Basics
Description
Interruption of blood flow to a specific brain region:
- Neurologic findings are determined by specific area affected
- Onset may be sudden and complete, or stuttering and intermittent
- Responsible for 1 in 18 deaths in US
- 610,000 new strokes every year in US
Risk Factors
- Diabetes
- Smoking
- HTN
- Coronary artery disease, dysrhythmias
- Peripheral vascular disease
- Oral contraceptive use
- Polycythemia vera
- Sickle cell anemia
- Deficiencies of antithrombin III, protein C or S
Etiology
- May be ischemic (thrombotic, embolic, or secondary to dissection/hypoperfusion) or hemorrhagic
- Thrombotic stroke is caused by occlusion of blood vessels:
- Clot formation at an ulcerated atherosclerotic plaque is most common
- Sludging (sickle cell anemia, polycythemia vera, protein C deficiency)
- Embolic stroke is caused by acute blockage of a cerebral artery by a piece of foreign material from outside the brain, including:
- Cardiac mural thrombi associated with mitral stenosis, atrial fibrillation, cardiomyopathy, CHF, or MI
- Prosthetic or abnormal native valves
- Atherosclerotic plaques in the aortic arch or carotid arteries
- Atrial myxoma
- Ventricular aneurysms with thrombi
- Arterial dissection:
- Carotid artery dissection
- Arteritis (giant cell, Takayasu)
- Fibromuscular dysplasia
- Global ischemic or hypotensive stroke is caused by an overall decrease in systemic BP: Sepsis, hemorrhage, shock
- Hemorrhagic stroke:
- Intracranial hemorrhage
- Subarachnoid hemorrhage
- Usually attributable to an underlying disease process, such as sickle cell anemia, leukemia, infection, or a blood dyscrasia
- Younger children often present with seizures and/or altered mental status
Diagnosis
Signs and Symptoms
History
- Time of onset (or time last seen at baseline)
- Trauma/surgery
- Medications
- Altered mentation/confusion
- Headache
- Vertigo/dizzy
- Focal neurologic deficits
Physical Exam
- General:
- Cheyne-Stokes breathing, apnea
- HTN
- Cardiac dysrhythmias, murmurs
- Anterior cerebral artery:
- Contralateral hemiplegia (lower/upper)
- Hemisensory loss
- Apraxia
- Confusion
- Impaired judgment
- Middle cerebral artery:
- Contralateral hemiplegia (upper/lower)
- Hemisensory deficits
- Homonymous hemianopsia
- Dysphasia
- Dysarthria
- Agnosia
- Posterior cerebral artery:
- Cortical blindness in half the visual field
- Visual agnosia
- Altered mental status
- Impaired memory
- 3rd-nerve palsy
- Hemiballismus
- Vertebrobasilar system:
- Impaired vision, visual field defects, nystagmus, diplopia
- Vertigo, dizziness
- Crossed deficits: Ipsilateral cranial nerve deficits with contralateral motor and sensory deficits
- Basilar system:
- Quadriplegia
- Locked-in syndrome
- Coma
- Watershed area (boundary zone between anterior, middle, and posterior circulation):
- Cortical blindness
- Weakness of proximal upper and lower extremities with sparing of face, hands, and feet
Essential Workup
- Detailed neurologic exam; consider calculating National Institutes of Health stroke scale (NIHSS).
- Emergent noncontrast head CT scan to distinguish ischemic from hemorrhagic events:
- May be normal in 1st 24-48 hr
- GOALS:
- CT completed within 25 min of arrival
- CT read by a radiologist within 45 min
- Thrombolytics administered within 1 hr of presentation
- If CT is normal and subarachnoid hemorrhage is suspected, emergent lumbar puncture is indicated
- EKG to evaluate for dysrhythmias or presence of MI
- Oxygen saturation measurement
- Rapid glucose determination
Diagnosis Tests & Interpretation
Lab
- Baseline CBC, electrolytes, renal function tests, liver function test, prothrombin time, partial thromboplastin time
- Urinalysis:
- Hematuria can be seen in subacute bacterial endocarditis with embolic stroke.
- Sedimentation rate:
- Elevated in subacute bacterial endocarditis, vasculitis, hyperviscosity syndromes
- Consider additional tests: Cardiac enzymes, urine pregnancy test, drug screen, alcohol level, ABG, and blood cultures.
Imaging
- Noncontrast head CT
- MRI can detect ischemia <2 hr after onset
- CXR
- Carotid US
Diagnostic Procedures/Surgery
- EKG to evaluate for arrhythmia
- Lumbar puncture if subarachnoid hemorrhage is suspected and head CT nondiagnostic
Differential Diagnosis
- Intracranial bleeding
- Hypoglycemia
- Seizure disorder; Todd paralysis
- Panic attacks, depression, conversion reaction
- Transient global amnesia
- Meningoencephalitis
- Peripheral neuropathy
- Intracranial abscess
- Migraine
- Air embolism
- Transient ischemic attack
- Encephalopathy
- Neoplasm
- Giant cell/Takayasu arteritis
- Multiple sclerosis
- Compressive myelopathy
- Vestibulitis
- Medication effect/toxidrome
Treatment
Pre-Hospital
- Patients may have difficulty moving or communicating after cerebral vascular accident
- Neurologic exam in field is helpful:
- Should include assessment of consciousness level, Glasgow coma scale score, gross motor deficits, speech abnormalities, gait disturbance, facial asymmetry, and other focal deficits
- Check fingerstick glucose
Initial Stabilization/Therapy
- Manage airway:
- Supplemental oxygen 2-4 L
- Rapid-sequence intubation may be required for airway protection or controlled ventilation to decrease intracranial pressure
- For altered mental status, give naloxone and thiamine and check blood glucose
Ed Treatment/Procedures
- Treat elevated BP with labetalol, nicardipine, nitroprusside, or hydralazine:
- Systolic BP >220 mm Hg or diastolic BP >120 mm Hg on repeated measurements
- If indicated for other concurrent problems (MI, aortic dissection, CHF, hypertensive encephalopathy)
- Initial goal is systolic BP <180 mm Hg, diastolic <110 mm Hg
- Control seizures with benzodiazepines, then fosphenytoin/phenytoin
- Maintain euvolemia and normothermia.
- Thrombolytics:
- Ischemic stroke only; administer within 4.5 hr of symptom onset
- Contraindications:
- Any history of intracranial hemorrhage
- Recent stroke or head trauma <3 mo ago
- Major surgery <14 days ago
- Systolic BP >185 mm Hg; diastolic BP >110 mm Hg
- Bleeding diathesis
- Noncompressible arterial puncture <7 days ago
- MI <3 mo ago
- Anticoagulation: INR >1.7, PT >15 sec, or prolonged PTT; use of heparin within 48 hr
- Platelets <100,000
- Intracranial neoplasm
- Seizure at stroke onset
- Minor or rapidly improving symptoms
- Pregnancy
- Internal bleed (GI/GU) <3 wk ago
- Blood glucose <50
- Age <18 yr
- Avoid anticoagulants and antiplatelet drugs for 24 hr
- Treat increased intracranial pressure and cerebral edema:
- Elevate head of bed 30 °
- Controlled ventilation to keep partial pressure of carbon dioxide 35-40 mm Hg
- Mannitol
- Urgent neurosurgical decompression may be required with brainstem compression in cases of vertebrobasilar stroke or hemorrhage.
- In patients with completed or minor strokes, aspirin may prevent recurrence.
- For focal embolic/thrombotic strokes:
- Recannulation
- US-enhanced thrombolysis
- Intra-arterial thrombolysis or clot retrieval
For patients presenting between 3 and 4.5 hr of onset, there are additional exclusion criteria:
- Age >80 yr
- Oral anticoagulant use (regardless of INR)
- NIH-SS >25 or >1/3 MCA territory involved
- History of previous stroke and diabetes
Medication
First Line
- Alteplase (tPA): 0.9 mg/kg IV; max. 90 mg, with 10% of dose given as bolus and remainder infused over 60 min
- Aspirin: 81-325 mg PO/PR
- Labetalol: 10-20 mg IV bolus, repeat q10min max. 300 mg; follow with continuous infusion 0.5-2 mg/min
Second Line
- Clopidogrel: 75 mg PO daily
- Diazepam: 5 mg IV q5-10min max. 20 mg
- Enalapril: 0.675-1.25 mg IV
- Hydralazine: 10-20 mg IV q30min
- Mannitol (15-25% solution): 0.5-2 g/kg IV over 5-10 min, then 0.5-1 g/kg q4-q6h
- Nicardipine: 5 mg/h IV, increase by 2.5 mg/h q5-15min max. 15 mg/h
- Nitroprusside: 0.25-10 μg/kg/min IV
- Trimetaphan: 1-4 mg/min IV
- Heparin or low-molecular-weight heparin is often used in children with ischemic stroke
- May call 1-800-NOCLOTS for pediatric stroke consultation and guidance
Follow-Up
Disposition
Admission Criteria
- Patients with acute cerebral vascular accident should be admitted to hospital
- Indications for ICU:
- Severely decreased level of consciousness
- Hemodynamic instability
- Life-threatening cardiac dysrhythmias
- Significantly increased intracranial pressure
- Administration of alteplase
Discharge Criteria
- Patients who present with completed strokes that are days to weeks old may be discharged if they are able to function independently or have adequate social support
- Patients with multiple prior strokes who experience relatively minor new episodes may also be treated on outpatient basis if similar criteria are met and stroke is completed
Follow-Up Recommendations
- Neurology
- Primary care
- Speech therapy/occupational therapy
Pearls and Pitfalls
- Always note pre-hospital observations
- Onset of symptoms is crucial to determining treatment with tPA
- Include additional exclusion criteria between 3 and 4.5 hr
- Avoid aggressive BP correction due to risk of hypoperfusion and extension of stroke
- Door to needle goal is <60 min
Additional Reading
- Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department. Ann Emerg Med. 2013;61:225-243.
- Freundlich CL, Cervantes-Arslanian AM, Dorfman DH. Pediatric stroke. Emerg Med Clin N Am. 2012;30:805-828.
- Fulgham JR, Ingall TJ, Stead LG, et al. Management of acute ischemic stroke. Mayo Clin Proc. 2004;11:1459-1469.
- Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professional from American Heart Association/American Stroke Association Stroke Council. Stroke. 2013;44:870-947.
- Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcomes of stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695-1703.
- Leira EC, Ludwig BR, Gurol ME, et al. The types of neurological deficits might not justify withholding treatment in patients with low National Institutes of Health Stroke Scale scores. Stroke. 2012;43:782-786.
- Perry JM, McCabe KK. Recognition and initial management of acute ischemic stroke. Emerg Med Clin North Am. 2012;30:637-657.
- www.ninds.nih.gov/doctors
See Also (Topic, Algorithm, Electronic Media Element)
- Transient Ischemic Attack
- Intracranial Hemorrhage
Codes
ICD9
- 434.01 Cerebral thrombosis with cerebral infarction
- 434.11 Cerebral embolism with cerebral infarction
- 434.91 Cerebral artery occlusion, unspecified with cerebral infarction
- 431 Intracerebral hemorrhage
ICD10
- I63.59 Cereb infrc due to unsp occls or stenosis of cerebral artery
- I63.8 Other cerebral infarction
- I63.9 Cerebral infarction, unspecified
- I61.9 Nontraumatic intracerebral hemorrhage, unspecified
- I63.49 Cerebral infarction due to embolism of other cerebral artery
SNOMED
- 230690007 Cerebrovascular accident (disorder)
- 422504002 ischemic stroke (disorder)
- 371041009 Embolic stroke (disorder)
- 5571000124103 Cerebrovascular accident with intracranial hemorrhage (disorder)