Stroke
In patients presenting with symptoms and/or signs suggestive of stroke, include other diagnoses in the differential diagnosis (e.g., transient ischemic attack [TIA], brain tumour, hypoglycemia, subdural hematoma, subarachnoid bleed).
In a patient presenting with a stroke, differentiate, if possible, hemorrhagic from embolic/thrombotic stroke (e.g., through the history, physical examination, and ancillary testing, such as scanning and electrocardiography), as treatment differs.
Assess patients presenting with neurologic deficits in a timely fashion, to determine their eligibility for thrombolysis.
In a patient diagnosed with stroke, involve other professionals as needed (e.g., a physical therapist, an occupational therapist, social service personnel, a physiatrist, a neurologist) to ensure the best outcome for the patient.
When caring for a stroke patient with severe/serious deficits, involve the patient and her or his family in decisions about intervention (e.g., resuscitation, use of a feeding tube, treatment of pneumonia).
In patients who have suffered stroke, diagnose “silent” cognitive deficits (not associated with sensory or motor symptoms or signs, such as inattention and impulsivity) when they are present.
Provide realistic prognostic advice about their disabilities to stroke patients and their families.
In stroke patients with disabilities, evaluate the resources and supports needed to improve function (e.g., a cane, a walker, home care).
In the continuing care of stroke patients with deficits (e.g., dysphagia, being bedridden), include the prevention of certain complications (e.g., aspiration pneumonia, decubitus ulcer) in the treatment plan, as they are more common.
In patients at risk of stroke, treat modifiable risk factors (e.g., atrial fibrillation, diabetes, hyperlipidemia, and hypertension).
In all patients with a history of TIA or completed stroke, and in asymptomatic patients at high risk for stroke, offer antithrombotic treatment (e.g., acetylsalicylic acid, clopidogrel) to appropriate patients to lower stroke risk.
General Overview
Transient ischemia attacks (TIA)
Brief episode of neurological dysfunction without evidence of acute infarction, back to baseline <24h
3% risk of stroke in first 2 days after TIA, risk stratify with ABCD2 score >3 admission
Stroke
Sudden onset focal neurological dysfunction from infarction or hemorrhage in the brain lasting >24h
Signs/Symptoms
Acute onset
Hemiparesis / Motor weakness
Neglect
Amaurosis fugax
Slurred speech
Dysphagia
Sensory deficits / Decreased reflexes
Mental status change / Confusion / Inattention
Impulsivity
Syndromes
Supratentorial (most common)
Left
Aphasia, right hemiparesis / right hemianopia
Right
Left hemispatial neglect, left hemiparesis / hemianopia
Posterior or infratentorial
Mental status changes / Confusion
Diplopia
Dysphagia
Unilateral dysmetria/incoordination
Risk Factors
Smoking
Obesity / hyperlipidemia
Alcohol
Hypertension
Diabetes
Prior TIA/stroke
Atrial fibrillation
Coagulopathy
Age
Aboriginal/Black
Family History
Acute Management
ABC
Vitals, serum glucose
12-lead EKG, cardiac monitor
IV x 2
Oxygen >90%
Determine onset of stroke symptoms (or last observed normal)
Neurological Screen (FAST: Facial droop, Arm drift, Speech disturbance, Time is tissue!)
Facial droop (show me your teeth)
Arm drift (close your eyes and extend both arms out with your palms facing upwards)
Abnormal speech (say "you can't teach an old dog new tricks")
Consult neurology/stroke team
Consider stroke mimics
Recrudescence of old stroke from metabolic or infectious stress
Todd’s paralysis after seizure
Complex migraine
Psych
Mass/tumor
Hypoglycemia
CNS infections
Bells palsy (central causes will spare the forehead)
Subarachnoid hemorrhage (sudden onset severe headache, stiff neck, photophobia, diplopia)
Subdural hematoma
Labs
CBC (platelets)
Blood type and screen
Chem 7 (creatinine, eGFR)
INR
CBGM
Consider ECG (r/o Afib)
Consider Troponin
Stat CT head +/- CT Angio (r/o hemorrhagic stroke, note infarcts may take 24-48h to appear)
Hemorrhagic
Reverse anticoagulation
Monitor ICP
Consult Neurosurgery
Non-hemorrhagic (ASPECT score 6+) and symptomatic
Eligibility for tPA
Age 18 years or older
Clinical diagnosis of ischemic stroke causing neurological deficit
Time of symptom onset <3-4.5 hours
One study showed benefit up to 9 hours or on awakening
Contraindications to tPA
Active or history of intracranial hemorrhage
<3 months neurosurgery, head trauma, stroke
Uncontrolled hypertension >185/110
Known intracranial AV malformation, neoplasm, aneurysm
Active internal bleeding
Suspected endocarditis, suspected subarachnoid hemorrhage
Bleeding disorder (Plat<100, heparin with elevated aPTT, INR>1.7, DOAC)
Abnormal glucose <2.7mmol/L
IV thrombolysis alteplase (within 3-4.5h of symptom onset if no contraindications)
No anticoagulation x 24h
If not candidate for fibrinolysis, give ASA if no hemorrhage (loading dose)
Target BP <185/110 prior to treatment, and <180/105 for first 24h if thrombolytic therapy
If no thrombolytic, only treat if >220/120 or other indication
Consider Labetalol, Nicardipine, Clevidipine
Eligibility for endovascular neurointerventional care (large vessel occlusion [MCA, ACA, Carotid], small infarct, large penumbra)
National Institutes of Health Stroke Scale (NIHSS) >6
Vision, aphasia, neglect (VAN) assessment +
Pronator drift x10s, only continue if positive (mild drift, severe weakness, or paralysis)
Stroke vision
Aphasia
Neglect
Multidisciplinary team:
Early mobilization (<24h post-stroke),
NPO until Swallowing assessment
Nutritional support
Dedicated stroke unit
Assess for functional impairment
Referral for nondisabling stroke and TIA
High Risk of Stroke Recurrence
<48h of TIA or nondisabling stroke and transient, fluctuating and/or persistent unilateral weakness or speech disturbance
Immediate referral to ER with capacity for advanced stroke care (access to tPA)
CT or MRI and noninvasive vascular imaging (eg. CTA or MRA from arch to vertex)
ECG
<48h without motor weakness or speech disturbance
Same-day assessment (ER or stroke prevention clinic)
Increased risk
48h-2w with symptoms of transient, fluctuating or persistent unilateral weakness or speech disturbance
24h clinical evaluation and investigation
48h-2w without motor weakness or speech disturbance
2w clinical evaluation and investigation
>2w of TIA or nondisabling ischemic stroke
<1 month by neurologist
Work-up
Highest risk within 48h of TIA or stroke
Brain imaging (CT or MRI) with vascular imaging (CTA or MRA from aortic arch to vertex, or carotid doppler)
>50% symptomatic (>60% asymptomatic) carotid stenosis should be offered carotid endarterectomy as soon as possible
ECG and 24-hour cardiac monitoring + Holter (if no Afib on ECG and 24h monitor)
TTE (or TEE if high suspicion)
Thrombi, endocarditis, calcifications, tumour
Patent foramen ovale (No clear evidence for PFO closure)
Antiphospholipid
Vasculitis
Prevention
Antiplatelets
Clopidogrel (75mg daily) vs. aspirin/dipyridamole (25/200mg BID) vs. aspirin alone (delay 24h if given tPA)
For minor stroke and TIA, consider dual antiplatelet for 10-21d
Lifestyle:
Smoking / Alcohol
Obesity (Weight loss)
Diet (avoid fat, sodium, sugar)
Physical activity
Atrial fibrillation (anticoagulate as per CHADS65)
If ECG negative, can consider prolonged ECG monitoring (Holter)
Lipids (Statin in all ischemic stroke/TIA)
Screen and Treat:
Diabetes (HbA1c)
Blood pressure
Hormone (Consider stopping hormone replacement therapy and OCP)
OSA
Review FAST (symptoms of stroke)
Complications
Cardiac
Depression
Dementia
Dysphagia
Fatigue
Ulcer
Venous thromboembolus (25% early death post-stroke is from PE, consider prophylaxis)
Pain
Seizure (no evidence for prophylaxis)
References:
AHA Primary Prevention of Stroke 2024. https://www.ahajournals.org/doi/10.1161/STR.0000000000000475?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
CFP 2019. http://www.cmaj.ca/content/191/15/E418
AHA/ASA 2018. http://stroke.ahajournals.org.proxy3.library.mcgill.ca/content/49/3/e46/tab-figures-data
Canadian Stroke Best Practice Recommendations http://www.strokebestpractices.ca/
Secondary Prevention Update 2017. http://journals.sagepub.com/doi/pdf/10.1177/1747493017743062
Hyperacute Stroke Care Update 2015. http://onlinelibrary.wiley.com/doi/10.1111/ijs.12551/full
Royal College of Physicians National Clinical Guideline for Stroke 2016. https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx
BC Guidelines 2015. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/stroketia_2015_full.pdf
National Stroke Foundation 2010. http://www.pedro.org.au/wp-content/uploads/CPG_stroke.pdf
LOC
Month and age (orientation)
Blink eyes & squeeze hands (tasks)
Horizontal EOM (gaze palzy)
Visual fields (flick near eyes)
Facial palsy (grimace)
Pronator drift (10 seconds)
Leg motor drift (5 seconds)
Limb ataxia (FNF/heel-shin)
Sensation
Language/aphasia (name the words: pencil, watch)
Dysarthria (Read the words)
Extinction/inattention