Clinical Presentation
- ACA: contralateral leg > arm
- Gait, bladder incontinence, amnesia
- MCA
- Contralateral sensorimotor
- Contralateral homonomous hemianopsia
- Gaze deviation
- Aphasia, dysarthria, hemineglect
- PCA
- Contralateral homonymous hemianopsia
- Sensorimotor
- Aphasia
- Memory defects
- Disorientation
- Behavioural disturbance
- Visual agnosia
- Prosopagnosia
- Cerebellar: ataxia, vertigo, dysarthria, nystagmus, headache/nausea/vomiting, rapid deterioration in LOC
- Vertebroasialar stroke: loss of consciousness, nausea/vomiting, cranial nerve deficits, Horner syndrome, crossed sensory loss, crossed motor deficits, ataxia
- Thalamic stroke: contralateral sensory and/or motor loss, aphasia (if dominant side), executive dysfunction, decreased LOC, memory impairment
- Lacunar stroke
- Pure motor hemiparesis
- Pur sensory stroke
- Sensorimotor stroke
- Ataxic hemiparesis: ipsilateral leg
- Clumsy hand syndrome
Differential Diagnosis
- migraines, seizures, todd paresis, malignancy, MS, SAH, ...
Investigations
Management
- If CT head negative for ICH
- Antiplatelets
- Carotid revascularization: consider if stenosis 50-99% on symptomatic side fo TIA/stroke
- Anticoagulation
- Something else
Thrombolysis
- Indicated for >18 years with symptoms within 4.5 hours of presentation
- Contraindications
- Absolute:
- Any active bleeding or any condition that raises the risk of major bleeding (but not anticoagulation, that’s relative)
- Any hemorrhage on brain imaging
- Relative:
- On history
- Prior ICH, ever
- Stroke or head trauma in the last 3 months
- Major surgery in the last 14 days
- Non-compressible arterial puncture in the last 7 days
- On exam
- Symptoms of SAH
- Another cause of stroke syndrome (e.g. Todd’s paralysis or hypoglycemia)
- Blood pressure ≥180/105 (must be controlled first)
- Taking DOACs
- On imaging
- Signs of early extensive infarction
- On bloodwork
- Sugar <2.7
- Elevated PTT
- INR >1.7
- Platelets <100
- No benefit if NIHSS 0-5 based on PRISMS RCT
- Dose is alteplase 0.9 mg/kg, given as 10% bolus over 1 min then 90% over 1 hour
- Outcomes
- Better function at 3 to 6 months
- Risk of major bleeding 5 to 7%, with 2% fatal
- Risk of angioedema
Endovascular Thrombectomy
- Indicated within 6 hours of onset
- Functionally independent with life expectancy over 3 months
- Small to moderate ischemic core with ASPECTS ≥6
- Proximal large vessel, or distal ICA/MCA
- Less clear with basilar artery
- Maybe within 24 hours of onset based on CT perfusion or MRI
Admission Orders
Admission Orders With TPA
- Admit to ICU for 24 hours
- IV (before TPA)
- Foley and other catheters
- BP <185/110 at time of bolus then 180/105 for infusion
- Frequent neurovitals and BP monitoring
- Repeat CT head at 24 hours
- No anticoagulation/antithrombotics for 24 hours
- Transfer to Stroke Unit after ICU
Admission Orders Without TPA
- Admit to Stroke Unit
- Different BP parameters
Post-Admission Management
- Need to workup while in hospital to decrease further risk of stroke
- Establish etiology
- Blood pressure management:
- Ischemic stroke: start antihypertensives after 24 to 48 hours of permissive hypertension
- Non-TPA ischemic stroke >220/120: reduce by 15-25% within 24 hours
- Hemorrhagic: target 140-160 in hemorrhagic
- Antiplatelets
- ASA as first-line
- Dual antiplatelets ASA + clopidogrel for 90 days for minor stroke (NIHSS ≤3) or TIA within 24 hours for 21 days (based on CHANCE and POINT trials)
- ASA plus rivaroxaban may be helpful in patients with peripheral arterial disease (COMPASS trial)
- Excludes previous ICH, recent stroke, lacunar strokes
- If occurred while on antiplatelet, may be helpful to switch
- Consider 2 week Holter monitor for cryptogenic stroke to diagnose atrial fibrillation
- For atrial fibrillation:
- Start after 1 day in minor stroke
- Start after 6 days in severe stroke?
- Carotid endarterectomy
- Refer if woman with 70-99% obstruction or man with 50-99% on symptomatic side
- Could be considered for women with 50-69% obstruction
- Vertebral artery stenosis
- Medical treatment preferred
- Intracrainial artery stenosis 70-99%: 3 months of DAPT with ASA+Plavix then monotherapy, plus high dose statin
- Cervicocephalic artery dissection: antithrombotics
- PFO
- Increased risk of stroke with 18 to 60 year olds with cryptogenic stroke and presumed paradoxical embolism, especially if
- Atrial septal aneurysm (6-fold increase in stroke risk)
- Larger PFO and right to left shunt, ≥2 mm, more microbubbles >20
- Hypercoagulable state
- Consider ruling out atrial fibrillation
- Consider PFO closure in <60 years old with minimal risk factors
- Risk factor targets
- Blood pressure <140/90, or 130/80 in lacunar and hemorrhagic strokes
- Preferred ACE inhibitors and thiazides
- LDL <1.8, using statins and ezetimibe
- HbA1c ≤7%
Further Reading
