Transcript Diagnosis of Acute Ischemic and Hemorrhagic Stroke

Diagnosis of
Acute Ischemic and Hemorrhagic
Stroke
Ischemic Stroke
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Low blood flow to focal part of brain
Usually caused by thromboembolism
Acute therapy includes thrombolysis
2 prevention depends on source of
thromboembolus
• Accounts for  85% of strokes
Transient Ischemic Attack (TIA)
• Reversible focal dysfunction, usually lasts
minutes
• Among TIA pts who go to ED:
– 5% have stroke in next 2 days
– 25% have recurrent event in next 3 months
• Stroke risk decreased with proper therapy
Intracerebral Hemorrhage
• Bleeding into brain tissue
• Usually caused by chronic hypertension
• Non-hypertension cause more likely if:
– No past history of hypertension
– Lobar (i.e., peripheral, not subcortical)
• May require emergency surgery
• Accounts for  10% of strokes
Subarachnoid Hemorrhage
• Bleeding around brain
• Usually caused by ruptured aneurysm
• Surgical emergency
– Cerebral angiography
– Aneurysmal clipping
• Accounts for  5% of strokes
Five Major Stroke Syndromes
for Rapid Recognition in the ED
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All Occur Suddenly in Stroke Patients
Left (dominant) cerebral hemisphere
Right (nondominant) cerebral hemisphere
Brainstem
Cerebellum
Hemorrhage
Note: The dominant cerebral hemisphere is the side
that controls language function.
Left (Dominant)
Cerebral Hemisphere
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Aphasia
L gaze preference
R visual field deficit
R hemiparesis
R hemisensory loss
Right (Nondominant)
Cerebral Hemisphere
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Neglect (= L hemi-inattention)
R gaze preference
L visual field deficit
L hemiparesis
L hemisensory loss
Brainstem
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Hemi- or quadriparesis
Sensory loss in hemibody or all 4 limbs
Crossed signs (face 1 side, body other side)
Diplopia, dysconjugate gaze, gaze palsy
Vertigo, tinnitus
Nausea, vomiting
Hiccups, abnormal respirations
Decreased consciousness
Cerebellum
• Truncal = gait ataxia
• Limb ataxia
Hemorrhage
Symptoms only suggestive of hemorrhage.
CT or LP needed for definitive diagnosis.
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Headache
Neck stiffness
Neck pain
Light intolerance
Nausea, vomiting
Decreased consciousness
Acute Stroke Scales
Most Commonly Used in the U.S.
• Glasgow Coma Scale ( LOC)
• Hunt & Hess Scale (SAH)
• NIH Stroke Scale (AIS)
Glasgow Coma Scale
Add the 3 scores (1 from each category)
Eye Opening
Best Motor
Best Verbal
4 spontaneous
3 to speech
2 to pain
1 none
6 obeys commands
5 localizes pain
4 withdraws to pain
3 abnl flexion to pain
2 extension to pain
1 none
5 oriented
4 confused
3 inappropriate
2 incomprehensible
1 none
Quantifies deficits in pt w/  LOC:
GCS < 9 carries poor prognosis
Hunt and Hess Scale
Choose the single-most-appropriate grade
• Grade I: asx; mild HA; slight nuchal rigidity
• Grade II: moderate-to-severe HA; nuchal rigidity;
no neuro deficit other than CN palsy
• Grade III: drowsiness/confusion; mild focal deficit
• Grade IV: stupor; moderate-to-severe hemiparesis
• Grade V: coma; decerebrate posturing
Prognostic value in SAH pts:
Grades I-III better prognosis & surgical candidates
Urgent Evaluation of Patients with
Focal Neurologic Deficits
• Complete neurologic exam
– lengthy, variable, parts not reproducible
– inappropriate in acute setting
• Glasgow Coma Scale
– valuable for pts w/  LOC
– does not quantify focal neurologic deficit
• Hunt & Hess Scale
– value is specific to SAH pts
NIH Stroke Scale
• Designed for acute ischemic stroke trials
• Relatively quick (5-10 min) and reproducible
• Requires speech-&-language cards, safety
pin, complex grading scale
• Quantifies stroke deficit:
< 4 = mild stroke
> 15 = poor prognosis if no treatment
> 22 =  risk for intracranial hemorrhage after t-PA
NIH Stroke Scale:
Modified arrangement of items
Mental Status
• LOC
• Questions
• Commands
• Language
• Neglect
Cranial Nerves
• Visual fields
• Horizontal gaze
• Face strength
• Dysarthria
Limbs
• R/L arm motor
• R/L leg motor
• Coordination
• Sensation
NIH Stroke Scale:
“Traditional” order of items
1a.
1b.
1c.
2.
3.
4.
5a.
5b.
LOC
LOC questions
LOC commands
Best gaze
Visual fields
Facial palsy
Right arm motor
Left arm motor
6a.
6b.
7.
8.
9.
10.
11.
Right leg motor
Left leg motor
Limb ataxia
Sensory
Best language
Dysarthria
Extinction/
inattention
NIH Stroke Scale:
Caveats re: “traditional” version
• Item 12—Distal Motor Function
– was never included in total NIHSS score
– is supplemental and not necessary
• Grades of “9”—Untestable
– used only for motor, ataxia, and dysarthria
– number 9 assigned for computer purposes
– do NOT give 9 points for untestable items
Stroke Differential Diagnosis:
Sudden Onset Persistent Focal Deficit
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Ischemic stroke
Intracerebral hemorrhage
Partial seizure with postictal (Todd’s) paralysis
Abscess with seizure
Tumor with bleed or seizure
Toxic-metabolic insult with old cerebral lesion
Hypoglycemia
Subdural hematoma (acute)
Multiple sclerosis
Cerebritis
Stroke Differential Diagnosis:
Sudden Onset Transient Focal Deficit
• Transient ischemic attack
• Partial seizure
• Migraine with aura
NOTE:
AVMs can cause all three types of
transient focal neurologic deficits.
Stroke Differential Diagnosis:
Depressed LOC without Focal Deficit
Persistent  LOC
Transient  LOC
• Subarachnoid hemorrhage
• Seizure
• Meningitis
• Syncope
• Drug overdose
• Toxic-metabolic insult
• Seizure with postictal state
• Subclinical status epilepticus