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:

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:

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

NIH Stroke Scale/Score (NIHSS)

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