- sudden onset of focal neurological deficits due to a vascular cause
- needs imaging to distinguish between hemorrhagic & ischemic
stroke
progresses fast so triage with high importance even if deficits arent ba
3 types of ischemic strokes
thrombotic d/t atherosclerosis
embolic d/t cardiac source
lacunar/small vessel
typically causes pure motor OR pure sensory sx
lacunar ischemic stroke
- Sudden onset of neurological or retinal symptoms (e.g., hemiparesis, hemi-sensory loss, aphasia, neglect, amaurosis fugax, hemianopsia, or ataxia)
- Lasts < 24 hours before resolving completely (often < 15 min)
- Not associated with any acute infarction on neuroimaging
TIA
clot formation causes narrowed lumen which blocks blood movement
what type of stroke
thrombotic stroke
clot or debris circulating that gets stuck in a brain vessel
“showered” from heart
embolic stroke
burst blood vessel that may allow blood to seep into brain tissue until clotting shuts off the leak
hemorrhagic stroke
what is the point of recanalization in the evolution of acute ischemic stroke
it makes it so the pneumbra (at risk area) is saved. the core (irreversible damaged area) stays infarcted
6 risk factors for AIS & which ones are modifiable
- Older age
- HTN, Hyperlipidemia
- Smoking
- DM
- Hypercoagulability
- Cardiac arrhythmias
bolded are modifiable!
general sx of AIS
- weakness, numbness
- aphasia
- dysarthira
- gaze deviation, vertigo
- facial droop
- ataxia, gait instability
- vision changes, N/V
general MCA occlusion sx; Left & Right specific sx (4)
- ipsilateral gaze deviation
- contralateral sensory loss, facial droop, visual field deficit and arm weakness
- Left MCA: aphasia
- Right MCA: left hemi-neglect, speech intact
- Crossed signs of CN deficits (gaze palsies, facial droop) mixed with contralateral weakness
- Alternating hemiparesis or posturing
- Locked-in syndrome
- Acutely obtunded or comatose – with pinpoint pupils
- Myoclonic jerks simulating status epilepticus
where is the occlusion
basilar/vertebral artery
- Contralateral LEG weakness and sensory loss
- Variable loss of executive function
where is the occlusion
ACA
- Contralateral visual field deficit (complete or partial)
- Occasional sensory deficits
- Occasional contralateral leg > arm weakness
- Occasional memory loss
where is the occlusion
PCA
differentiate stroke from bells palsy
- bells has a more gradual onset
- bells palsy is NOT forehead sparing (it wont raise)
central vs peripheral lesions
- unilateral droop w/ intact forehead raise
central lesion
how is bells palsy managed? what if its bilateral?
- eye drops, tape eyelid shut at night
- if bilateral, must r/o Lyme dz
what should you do If your patient developed a focal neuro deficit within the last 24 hours
CALL STROKE CODE
what is the door-to-needle time goal when there is a code stroke?
under 60 minutes
parts of NIH stroke scale
- level of consciousness (LOC)
- LOC questions & commands
- best gaze
- visual fields
- facial paresis
- motor each arm & leg
- limb ataxia
- sensory
- langauage/aphasia
- dysarthria
- extinction
if no tPA, permissive HTN up to?
BP should be blow what prior to giving tPA?
- permissive HTN up to 220/120
- BP under 185/110 prior to tPA
try to list 8 absolute C/I to IV tPA
- Significant head trauma, stroke, intracranial or spinal surgery in prior 3 months
- Prior history of ICH or intracranial neoplasm
- GI malignancy or bleeding within 21 days
- CT with ICH or large hypodensity (> 1/3 of cerebral hemisphere)
- Currently taking DOACs or warfarin (in case of warfarin, INR > 1.7 = cutoff)
- Platelet count < 100,000
- Blood glucose < 50 mg/dL
- BP sustained over 185/110 mmHg
No antiplatelet agents, anticoagulation, or DVT chemoprophylaxis for ____ after tPA bolus
24 hours
what is the BP goal when using tPA? how do you treat elevations?
SBP under 180, DBP under 105
tx w/ labetalol 10mg IV OR hydralazing +/- continuous nicardipine infusion
