Stroke resident survival guide
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), 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.
- Atrial fibrillation
- Infective endocarditis
- Myocardial infarction
- Pulmonary embolism
- Arteriovenous malformations
- Atrial fibrillation
- Subarachnoid hemorrhage
- Transient ischemic attack
- Traumatic brain injury
Shown below is an algorithm summarizing the diagnosis of stroke according to the American Academy of Neurology guidelines:
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
❑ 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).
- To view the specific treatment of hemorrhagic stroke click here.
- To view the specific treatment of ischemic stroke click here.
- Perform tertiary preventive measure to decrease subsecuent episodes, such as using statins and anticoagulants, controling glucose levels and blood pressure.
- Do not lower blood pressure in hypertensive patients with ischemic stroke when below
- 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