Stroke

Transient Ischemic Attack (TIA)

Pt with h/o cigarette smoking, DM, HLD and previous TIA presents with sudden onset focal neurologic deficit. Reports monocular blindness, difficulty speaking, unilateral weakness/paresthesias, dizziness. Denies LOC, memory loss, headache, blurry vision, convulsions, bladder/bowel dysfunction. Speech disturbance, facial droop, unilateral weakness, unilateral dysmetria with FTN/heel-to-shin reported on initial exam. HTN, carotid bruit, arrhythmia on repeat exam; initial neurologic findings resolving.

• Initial evaluation

  • Low suspicion for seizure, migraine, metabolic disturbance, syncope

  • Event occurred < 72 hours ago with ABCD2 score 4 or greater; admit for observation and telemetry

• Labs

  • Fingerstick glucose, BMP WNL

  • Obtain CBC, PT/PTT/INR, lipid panel; consider UDS, RPR

• Imaging

  • EKG showing atrial-fibrillation; obtain f/u cardiac echo

  • Stat CT to evaluate for intracranial hemorrhage

  • MRI within 24 h of symptom onset to evaluate for infarction

  • Carotid doppler or CT angio recommended within 1 week

• Treatment

  • Obtain neurology consult

  • Maintain BP goals and administer IV labetalol 20 mg for HTN

    • TPA administered: 140/90 < BP < 180/110

    • No tPA: 140/90 < BP < 220/120

  • Start aspirin 81 mg qd, atorvastatin 80 mg qd

  • F/u s/p discharge to address DM type 2 (goal HbA1c < 7%) and HTN

• Pt advised to stop smoking, start exercising, adhere to Mediterranean diet

Ischemic Stroke

Pt with h/o HTN, AFib, symptomatic CAD, sickle cell disease, DM, physical inactivity, and smoking awoke with focal neurological deficit. Reports acute vertigo lasting > 1 hour, H/A, N/V. Denies LOC, convulsions. No h/o coagulopathy. Speech disturbance, facial droop, and unilateral weakness on exam.

• Labs

  • Fingerstick glucose, whole blood glucose WNL

  • Obtain SPO2, CMP, CBC, troponins, PT/PTT/INR, UDS

• Imaging

  • EKG shows atrial fibrillation

  • Head CT negative for acute intracranial hemorrhage

  • Obtain MRI or head/neck CT angio within 24 hours

  • Concern for acute vestibular syndrome and/or posterior infarction: Obtain f/u MRI in 3-7 days if initial imaging is negative

• Treatment

  • Consider tPA if symptom onset prior to arrival <

    • 4.5 hr with suspicion for small vessel disease

    • 16 hr with suspicion for large vessel occlusion

  • Initiate mechanical thrombectomy for pt meeting the following criteria:

    • Suspected internal carotid artery/proximal MCA occlusion

    • Symptom onset within 6 hours

    • Age ≥ 18 years

    • NIHSS score ≥ 7

  • Maintain BP goals and administer IV labetalol 20 mg for HTN

    • TPA administered: 140/90 < BP < 180/110

    • No tPA: 140/90 < BP < 220/120

  • Start aspirin 24h s/p tPA

  • Neurology consult

• Counseling

  • Pt and family educated about stroke symptoms and need for urgent evaluation

  • Pt counseled to exercise regularly, decrease sweetened beverage consumption, and follow the Mediterranean diet

Hemorrhagic Stroke

• Coming soon!

Notes

• Ischemic stroke: 80-85% of all strokes

  • Thrombotic: 50% of ischemic stroke

  • Embolic

    • 30% of ischemic stroke (e.g. due to atrial fibrillation)

    • NNT warfarin to reduce 1 stroke over 1 year = 30 patients

• Antiplatelet therapy

  • Aspirin is the only antiplatelet agent shown to be effective in treatment of early acute ischemic stroke

  • Dual antiplatelet therapy (aspirin + Plavix) is only recommended for up to 90 days s/p stroke

• Permissive hypertension

  • < 72 hours s/p stroke, goals apply to patients without comorbid conditions, e.g. acute MI, acute HF, aortic dissection

  • ≥ 72 hours s/p stroke in patients with stable neurologic condition, goal BP returns to <140/<90

• 2018 American Stroke Association Early Ischemic Stroke Management Guidelines

ABCD Score for Transient Ischemic Attack

• Age ≥ 60 years (1)

• Blood pressure: systolic ≥ 140 mm Hg or diastolic ≥ 90 mm Hg (1)

• Clinical presentation

  • Unilateral weakness (2)

  • Speech impairment without weakness (1)

  • History of diabetes mellitus (1)

• Duration of symptoms

  • ≥ 60 minutes (2)

  • < 60 minutes (1)

If event occurred <72 hours ago and score is 4 or greater, admit for observation and telemetry