Stroke resident survival guide

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

Synonyms and Keywords: stroke management, stroke workup, stroke approach, approach to stroke, stroke treatment


Stroke is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013),[1] 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.


Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

  • All strokes can potentialy lead to death or permanent disability within 24 hours if left untreated.

Common Causes

  • Aneurysms
  • Atrial fibrillation
  • Eclampsia
  • Infective endocarditis
  • Myocardial infarction
  • Pulmonary embolism
  • Arteriovenous malformations
  • Atherosclerosis
  • Atrial fibrillation
  • Embolism
  • Hypertension
  • Subarachnoid hemorrhage
  • Thrombosis
  • Transient ischemic attack
  • Traumatic brain injury
  • Warfarin


Shown below is an algorithm summarizing the diagnosis of stroke according to the American Academy of Neurology guidelines:

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
❑ 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
❑ 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


The management of stroke will greatly depend on the type of stroke (if it is either hemorrhagic or ischemic).



  • Do not lower blood pressure in hypertensive patients with ischemic stroke when below


  1. Sacco, RL.; Kasner, SE.; Broderick, JP.; Caplan, LR.; Connors, JJ.; Culebras, A.; Elkind, MS.; George, MG.; Hamdan, AD. (2013). "An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (7): 2064–89. doi:10.1161/STR.0b013e318296aeca. PMID 23652265. Unknown parameter |month= ignored (help)

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