Stroke resident survival guide

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

Overview

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), 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.

Management

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