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ACUTE ISCHEMIC
STROKE
Internal Medicine
Mini Lecture
June 2016
Objectives
• Establish the components in diagnosing a stroke
• Learn which initial imaging is available in acute stroke
• Know the management of acute ischemic strokes
Causes
• Ischemic stroke (85% of all strokes)
• Atherosclerotic disease
• Cardioembolic
• Other (cervical artery dissection, endocarditis, vasculitis,
hypercoagulable state, herniation)
• Hemorrhagic stroke (15% of all strokes)
• Intracerebral hemorrhage (ICH)
• Subarachnoid hemorrhage (SAH)
CODE STROKE
• Focused history and physical
• Including contraindications to thrombolytic therapy
• Neurologic assessment
• facial paresis, arm drift/weakness, and abnormal speech indicate
high positive predictive value for stroke
• Vitals, glucose
• Noncontrast CT Head STAT
• To distinguish intracranial hemorrhage from ischemic stroke
National Institutes of Health Stroke Scale
(NIHSS)
• Provides a structured, quantifiable neurologic examination
• NIHSS has 11 parts similar to our neurologic exam
• Score between 0 and 42
• NIHSS scores ≥20 indicate a severe stroke
• NIHSS score on admission has been correlated to stroke
outcome
• http://www.mdcalc.com/nih-stroke-scale-score-nihss/
Time is Brain
• Time of ischemic stroke symptom onset is critical
• If unknown, then time the patient was last awake and free
of stroke symptoms
Initial Imaging
• Noncontrast CT
• CT Angiography
• visualizes great vessels, occlusion, and can reconstruct circle of
Willis and extracranial cerebral arteries
• CT Perfusion
• areas of hypoattenuation correlates with ischemic brain regions
• Absolute Exclusion:
• Head trauma or stroke in last 3 months
• Previous ICH, Intracranial tumor, AVM, or aneurysm
• Recent intracranial or intraspinal surgery
• Active internal bleeding
• Bleeding diatheses (plt<100, heparin in last 48h ie abnormal PTT,
current anticoagulant use ie INR>1.7)
• More exclusion criteria
Blood pressure in ischemic stroke
• If receiving lytic therapy
• Prior to: Recommend SBP ≤185 mmHg and DBP ≤110 mmHg
• Afterwards: stabilize and maintain BP <180/105 mmHg for at least
24 hours after thrombolytic treatment.
• No thrombolytic therapy
• BP should not be treated acutely unless hypertension is extreme
SBP>220 mmHg or DBP>120 mmHg or other acute issues exist*
• When treatment is indicated, cautious lowering of blood pressure
by approximately 15% during the first 24h
Additional Medical Management
• Antithrombotic treatment
• Aspirin 160 to 325 mg within 48 hours
• High dose statin
• Atorvastatin 80mg
• Anticoagulation: only in cardioembolic stroke
• IV not recommended during first 48h after acute ischemic stroke
• Warfarin can be started for small or moderate-sized infarct after 24
hours
Neurologic symptoms
suggestive of acute
stroke
Outside therapeutic
within 4.5 hours Within 6 hours
Admit to ICU, reverse window
coagulopathy,
manage BP, call
Neurosurgery
IV TPA
BP in stroke
Ischemic
stroke
TPA No TPA
BP<185/110 Permissive
prior to HTN to
giving 220/120
BP<180/105
for 24h
afterwards
Case Vignette
• A 57-year-old man is evaluated in the emergency
department 45 minutes after developing acute-onset left
arm weakness. He has a 50-pack-year smoking history.
He has no history of stroke, trauma, bleeding, cardiac
disease, or surgery. His only medications is atorvastatin.
• On physical examination, blood pressure is 168/98 mm
Hg and pulse rate is 86/min and irregular. Neurologic
examination reveals left hemineglect, an inferior left visual
field deficit, left facial weakness, mild dysarthria, and left
arm and leg drift. He scores 6 on the National Institutes of
Health Stroke Scale, indicating a moderate stroke.
Case Vignette
What is the next step?
Case Vignette
What is the next step?