Diagnosis of Acute Ischemic and Hemorrhagic Stroke

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Diagnosis of Acute Ischemic and Hemorrhagic
Stroke
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Ischemic Stroke

• Low blood flow to focal part of brain
• Usually caused by thromboembolism
• Acute therapy includes thrombolysis
• 2? prevention depends on source of thromboembolus
• Accounts for ? 85 of strokes

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Transient Ischemic Attack (TIA)

• Reversible focal dysfunction, usually lasts
  minutes
• Among TIA pts who go to ED
• 5 have stroke in next 2 days
• 25 have recurrent event in next 3 months
• Stroke risk decreased with proper therapy

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Intracerebral Hemorrhage

• Bleeding into brain tissue
• Usually caused by chronic hypertension
• Non-hypertension cause more likely if
• No past history of hypertension
• Lobar (i.e., peripheral, not subcortical)
• May require emergency surgery
• Accounts for ? 10 of strokes

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Subarachnoid Hemorrhage

• Bleeding around brain
• Usually caused by ruptured aneurysm
• Surgical emergency
• Cerebral angiography
• Aneurysmal clipping
• Accounts for ? 5 of strokes

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Five Major Stroke Syndromesfor Rapid Recognition
in the ED

• All Occur Suddenly in Stroke Patients
• Left (dominant) cerebral hemisphere
• Right (nondominant) cerebral hemisphere
• Brainstem
• Cerebellum
• Hemorrhage
• Note The dominant cerebral hemisphere is the
  side that controls language function.

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Left (Dominant)Cerebral Hemisphere

• Aphasia
• L gaze preference
• R visual field deficit
• R hemiparesis
• R hemisensory loss

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Right (Nondominant)Cerebral Hemisphere

• Neglect ( L hemi-inattention)
• R gaze preference
• L visual field deficit
• L hemiparesis
• L hemisensory loss

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Brainstem

• Hemi- or quadriparesis
• Sensory loss in hemibody or all 4 limbs
• Crossed signs (face 1 side, body other side)
• Diplopia, dysconjugate gaze, gaze palsy
• Vertigo, tinnitus
• Nausea, vomiting
• Hiccups, abnormal respirations
• Decreased consciousness

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Cerebellum

• Truncal gait ataxia
• Limb ataxia

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Hemorrhage Symptoms only suggestive of
hemorrhage. CT or LP needed for definitive
diagnosis.

• Headache
• Neck stiffness
• Neck pain
• Light intolerance
• Nausea, vomiting
• Decreased consciousness

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Acute Stroke ScalesMost Commonly Used in the U.S.

• Glasgow Coma Scale (? LOC)
• Hunt Hess Scale (SAH)
• NIH Stroke Scale (AIS)

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Glasgow Coma ScaleAdd the 3 scores (1 from each
category)
Best Verbal 5 oriented 4 confused 3
inappropriate 2 incomprehensible 1 none
Eye Opening 4 spontaneous 3 to speech 2 to pain 1
none
Best Motor 6 obeys commands 5 localizes pain 4
withdraws to pain 3 abnl flexion to pain 2
extension to pain 1 none
Quantifies deficits in pt w/ ? LOC GCS lt 9
carries poor prognosis
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Hunt and Hess ScaleChoose the single-most-appropr
iate grade

• Grade I asx mild HA slight nuchal rigidity
• Grade II moderate-to-severe HA nuchal
  rigidity
• no neuro deficit other than CN palsy
• Grade III drowsiness/confusion mild focal
  deficit
• Grade IV stupor moderate-to-severe hemiparesis
• Grade V coma decerebrate posturing
• Prognostic value in SAH pts
• Grades I-III better prognosis surgical
  candidates

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Urgent Evaluation of Patients with Focal
Neurologic Deficits

• Complete neurologic exam
• lengthy, variable, parts not reproducible
• inappropriate in acute setting
• Glasgow Coma Scale
• valuable for pts w/ ? LOC
• does not quantify focal neurologic deficit
• Hunt Hess Scale
• value is specific to SAH pts

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NIH Stroke Scale

• Designed for acute ischemic stroke trials
• Relatively quick (5-10 min) and reproducible
• Requires speech--language cards, safety pin,
  complex grading scale
• Quantifies stroke deficit
• lt 4 mild stroke
• gt 15 poor prognosis if no treatment
• gt 22 ? risk for intracranial hemorrhage after
  t-PA

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NIH Stroke ScaleModified arrangement of items

• Limbs
• R/L arm motor
• R/L leg motor
• Coordination
• Sensation

• Mental Status
• LOC
• Questions
• Commands
• Language
• Neglect

• Cranial Nerves
• Visual fields
• Horizontal gaze
• Face strength
• Dysarthria

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NIH Stroke ScaleTraditional order of items

• 1a. LOC
• 1b. LOC questions
• 1c. LOC commands
• 2. Best gaze
• 3. Visual fields
• 4. Facial palsy
• 5a. Right arm motor
• 5b. Left arm motor

• 6a. Right leg motor
• 6b. Left leg motor
• 7. Limb ataxia
• 8. Sensory
• 9. Best language
• 10. Dysarthria
• 11. Extinction/
• inattention

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NIH Stroke ScaleCaveats re traditional
version

• Item 12Distal Motor Function
• was never included in total NIHSS score
• is supplemental and not necessary
• Grades of 9Untestable
• used only for motor, ataxia, and dysarthria
• number 9 assigned for computer purposes
• do NOT give 9 points for untestable items

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Stroke Differential DiagnosisSudden Onset
Persistent Focal Deficit

• Ischemic stroke
• Intracerebral hemorrhage
• Partial seizure with postictal (Todds) paralysis
• Abscess with seizure
• Tumor with bleed or seizure
• Toxic-metabolic insult with old cerebral lesion
• Hypoglycemia
• Subdural hematoma (acute)
• Multiple sclerosis
• Cerebritis

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Stroke Differential DiagnosisSudden Onset
Transient Focal Deficit

• Transient ischemic attack
• Partial seizure
• Migraine with aura
• NOTE AVMs can cause all three types of
  transient focal neurologic deficits.

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Stroke Differential DiagnosisDepressed LOC
without Focal Deficit

• Persistent ? LOC
• Subarachnoid hemorrhage
• Meningitis
• Drug overdose
• Toxic-metabolic insult
• Seizure with postictal state
• Subclinical status epilepticus

• Transient ? LOC
• Seizure
• Syncope