# *** Stroke

Checklist
-- 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) 
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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: ***.
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Sensation
-- Pinprick: ***
-- Pain/Temperature: *** 
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Coordination
-- 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: ***.

Assessment:
-- 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 ***.

Plan:
Workup
-- 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

Treatment
-- 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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