stroke quiz

aspirin

Antiplatelet

coumadin/ warfarin

anticoagulant

A 78-Year-Old Woman with Slurred Speech Mrs Oswald is a 78-year-old female who presents to the emergency department with a 2-hour history of slurred speech. She also complains of difficulty with word-finding and right-sided weakness and numbness. She denies any vision changes, headache, fever, trauma, chest pain, or abdominal pain. She has a history of hypertension, hyperlipidemia, and atrial fibrillation. Her medications include hydrochlorothiazide, metoprolol, fish oil, and aspirin. She has not taken warfarin for the last 3 years after an incident of diverticular bleeding. She does not smoke or use alcohol. On examination, she is awake yet anxious, with a blood pressure of 194/102 mm Hg, heart rate of 116 bpm, respiratory rate of 20 breaths/min, and oxygen saturation of 96% on room air. Chest auscultation reveals clear lungs and an irregularly irregular rhythm. Abdominal examination reveals a soft, nontender abdomen and normal bowel sounds. Neurological examination reveals expressive aphasia, left facial droop, right-sided sensory deficits, and right-sided motor strength of 3/5. Left arm and leg sensory and motor examination are normal. Lab data show hemoglobin 12.6, hematocrit 38, WBCs 10,600, and platelets 186,000. Basic metabolic panel is normal. Point-of-care glucose is 109. CT scan of the head is normal. Questions 1. What is the most likely diagnosis? 2. What is the most likely cause of this new diagnosis? 3. What else should be considered in the differential diagnosis?

Answers This is a 78-year-old with risk factors for stroke (age, hypertension, hyperlipidemia, atrial fibrillation) who presents with sudden stroke-like symptoms. Her vital signs reveal compensatory measures being taken by the body. Her normal head CT scan has ruled out an acute hemorrhage. Her stroke is most likely embolic in nature, related to not being on anticoagulation for the atrial fibrillation. Other potential diagnoses to consider include complex migraine headache, tumor or mass, and toxic-metabolic abnormalities.

when to use thrombolytics for stroke

It is critical to find out the exact onset of stroke symptoms, as thrombolytics can only be given within a 4.5-hour window from the onset of symptoms in ischemic strokes. If the patient awoke with symptoms or is unable to communicate, the physician must determine when the patient was last awake and "normal."

Diagnosis of stroke

The World Health Organization has defined stroke as a neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours. Stroke is suspected clinically and is typically confirmed by subsequent imaging techniques.

A 71-year-old female has been diagnosed with a hemorrhagic stroke due to intraparenchymal hemorrhage. Her vital signs include a blood pressure of 166/98 mm Hg. What is the next step in managing this patient's blood pressure? A Do nothing. Her blood pressure is at an ideal range to maintain cerebral perfusion. B Start intravenous fluids. Her intravascular volume should be increased so as to raise the systolic blood pressure to 180 mm Hg. C Start intravenous labetolol. The goal systolic blood pressure is <140 mm Hg.

The correct answer is C. Explanation: Blood pressure management differs in the setting of hemorrhagic stroke versus ischemic stroke. For patients with hemorrhagic stroke, the blood pressure should be normalized as soon as possible so as to potentially avoid worsening the area of hemorrhage. Maintaining the current blood pressure, or adding measures that may increase it, will put the patient at a higher risk for worsening stroke symptoms.

A 64-year-old male suffered an ischemic stroke 4 weeks ago. The determined cause of his stroke was left internal carotid artery stenosis. He has residual deficits of minimal right hand weakness. He has stopped smoking. His medications include aspirin, atorvastatin, ramipril, and metoprolol. His vital signs are normal. What is the next step for the secondary prevention of stroke? A Add clopidogrel. B Add warfarin. C Maintain current medication and rehabilitation regimen. D Refer for carotid endarterectomy.

correct answer is D. Explanation: This patient should be referred for carotid endarterectomy. Doing nothing allows the continued stenosis and presumed atherosclerotic disease to place this patient at a high risk for another stroke. The patient is already on aspirin, so clopidogrel does not necessarily need to be added. Some sources will argue that the aspirin should be changed to clopidogrel or dipyridamole. There is no mention of atrial fibrillation, so warfarin is not indicated.

In patients who are eligible for tPA, the goal BP is

less than 185/110 mm Hg.

when to Consider thrombolytic medications for stroke

such as tPA, for stroke patients presenting within 3 hours of symptom onset. Be aware of tPA contraindications.

clopidogrel

Antiplatelet Plavix Platelet Aggregation Inhibitor

the most urgent diagnostic studies in suspected stroke

A bedside glucose measurement and a CT scan of the head

thrombolytics

Medications that act to degrade clots and are used in the treatment of myocardial infarctions, pulmonary embolisms, and strokes. Alteplase (Activase) Streptokinase Drug used after a stroke that dissolves clots

TRANSIENT ISCHEMIC ATTACK (TIA) definition

Occurs when the blood supply to a particular area of the brain is interrupted. It is often referred to as a "mini stroke," and the symptoms typically last minutes to hours, but resolve within 24 hours.

risk factors for stroke

Strokes are more common in the elderly (75% occur in patients older than 75 years), males, and African Americans. Other risk factors for stroke include a history of TIA or previous stroke, hypertension, atherosclerosis, cardiac disease (eg, atrial fibrillation, myocardial infarction, and valvular disease), diabetes, carotid stenosis, dyslipidemia, hypercoagulable states, tobacco, and alcohol use.

Hemorrhagic Stroke Syndromes

Syndrome Symptoms Intracerebral hemorrhage: May be clinically indistinguishable from infarction; contralateral numbness and weakness; aphasia, neglect (depending on hemisphere); headache, vomiting, lethargy, marked hypertension more common Cerebellar hemorrhage: Sudden onset of dizziness, vomiting, truncal instability, gaze palsies, stupor

59-year-old man with a history of hypertension presents to the emergency department (ED) with right-sided paralysis and aphasia. The patient's wife states he was in his normal state of health until 1 hour ago, when she heard a thud in the bathroom and walked in to find him collapsed on the floor. She immediately called emergency medical services, which transported the patient to your ED. En route, his fingerstick blood sugar was 108 mg/dL. On arrival in the ED, the patient is placed on monitors and an IV is established. His temperature is 36.8°C (98.2°F), blood pressure is 169/93 mm Hg, heart rate is 86 beats per minute, and respiratory rate is 20 breaths per minute. The patient has a noticeable left-gaze preference and is verbally unresponsive, although he will follow simple commands such as raising his left thumb. He has a normal neurologic examination on the left, but on the right he has a facial droop, no motor activity, decreased deep tendon reflexes (DTRs), and no sensation to light-touch. questions What is the most likely diagnosis? What is the most appropriate next step? What is the best therapy?

Summary: This is a 59-year-old man with acute onset of aphasia and right-sided paralysis 60 minutes prior to arrival in the ED. Most likely diagnosis: Stroke. Most appropriate next step: CT scan of the head. Best therapy: Thrombolytics. Considerations This 59-year-old man presents with an acute onset of focal neurologic deficits, which are typical for a cerebrovascular accident (CVA). Management priorities include: ABCs (airway, breathing, and circulation), stabilization of vitals, and a careful history and physical to distinguish CVA from other etiologies which may present similarly, such as hypoglycemia. Non-contrast CT is used to quickly determine whether the CVA is ischemic or hemorrhagic. If the event is ischemic, the patient may be a candidate for thrombolytic administration. The goal is to complete an evaluation and, if the patient is eligible, initiate treatment within 60 minutes of the patient's arrival to the ED. We must be cognizant that "Time is Brain Tissue."

stroke Differential Diagnosis

The differential diagnosis list for patients presenting with stroke-like symptoms should include the following: Complex migraine headache Head trauma Brain tumor Todd's palsy Conversion disorder Systemic infection/meningitis/encephalitis Toxic-metabolic abnormalities (hypoglycemia, renal failure, liver failure, illicit drug use)

Some of the major contraindications to thrombolytic therapy include

hemorrhagic stroke, severe hypo- or hyperglycemia, uncontrolled severe hypertension, or significant bleeding conditions.

Determine and treat underlying causes of stroke

statin medications for hyperlipidemia, cessation counseling for smokers, anticoagulation for atrial fibrillation, and carotid endarterectomy for carotid artery stenosis.

For ischemic strokes, the guideline for the administration of rtPA (recombinant tissue-type plasminogen activator) in eligible patients is exclusion and inclusion criteria for Intravenous Thrombolysis in Ischemic Stroke

within 60 minutes of arrival to the facility, within the "golden hour" of stroke care. INCLUSIONS • Age 18 years or older • Clinical criteria of ischemic stroke • Time of onset well established, <3 hours EXCLUSIONS • Minor stroke symptoms • Rapidly improving neurological signs • Prior intracranial hemorrhage or intracranial neoplasm • Arteriovenous malformation or aneurysm • Blood glucose <50 mg/dL or >400 mg/dL • Seizure at onset of stroke • Gastrointestinal or genitourinary bleeding within preceding 21 days • Arterial puncture at a noncompressible site or lumbar puncture within 1 week • Recent myocardial infarction • Major surgery within preceding 14 days • Sustained pretreatment severe hypertension (systolic blood pressure >185 mm Hg, diastolic blood pressure >110 mm Hg) • Previous stroke within past 90 days • Previous head injury within past 90 days • Current use of oral anticoagulant or prothrombin time >15 seconds or INR >1.7 • Use of heparin within preceding 48 hours or prolonged partial thromboplastin time • Platelet count <100,000/mm3

location of stroke and symptoms

Anterior cerebral artery strokes may present with motor and/or sensory deficits, grasp and sucking reflexes, abulia, and gait apraxia. Middle cerebral artery strokes present differently, depending on which hemisphere is involved. Dominant hemisphere signs include aphasia, motor and sensory deficits, and homonymous hemianopia. Nondominant hemisphere signs include neglect, anosognosia, motor and sensory deficits, and homonymous hemianopia. Posterior cerebral artery strokes may present with homonymous hemianopia, alexia without agraphia, and visual disturbances. Vertebrobasilar artery strokes may present with cranial nerve palsies, diplopia, dizziness, nausea, dysarthria, dysphagia, gait ataxia, and even coma.

stroke diagnostics

CT scan without contrast is the preferred initial imaging modality in determining ischemia versus hemorrhage. This distinction is important because management will be different. CT scan is preferred over MRI scan because it is cheaper and faster, with the same sensitivity for identifying hemorrhage. Acute ischemic strokes are unlikely to show up on CT scan. Further workup focuses on potential causes. Imaging of the carotid arteries is used to detect stenosis or dissection. Echocardiogram is used to identify intracardiac thrombosis. Electrocardiogram and telemetry are used to detect arrhythmias, such as atrial fibrillation. Fasting cholesterol panel is ordered to look for hyperlipidemia. For younger patients and those who cause a high clinical suspicion, a workup for a hypercoagulable state is indicated. These states may include sickle cell anemia, protein C or S deficiency, factor V Leiden, and antiphospholipid syndrome, among others.

Stroke review

Strokes are the result of ischemia or hemorrhage of affected brain tissue. They are the leading cause of adult disability in the United States and the second leading cause of death worldwide. Risk factors include elderly age, hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, previous stroke or transient ischemic attack, and cigarette smoking. Ischemic stroke and hemorrhagic stroke are the 2 major categories. Eighty percent to 90% of strokes are ischemic in nature. Ischemic strokes are due to 4 main causes: arterial thrombosis, embolism, hypoperfusion, and venous thrombosis. Arterial thrombosis is usually in the setting of atherosclerosis, but may also be seen with arterial dissection or vasculitis. Arterial embolism typically arises in the heart, such as in the setting of atrial fibrillation, left ventricular thrombus, or infective endocarditis. Hypoperfusion seen in the setting of such disease states as decompensated congestive heart failure and septic shock may lead to inadequate blood flow to areas of the brain, causing a stroke. Cerebral venous sinus thrombosis causes stroke due to increased local pressures. Hemorrhagic strokes are further classified based on the location of the bleed. These include intraparenchymal hemorrhage, intraventricular hemorrhage, epidural hematoma, subdural hematoma, and subarachnoid hemorrhage. Potential causes include vascular malformations, amyloidosis, trauma, bleeding disorders, illicit drug use, and secondary conversion of an ischemic stroke.

A 58-year-old man experienced a neurologic deficit and is diagnosed as having a stroke. Which of the following is the most likely etiology? A Ischemic B Hemorrhagic C Drug-induced D Trauma-induced E Metabolic-related

The correct answer is A. Explanation: A. Ischemia is the most common etiology of stroke (due to thrombosis, embolism, or hypoperfusion) and is responsible for up to 80% of strokes.

An 80-year-old man is being evaluated for possible thrombolytic therapy after presenting with 2 hours of right arm weakness and aphasia. Which of the following is a contraindication for thrombolytic therapy? A Bilateral cerebral infarct B Hemorrhagic stroke C Hypertension-related stroke D Age of 80 years

The correct answer is B. Explanation: B. Indications for tPA administration include an ischemic stroke with a clearly defined time of onset, measurable neurologic deficit, and a baseline CT with no evidence of intracranial hemorrhage. Contraindications for tPA therapy vary and include, but are not limited to: seizure at the time of stroke, history of intracranial hemorrhage, persistent blood pressure greater than 185/110 mm Hg despite antihypertensive therapy, recent surgery or GI bleed, recent MI, pregnancy, elevated aPTT or INR due to heparin or warfarin use, or platelet count less than 100,000.

An otherwise healthy 65-year-old woman is taken to the ED with probable stroke. Which of the following are the most urgent diagnostic studies? A Coagulation studies B ECG and cardiac enzymes C Bedside blood glucose and CT scan of the head D MRI of the head with and without contrast

The correct answer is C. Explanation: C. Bedside blood glucose and CT scan of the head are the most urgent diagnostic studies in evaluating possible stroke patients. Coagulation studies, a complete blood count or platelet count should not delay tPA administration unless the patient is taking anticoagulation or has suspected thrombocytopenia. Non-contrast head CT is generally the initial imaging study, not MRI, to exclude hemorrhage or tumor as a cause of neurologic deficits. Though MRI provides more information, its cost, limited availability, restricted patient access, and other contraindications such as patient claustrophobia or metal implants limit its use.

A 67-year-old woman is seen in the emergency room with left arm weakness and right facial droop. Her blood pressure is 180/105 mm Hg. Which of the following is the best management for the hypertension? A Lower the blood pressure to less than 160/80 mm Hg by giving a small dose of labetalol. B Lower the blood pressure to less than 120/80 mm Hg. C No intervention for her blood pressure, but continue to monitor. D Lower the blood pressure to below 160/80 mm Hg if she is eligible for tPA.

The correct answer is C. Explanation: C. Emergency administration of antihypertensive agents should be withheld in acute stroke to maintain cerebral perfusion pressure, unless the blood pressure is greater than 220/120 mm Hg. In patients who are eligible for tPA, the goal BP is less than 185/110 mm Hg. If patients have concurrent conditions (eg, aortic dissection, hypertensive encephalopathy, acute renal failure, or congestive heart failure) that require acute lowering of blood pressure, a reasonable goal is to lower their mean arterial pressure 15% to 25% within the first 24 hours.

Mrs Oswald is a 78-year-old female who presents to the emergency department with a 2-hour history of slurred speech. She also complains of difficulty with word-finding and right-sided weakness and numbness. She denies any vision changes, headache, fever, trauma, chest pain, or abdominal pain. She has a history of hypertension, hyperlipidemia, and atrial fibrillation. Her medications include hydrochlorothiazide, metoprolol, fish oil, and aspirin. For Mrs Oswald, which of the following medications is not obviously indicated for stroke treatment or secondary prevention? A Warfarin B Simvastatin C Lisinopril

The correct answer is C. You answered A. Explanation: All patients with a diagnosis of stroke should be treated with a statin medication. The LDL should be lowered to a goal of <100. Because of her atrial fibrillation and subsequent increased stroke risk, this patient should be placed on anticoagulation with warfarin. Lisinopril may be a helpful addition for controlling the blood pressure, but does not in itself have a role for acute stroke management or secondary prevention

stroke symptoms

The history and physical examination remains the cornerstone of evaluating stroke patients. The symptoms may include weakness, numbness, or discoordination of the limbs or face, cranial nerve palsies, dysarthria, or cognitive impairments such as aphasia or neglect. It is possible, although challenging, to clinically infer the location of the anatomic insult to the clinical presentation by correlating symptoms with circulatory region. For instance, aphasia usually corresponds to a left hemispheric stroke; neglect generally indicates a right hemispheric stroke; crossed signs (eg, right-sided facial droop with left-sided extremity weakness) typically indicate brainstem involvement.

stroke Treatment

Treatment is aimed at stabilizing the ABCs, evaluating for possible thrombolytic administration, and addressing comorbid conditions such as hypertension. Thrombolytic therapy should be initiated in patient with an ischemic stroke as soon as possible since "time is brain." Management focuses both on the acute event and on secondary prevention. It differs between ischemic strokes and hemorrhagic strokes. For ischemic strokes, antithrombotic medications, such as aspirin, clopidogrel, and dipyridamole, are used to prevent further platelet aggregation. Statin drugs are indicated as a means to stabilize atherosclerotic plaques. Thrombolytic medications, such as tissue plasminogen activator (tPA), are recommended within 3 hours of stroke-symptom onset. Contraindications for tPA include recent stroke, recent major surgery, recent myocardial infarction, resolving stroke symptoms, intracranial hemorrhage, blood pressure of 185/110 mm Hg or higher, platelets <100,000, serum glucose <50, and INR >1.7. Blood pressure management typically revolves around a goal systolic blood pressure of 160 to 180 mm Hg, so as to maintain adequate perfusion to viable brain tissue immediately surrounding the area of ischemia without increasing the risk for hemorrhagic conversion. For hemorrhagic strokes, the acute management phase involves neurosurgical evaluation and hemodynamic stability. Antithrombotic and thrombolytic medications are contraindicated. Blood pressure should be kept within normal ranges, so as to avoid worsening of the hemorrhage. Subsequent treatment focuses on rehabilitation services, including physical therapy, occupational therapy, and speech therapy. Patients will often need these services even after discharge from the hospital. Social worker and counseling support should be provided to the patient and family, as this is often a life-altering event. Secondary prevention focuses on risk factors for subsequent strokes. Blood pressure, blood glucose, and cholesterol levels should be maintained within normal ranges. Smoking cessation counseling should be provided. Long-term anticoagulation medications are indicated for patients with atrial fibrillation (atrial fibrillation carries a 5% yearly risk of stroke). Patients who have carotid artery stenosis should be considered for carotid endarterectomy or carotid angioplasty. Statin medications and antithrombotic medications should be considered for lifelong usage.