inpatient / neurology

Stroke and TIA

Last Updated: 1/8/2023

# *** Stroke

-- NIHSS -
check conscioussness, month and age, blink eyes and squeeze hand, horizontal eye movements, visual fields, facial palsy, extremity drift, limb ataxia (heel/shin), sensation, language/aphasia (name items), dysarthria (read words), extinction/inattention
-- Chart Check: Contraindications for tPA - stroke or trauma last 3 mo, recent head surgery, prior ICH, intracranial malignancy, AVM, aneurysm, active bleeding, Plt <100, on AC in last 48 hrs, multilobar infarct or >⅓ involvement of cerebral hemisphere, BP >185/110, BG <50
-- HPI Intake: last known normal/seen well, baseline, AC or antiplatelet use, renal function
-- Can't Miss: large vessel occlusion and candidacy for thrombectomy, hemorrhagic transformation
-- Admission Orders: initially CBC, BMP, LFTs, coags, trop, UA/UCx, UDS, AED levels; keep NPO
-- Initial Treatment to Consider: thrombolytics if no contraindication and LSW <4.5 hours ago; thrombectomy if large vessel occlusion and LSW <6 hours ago

Full Neuro exam:
Mental Status
-- Attention: *** (Able to attend/track examiner, crosses midline)
-- Orientation: Oriented to person/place/time
-- Language: *** (Language output, and ability to follow commands - simple/embedded, midline/peripheral) 

Cranial Nerves
-- Pupils (II): PERRLA. There was no afferent pupillary defect.
-- Eye Movements (III, IV, VI): EOMI.
-- Facial Sensation (V): Intact/symmetric
-- Facial Strength (VII): Intact/symmetric
-- Hearing (VIII): Intact/symmetric
-- IX, X, XI, XII:  Palate movements were normal. Neck strength was normal. There was normal tongue bulk and speed of movement
-- MotorStrength: RUE: ***. LUE: ***. RLE: ***. LLE: ***.

-- Pinprick: ***
-- Pain/Temperature: *** 

-- Finger-Nose/Heel-Shin/Rapid alternating movements: No dysmetria/dysdiadocokinesia
-- DTRs: *** (0 - none / 1 - hyporeflexic / 2 - normal / 3 - hyperreflexic / 4 - clonus)
-- Primitive Reflexes: Babinski: ***. Palmar reflexes: ***.

-- History: *** last known normal, baseline function, AC or antiplatelet, CKD
-- Clinical/Exam: *** AMS, facial paresis, arm drift/weakness, abnormal speech
-- Data: *** Hgb, Plts, coags, CT Head, MRI stroke protocol
-- Etiology/DDx: *** Stroke - ischemic (cardioembolic, carotid stenosis, endocarditis) vs hemorrhagic; Mimics - migraine with aura, seizure with post-ictal phase, recrudescence, medication, intoxication, other primary neuro pathology (tumor, infection), PRES

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- Acute stroke labs - CBC, BMP, LFTs, PT/PTT, trop, UA/UCx, tox screen, AED levels
-- f/u lipids, A1c, UA, UDS, BNP, trop, D-Dimer, TSH, ESR/CRP, RPR
-- BCx if fevers or valve disease
-- Head and Neck CTA/MRI vs carotid US (if no contrast)
-- EKG, TTE (with bubble if <60 years old), 48 hours of telemetry

-- Consider thrombolytics if LSW <4.5 and NIHSS >3
-- Consider thrombectomy if disabling deficit and large vessel occlusion, LSW <6h
-- If acute, HOB flat with permissive hypertension <220/120 (if no tPA), or <180/105 if tPA, then by SBP 20 per day
-- Q4 neuro checks; STAT non-con CT Head if change
-- PT/OT and SLP - NPO until eval if c/f swallowing deficit
-- ASA load, followed by 81mg daily (24 hours after tPA if CT Head shows no hemorrhagic transformation); ok to start DVT ppx at same time
-- Atorvastatin 80mg daily, goal LDL <70

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If You Remember Nothing Else

If you are concerned about a stroke the most important data to collect early on is their last know normal or last see well (LSW), their neurological deficits (NIHSS), and their contraindications for tPA. Together, this information will inform what therapies can be offered. Involve neurology consultants immediately. Send the needed workup and get the stroke protocol imaging based on the institution. If a stroke is confirmed, the days following the acute event and management focus on identifying a likely etiology and managing risk for a repeat event.

Clinical Pearls

  • TIA - abrupt focal neuro symptoms which resolve within 24 hours (often much shorter) with no abnormality detected on imaging; these patients likely are having small strokes and thus are still at risk of stroke and should have a similar workup
  • Anterior Cerebral Artery - contralateral leg weakness and sensory loss, poor judgement and apraxia
  • Middle Cerebral Artery - contralateral hemiparesis of face and arm, sometimes hemisensory loss, conugate ipsilateral eye deviation, neglect of contralateral space; Broca's aphasia (issue with word forming), Wernicke's aphasia (form words, but do not make sense)
  • Posterior Cerebral Artery - various visual deficits including hemianopia. contralateral sensory loss if involves thalamus, alexia without agraphia (can write but can't read), trouble naming objects
  • Basilar Artery - impaired consciousness, quadriplegia, twitching/jerking, tremors, gaze palsies, bulbar symptoms,

Trials and Literature

  • ATTENTION Trial - endovascular tratment of acute basilar artery occlusion (NEJM, 2022)
  • SKIP Study - effect of thrombectomy with vs without thrombolysis on functional outcome in patients with acute ischemic stroke (JAMA, 2021)
  • Overviewof Acute Ischemic Stroke Evaluation and Management (Biomedicines, 2021)
  • Table of all Landmark Trials of Endovascular Thrombectomy in Acute Ischemic Stroke (Biomedicines, 2021)

Other Resources