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{{CMG}}; {{AE}}
 
==Definition==
{{CMG}}; {{AE}}[[User:MoisesRomo|Moises Romo M.D.]], {{AO}}
==Causes==
 
===Life Threatening Causes===
'''''Synonyms and Keywords:''' stroke management, stroke workup, stroke approach, approach to stroke, stroke treatment''
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
==Overview==
===Common Causes===
'''[[Stroke]]''' is used to describe [[pathological]] conditions caused by brain [[ischemia]] or [[hemorrhage]].  According to the American Heart Association/American Stroke Association (July, 2013),<ref name="Sacco-2013">{{Cite journal  | last1 = Sacco | first1 = RL. | last2 = Kasner | first2 = SE. | last3 = Broderick | first3 = JP. | last4 = Caplan | first4 = LR. | last5 = Connors | first5 = JJ. | last6 = Culebras | first6 = A. |last7 = Elkind | first7 = MS. | last8 = George | first8 = MG. | last9 = Hamdan | first9 = AD. | title = An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. | journal = Stroke | volume = 44 | issue = 7 |pages = 2064-89 | month = Jul | year = 2013 | doi = 10.1161/STR.0b013e318296aeca | PMID = 23652265 }}</ref>  it is defined as a [[neurological]] deficit attributed to an acute focal injury of the [[Central nervous system|central nervous system (CNS)]] by a [[vascular]] cause, including [[cerebral]] [[infarction]], [[Intracranial hemorrhage|intracerebral hemorrhage (ICH)]], and [[Subarachnoid hemorrhage|subarachnoid hemorrhage (SAH)]]. Therefore, by definition, [[trauma]] has to be ruled out before [[stroke]] can be [[Diagnosis|diagnosed]] in a patient with a focal [[neurological]] deficit.
==Management==
 
== Causes ==
 
=== 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
 
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[stroke]] according to the American Academy of Neurology guidelines:
 
===Initial Evaluation===
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | A01 |-|-|-|-|-|-| A02 |boxstyle_A01=BACKGROUND:SALMON|A01=<u>Evaluation</u><br>'''Goal: Evaluation done within 60 mins of patient's arrival'''<ref name="Jauch-2013">{{Cite journal  | last1 = Jauch | first1 = EC. | last2 = Saver | first2 = JL. | last3 = Adams | first3 = HP. | last4 = Bruno | first4 = A. | last5 = Connors | first5 = JJ. | last6 = Demaerschalk | first6 = BM. | last7 = Khatri | first7 = P. | last8 = McMullan | first8 = PW. |last9 = Qureshi | first9 = AI. | title = Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal = Stroke | volume = 44 | issue = 3 | pages = 870-947 | month = Mar | year = 2013 |doi = 10.1161/STR.0b013e318284056a | PMID = 23370205 }}</ref><br><br>Check vitals<br>ABCs<br>Rapid Hx - time of onset, time of arrival at the ED, medications (especially anticoagulants)<br>Rapid physical exam - neuro exam, '''NIHSS'''<br>Activate stroke team<br>'''Stat fingerstick'''<br>Labs<br>EKG, troponin, CXR<br>NPO<br>Obtain stroke protocol|A02=<u>Rule out DD</u><br>Seizure, syncope, migraine, hypoglycemia}}
{{familytree | | | | J01 | |J01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">'''Characterize the symptoms:''' <br> ❑ Sudden weakness/paralysis - face, arm or leg<br> ❑ Speech/visual difficulties<br> ❑ Altered/loss of consciousness<br> ❑ Sudden severe headache </div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | B01 |-|-|-| B02 |-|-| B03 |B01=Non-contrast enhanced CT (or MRI) to r/o hemorrhage|B02='''Bleed positive'''|B03='''Hemorrhagic stroke'''}}
{{familytree | | | | H01 | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> ❑ '''Head''' - trauma, tongue laceration <br>'''Neck''' - bruits, pulses<br> ❑ '''Limbs''' - pulses <br> ❑ '''Heart''' - murmurs<br> ❑ '''Skin''' - color changes<br>❑ Neurological exam, '''NIHSS'''</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | |!|}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | C01 | | | | | | | | | C02 | | | | | | | | | | | | | | | | | |C01='''Bleed negative'''|C02=Hemorrhagic stroke algorithm}}
{{familytree | | | | G01 | | | | | |G01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:''' <br> ❑ Psychogenic <br> ❑ [[Seizures]] <br> ❑ [[Hypoglycemia]]<br> ❑ Complicated migraine<br> ❑ [[Encephalopathy|Hypertensive encephalopathy]]<br> ❑ [[Wernicke encephalopathy]]<br> ❑ [[Brain abscess]]<br> ❑ [[Brain tumor]]<br> ❑ Drug toxicity</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01='''Acute ischemic stroke'''}}
{{familytree | | | | A01 |-| A02 | | | | | |A01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;"> ❑ Check vitals<br> ❑ Stabilize ABC<br> ❑ Brief Hx<br>❑ Activate stroke team<br> ❑ Stat fingerstick<br> ❑ '''Labs''' - CBC, serum electrolytes, urea, creatinine, troponin, EKG, PT/PTT/INR<br> ❑ NPO<br> ❑ Obtain stroke protocol</div>|A02=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Other labs in selected patients:'''<br>❑ Liver function tests<br> ❑ Toxicology screen (drug abuse, stroke in the young)<br> ❑ Blood alcohol level<br>❑ Arterial blood gas (hypoxia)<br> ❑ Chest radiograph (lung disease)<br> ❑ EEG (seizures)<br> ❑ Lumbar puncture (SAH)<br> ❑ Sepsis profile - urinalysis, blood culture (if fever is present)<br> ❑ Type and cross match FFP (coagulopathy)<br> ❑ Pregnancy test (in women of child-bearing age)</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |  }}
{{familytree | | | | |!|}}
{{familytree | | | | | | | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |E01=Time of onset}}
{{familytree | | | | B01 | | | | | | | | |B01='''Non-Contrast Enhanced CT''' (or MRI) to r/o hemorrhage}}
{{familytree | | | | | | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |,|-|^|-|.| | | | | | | | |}}
{{familytree | | | | | | | | | | | | | F01 | | | | | F02 | | | | | F03 | | | | | | | | | | | | | | | | | | | | | | |F01='''<3 hours'''|F02='''3 -4.5 hours'''|F03='''>4.5 hours'''}}
{{familytree | | C01 | | C02 | | | | | | | | | | | | | | | | | | | | | | | | |C01='''Bleed Negative'''|C02='''Bleed Positive'''}}
{{familytree | | | | | | | | | | | | | |!| | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | G01 | | | | | G02 | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | |G01=Eligibility criteria for IV rTPA|G02=Consider rTPA after '''excluding''' patients >80 years old, those taking anticoagulants regardless of INR, baseline NIHSS >25, those with imaging evidence of ischemic injury involving >1/3 of the MCA territory, or those with a history of both stroke and diabetes mellitus}}
{{familytree | | D01 | | D02 | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01=[[Ischemic stroke resident survival guide|Acute Ischemic Stroke]]|D02=[[Hemorrhagic stroke resident survival guide|Hemorrhagic Stroke]]}}
{{familytree | | | | | | | | | | | | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|.| | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | E01 | | E02 | | |E01=[[Hemorrhagic stroke resident survival guide#Intracerebral Hemorrhage|Intracerebral Hemorrhage]]|E02=[[Subarachnoid hemorrhage resident survival guide|Subarachnoid Hemorrhage]]}}
{{familytree | | | | | H01 | | | | | | | | | | H02 | |!| | | | | | H03 | | | | | | | | | | | | | | | | | | | | | | |H01=Eligible|H02=Not eligible|H03=Blood pressure control algorithm<br><br>Treat fever with IV antipyretics}}
{{familytree/end}}<br />
{{familytree | | | | | |!| | | | | | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | }}
 
{{familytree | |,|-|-|-|^|-|-|-|.| | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
== Treatment ==
{{familytree | I01 | | | | | | I02 | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | ||I01='''BP≤180/110'''|I02='''BP≥180/110'''}}
The management of stroke will greatly depend on the type of stroke (if it is either hemorrhagic or ischemic).
{{familytree | |!| | | | | | | |!| | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | |  }}
 
{{familytree | J01 | | | | | | JO2 | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |J01=IV rTPA 0.9 mg/kg (maximum of 90 mg) with 10% given as intravenous bolus over 1 minute and the rest as IV infusion over 1 hour|JO2=Commence IV antihypertensives}}
* To view the specific [[treatment]] of [[hemorrhagic stroke]] [[Hemorrhagic stroke management|click here]].
{{familytree | |!| | | | | | | | | | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
* To view the specific [[treatment]] of [[ischemic stroke]] [[Ischemic stroke medical therapy|click here]].
{{familytree | |!| | | | | | | | | | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | K01 |-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|'| | | | | | | | | | | | | | | | | | | | | |K01=Admit ICU for BP monitoring + bleeding complications<br>Vitals<br>Neurocheck hourly<br>Aspiration precautions}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | L01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |L01='''After 24 hours post rTPA or no rTPA'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | M01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |M01=Follow-up head CT/MRI before commencing antiplatelets}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | |,|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | N01 | | | | N02 | | | | | N03 | | | | | | | | | | | | | | | | | | | | | | |N01='''ASA''' 325 mg (if no contraindication)<br>'''Statins'''<br>'''DVT prophylaxis'''|N02=PTOT evaluation<br>Speech and swallow evaluation|N03='''Investigate the cause'''<br>MRA/CTA/carotid duplex<br>Venous doppler USS<br>Echocardiography}}
{{familytree/end}}


==Dos==
== Do's ==
===Determine the eligibility criteria for administration of IV recombinant TPA=== 
Below are the exclusion criteria:
* Significant head trauma or prior stroke in previous 3 months
* Symptoms suggest subarachnoid hemorrhage
* Arterial puncture at noncompressible site in previous 7 days
* History of previous intracranial hemorrhage
* Intracranial neoplasm, arteriovenous malformation, or aneurysm
* Recent intracranial or intraspinal surgery
* Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
* Active internal bleeding
* Acute bleeding diathesis, including but not limited to
* Platelet count <100 000/mm³
* Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
* Current use of anticoagulant with INR >1.7 or PT >15 seconds
* Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and
ECT; TT; or appropriate factor Xa activity assays)
* Blood glucose concentration <50 mg/dL (2.7 mmol/L)
* CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)


* Perform tertiary preventive measure to decrease subsecuent episodes, such as using statins and [[Anticoagulants|anticoagulant]]<nowiki/>s, controling [[glucose]] levels and [[blood pressure]].


Relative exclusion criteria
== Don'ts ==
* Only minor or rapidly improving stroke symptoms (clearing spontaneously)
* Pregnancy
* Seizure at onset with postictal residual neurological impairments
* Major surgery or serious trauma within previous 14 days
* Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
* Recent acute myocardial infarction (within previous 3 months)


==Don'ts==
* Do not lower [[blood pressure]] in hypertensive patients with ischemic stroke when below


<br />
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 02:26, 12 December 2020


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

Overview

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.

Causes

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

Diagnosis

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
Seizures
Hypoglycemia
❑ 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
❑ NPO
❑ 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
 
 


Treatment

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

Do's

Don'ts

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


References

  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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