.<ref name="Szostak-1988">{{Cite journal | last1 = Szostak | first1 = C. | last2 = Porter | first2 = L. | last3 = Jakubovic | first3 = A. | last4 = Phillips | first4 = AG. | last5 = Fibiger | first5 = HC. | title = Conditioned circling in rats: bilateral involvement of the mesotelencephalic dopamine system demonstrated following unilateral 6-hydroxydopamine lesions. | journal = Neuroscience | volume = 26 | issue = 2 | pages = 395-401 | month = Aug | year = 1988 | doi = | PMID = 3140048 }}</ref> | | This is a term used to describe stroke seen in individuals between 18 and 45 years of age.<ref name="Szostak-1988">{{Cite journal | last1 = Szostak | first1 = C. | last2 = Porter | first2 = L. | last3 = Jakubovic | first3 = A. | last4 = Phillips | first4 = AG. | last5 = Fibiger | first5 = HC. | title = Conditioned circling in rats: bilateral involvement of the mesotelencephalic dopamine system demonstrated following unilateral 6-hydroxydopamine lesions. | journal = Neuroscience | volume = 26 | issue = 2 | pages = 395-401 | month = Aug | year = 1988 | doi = | PMID = 3140048 }}</ref> |
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| ====Time of Onset====
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| Time of onset is defined as when the patient was last awake and symptom-free or known to be “normal".<ref name="Jauch-2013">{{Cite journal | last1 = Jauch | first1 = EC.| last2 = Saver | first2 = JL. | last3 = Adams | first3 = HP. | last4 = Bruno | first4 = A. | last5 = Connors | first5 = JJ. | last6 = Demaerschalk | first6 = BM. | last7 = Khatri | first7 = P. | last8 = McMullan | first8 = PW. | last9 = Qureshi | first9 = AI. | title = Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal = Stroke | volume = 44 | issue = 3 | pages = 870-947 | month = Mar | year = 2013 | doi = 10.1161/STR.0b013e318284056a | PMID = 23370205 }}</ref>
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| ==Causes==
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| ===Life Threatening Causes===
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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| * All the causes of stroke are life-threatening.
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|
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| ===Common Causes===
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| ====Ischemic Stroke====
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| *Embolic causes: [[Cardiac arrhythmia]]s, [[infective endocarditis]], [[left atrial myxoma]], [[cardiomyopathy]], [[thrombus|atrial or ventricular thrombus]]
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|
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| *Thrombotic causes: [[Atherosclerosis|Atherosclerosis of large vessels ]], [[arteritis]]/[[vasculitis]], [[Aortic dissection|dissection]], [[Takayasu arteritis]]
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|
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| *Systemic hypoperfusion (Watershed stroke): [[Myocardial infarction]], [[cardiac arrhythmia]]s, [[pericardial effusion]], [[pulmonary embolism]]
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|
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| ====Hemorrhagic Stroke====
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| * [[Hypertension]]
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| * [[Haemophilia|Bleeding disorders]]
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| * [[Drug use|Illicit drug use]] (e.g., [[amphetamines]] or [[cocaine]])
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| * [[Trauma]]
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| * Vascular malformations
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| * [[Aneurysm|Rupture of arterial aneurysms]]
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| ====Stroke in the Young==== | | ====Stroke in the Young==== |
| * Cardiac - [[Congenital heart disease]], [[atrial myxoma]], [[patent foramen ovale]], [[atrial fibrillation]], [[rheumatic heart disease]] | | * Cardiac - [[Congenital heart disease]], [[atrial myxoma]], [[patent foramen ovale]], [[atrial fibrillation]], [[rheumatic heart disease]] |
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| {{familytree | | C01 | | C02 | | | | | | | | | | | | | | | | | | | | | | | | |C01='''Bleed Negative'''|C02='''Bleed Positive'''}} | | {{familytree | | C01 | | C02 | | | | | | | | | | | | | | | | | | | | | | | | |C01='''Bleed Negative'''|C02='''Bleed Positive'''}} |
| {{familytree | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |}} | | {{familytree | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |}} |
| {{familytree | | D01 | | D02 | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01='''Acute Ischemic Stroke'''|D02=[[Hemorrhagic stroke resident survival guide|Hemorrhagic Stroke]]}} | | {{familytree | | D01 | | D02 | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01=[[Ischemic stroke resident survival guide|Acute Ischemic Stroke]]|D02=[[Hemorrhagic stroke resident survival guide|Hemorrhagic Stroke]]}} |
| {{familytree | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | |}} | | {{familytree | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | |}} |
| {{familytree | | | | E01 | | E02 | | |E01='''Intracerebral Hemorrhage'''|E02='''Subarachnoid Hemorrhage'''}} | | {{familytree | | | | E01 | | E02 | | |E01='''Intracerebral Hemorrhage'''|E02='''Subarachnoid Hemorrhage'''}} |
| {{familytree/end}} | | {{familytree/end}} |
|
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| ===Within the First 24 Hours===
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| {{familytree/start}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01='''Acute Ischemic Stroke'''}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |E01=Time of Onset}}
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| {{familytree | | | | | | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | F01 | | | | | F02 | | | | | F03 | | | | | | | | | | | | | | | | | | | | | | |F01='''<3 hours'''|F02='''3 - 4.5 hours'''|F03='''>4.5 hours'''}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | G01 | | | | | G02 | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | |G01=[[Stroke resident survival guide#Exclusion Criteria for IV Recombinant TPA Treatment|Eligibility criteria for IV rTPA]] (see below)|G02=Consider rTPA after reviewing the additional exclusion criteria for this category (see below)}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | |!| | | | | | |!| |}}
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| {{familytree | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|.| | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | H01 | | | | | | | | | | H02 | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |H01=Eligible|H02=Not eligible}}
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| {{familytree | |,|-|-|-|^|-|-|-|.| | | | | | | |`|-|-|+|-|-|-|-|-| M01 | | | | | | | | | | | | | | | | | | | | |M01=[[Stroke resident survival guide#Management of Blood Pressure|Blood Pressure Management]]<br><br>Treat fever with IV antipyretics ([[acetaminophen]])}}
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| {{familytree | I01 | | | | | | I02 | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | ||I01='''BP≤180/110'''|I02='''BP≥180/110'''}}
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| {{familytree | |!| | | | | | | |!| | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | J01 | | | | | | JO2 | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |J01=IV rTPA 0.9 mg/kg (maximum of 90 mg). Give the first 10% as IV bolus over 1 minute, then give the remaining as IV infusion over 1 hour|JO2=Ensure BP<180/110 mmHg before initiating rTPA (see [[Stroke resident survival guide#Management of Blood Pressure|Blood Pressure Management]])}}
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| {{familytree | |`|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|'| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |K01=Admit ICU (for BP monitoring + bleeding complications)<br><br>Hourly vitals and neurocheck<br>Aspiration precautions}}
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| {{familytree/end}}
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|
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| ===After 24 Hours===
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| {{familytree/start}}
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| {{familytree | | | | | L01 |L01='''After 24 hours post rTPA or no rTPA'''}}
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| {{familytree | | | | | |!| | | |}}
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| {{familytree | | | | | M01 | | |M01=Follow-up head CT/MRI before commencing antiplatelets}}
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| {{familytree | | | | | |!| ||}}
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| {{familytree | |,|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | |}}
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| {{familytree | N01 | | N02 | | N03 | | N04 | | |N01='''<u>Specific measures</u>'''<br>'''ASA''' 325 mg (if no contraindication)<br>'''Statins'''<br>'''DVT prophylaxis'''|N02='''<u>General measures</u>'''<br>PT/OT evaluation<br>Speech and swallow evaluation|N03='''<u>Investigate the etiology</u>'''<br>MRA/CTA/carotid duplex<br>Venous doppler USS<br>Echocardiography|N04=<u>'''Manage Complications'''</u><br>'''Hemorrhagic Infarction''' (manage as ischemic stroke)<br>'''Petechial hemorrhages secondary to CNS infarction''' (managed as ICH)}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree | | | | | | | | | N06 | | | | | | | | | | | | |N06=<u>'''Ages 18-45 years'''</u><br>Proteins C & S assay<br>[[antithrombin III|Antithrombin III assay]]<br>[[Factor V Leiden mutation]]<br>[[Prothrombin mutation]]<br> [[Lupus anticoagulant]]<br>[[Anti-cardiolipin antibodies]])<br>[[Hemoglobin electrophoresis]]<br>[[VDRL]]<br>[[Toxicology screen]]<br>[[CSF analysis]]<br>[[holter monitor|Holter monitoring]]}}
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| {{familytree/end}}
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|
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| ==Management of Blood Pressure==
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| {{familytree/start}}
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| {{familytree | | | | | | | | | A01 | | | | | | | |A01=Blood Pressure Management}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | |}}
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| {{familytree | | | | | | | | | B01 | | | | | | | | |B01='''Review Exclusion Criteria for IV rTPA Administration'''}}
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| {{familytree | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | |,|-|-|-|-|^|-|-|-|-|.| | | |}}
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| {{familytree | | | | C01 | | | | | | | | C02 | | |C01=Eligible|C02=Not eligible}}
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| {{familytree | |,|-|-|^|-|-|.| | | |,|-|-|^|-|-|.| |}}
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| {{familytree | D01 | | | | D02 | | D03 | | | | D04 | |D01=Before treatment|D02=During/After treatment|D03='''BP <220/120 mmHg'''|D04='''BP >220/120 mmHg'''}}
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| {{familytree | |!| | | | | |!| | | |!| | | | | |!| |}}
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| {{familytree | E01 | | | | |!| | | E02 | | | | E03 | | |E01=<u>'''BP>185/110 mm Hg'''</u><br>[[Labetalol]] 10–20 mg IV over 1–2 minutes, may repeat 1 time; or [[nicardipine]] 5 mg/h IV infusion; titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or other agents ([[hydralazine]], [[enalaprilat]], e.t.c.) may be considered when appropriate|E02='''Observe''' unless evidence of end-organ damage is present (e.g., acute [[myocardial infarction]], [[aortic dissection]], [[pulmonary edema]], [[hypertensive encephalopathy]])<br><br>Conservative management - treat fever, pain, headaches, nausea, vomiting|E03=[[Labetalol]] 10–20 mg IV over 1–2 minutes, may repeat or double every 10 minutes (maximum dose of 300 mg); or [[nicardipine]] 5 mg/h IV infusion; titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h<br>'''Aim at 15% reduction during the first 24 hours afte stroke onset'''}}
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| {{familytree | | | | | | | |!| | | | | | | | | | | | | |}}
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| {{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | |}}
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| {{familytree | | | F01 | | | | | | F02 | | | |F01='''SBP>180–230 mm Hg or DBP >105–120 mm Hg'''|F02='''BP not controlled or DBP >140 mm Hg'''}}
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| {{familytree | | | |!| | | | | | | |!| | | |}}
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| {{familytree | | | G01 | | | | | | G02 | | |G01=[[Labetalol]] 10 mg IV followed by continuous IV infusion 2–8 mg/min; or [[nicardipine]] 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h|G02=[[Sodium nitroprusside]] 0.5 mcg/kg/min IV infusion as initial dose, then titrate to desired blood pressure}}
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| {{familytree/end}}
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| ''All algorithms are based on recommendations from AHA/ASA for the early management of patients with acute ischemic stroke (2013)''
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|
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|
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| ====Exclusion Criteria for IV Recombinant TPA Treatment====
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| '''Less than 3 hours of onset'''
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| *<font size="1"> Significant head trauma or prior stroke in previous 3 months
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| * Symptoms suggest subarachnoid hemorrhage
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| * Arterial puncture at noncompressible site in previous 7 days
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| * History of previous intracranial hemorrhage
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| * Intracranial neoplasm, arteriovenous malformation, or aneurysm
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| * Recent intracranial or intraspinal surgery
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| * Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
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| * Active internal bleeding
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| * Acute bleeding diathesis, including but not limited to
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| * Platelet count <100,000/mm³
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| * Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
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| * Current use of anticoagulant with INR >1.7 or PT >15 seconds
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| * Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and
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| ECT; TT; or appropriate factor Xa activity assays)
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| * Blood glucose concentration <50 mg/dL (2.7 mmol/L)
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| * CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
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|
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| Relative exclusion criteria
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| * Only minor or rapidly improving stroke symptoms (clearing spontaneously)
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| * Pregnancy
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| * Seizure at onset with postictal residual neurological impairments
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| * Major surgery or serious trauma within previous 14 days
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| * Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
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| * Recent acute myocardial infarction (within previous 3 months)</font>
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| '''Between 3 and 4.5 hours of onset'''
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| * <font size="1">Aged >80 years
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| * Severe stroke (NIHSS>25)
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| * Taking an oral anticoagulant regardless of INR
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| * History of both diabetes and prior ischemic stroke</font>
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|
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| ==Dos==
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| * Obtain a brief history, including '''time of onset, time of arrival at the ED, and medications (especially anticoagulants)'''.
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| * Rule out conditions mimicking stroke (i.e., [[Seizure]]s, [[syncope]], [[migraine|migraine with aura]], [[hypoglycemia]], [[encephalopathy|hypertensive encephalopathy]], [[Wernicke encephalopathy]], CNS abscess, [[CNS tumor]], drug toxicity ([[lithium]], [[phenytoin]], [[carbamazepine]])
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| * Review the criteria for the administration of IV rTPA to determine the patient's eligibilty status.
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| * Order a limited number of investigation during the initial emergency evaluation. Only the estimation of blood glucose should precede the administration of IV rTPA.
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| * Cardiac monitoring for at least the first 24 hours to screen for [[atrial fibrillation]].
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| * Ensure blood pressure of ≤180/110 mmHg before initiating IV rTPA, and maintain it below 180/105 mmHg for at least the first 24 hours post-IV rTPA.
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| * Order a follow-up CT/MRI before commencement of antiplatelets.
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| * Give ASA 325 mg within 24 to 48 hours to most patients (except if contraindicated).
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| * Strict blood pressure monitoring for the first 24 hours, especially if rTPA was administered - every 15 minutes for 2 hours, then every 30 mins for 6 hours, and every hour for the next 16 hours.
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|
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| ==Don'ts==
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| * Do not treat hypertension except the blood pressure is >220/120 mmHg, and not until CT/MRI have been performed.
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| * Do not initiate anticoagulation treatment within the first 24 hours.
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| * Do not commence oral administration of medications before speech and swallow evaluation.
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| * Do not delay sending the patient to CT for any reason.
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|
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| ==References== | | ==References== |