Stroke resident survival guide

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


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),[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.


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


  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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