diagnosis of acute ischemic and hemorrhagic stroke l.
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Diagnosis of Acute Ischemic and Hemorrhagic Stroke. Ischemic Stroke. Low blood flow to focal part of brain Usually caused by thromboembolism Acute therapy includes thrombolysis 2  prevention depends on source of thromboembolus Accounts for  85% of strokes.

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ischemic stroke
Ischemic Stroke
  • Low blood flow to focal part of brain
  • Usually caused by thromboembolism
  • Acute therapy includes thrombolysis
  • 2 prevention depends on source of thromboembolus
  • Accounts for  85% of strokes
transient ischemic attack tia
Transient Ischemic Attack (TIA)
  • Reversible focal dysfunction, usually lasts minutes
  • Among TIA pts who go to ED:
    • 5% have stroke in next 2 days
    • 25% have recurrent event in next 3 months
  • Stroke risk decreased with proper therapy
intracerebral hemorrhage
Intracerebral Hemorrhage
  • Bleeding into brain tissue
  • Usually caused by chronic hypertension
  • Non-hypertension cause more likely if:
    • No past history of hypertension
    • Lobar (i.e., peripheral, not subcortical)
  • May require emergency surgery
  • Accounts for  10% of strokes
subarachnoid hemorrhage
Subarachnoid Hemorrhage
  • Bleeding around brain
  • Usually caused by ruptured aneurysm
  • Surgical emergency
    • Cerebral angiography
    • Aneurysmal clipping
  • Accounts for  5% of strokes
five major stroke syndromes for rapid recognition in the ed
Five Major Stroke Syndromesfor Rapid Recognition in the ED

All Occur Suddenly in Stroke Patients

  • Left (dominant) cerebral hemisphere
  • Right (nondominant) cerebral hemisphere
  • Brainstem
  • Cerebellum
  • Hemorrhage

Note: The dominant cerebral hemisphere is the side that controls language function.

left dominant cerebral hemisphere
Left (Dominant)Cerebral Hemisphere
  • Aphasia
  • L gaze preference
  • R visual field deficit
  • R hemiparesis
  • R hemisensory loss
right nondominant cerebral hemisphere
Right (Nondominant)Cerebral Hemisphere
  • Neglect (= L hemi-inattention)
  • R gaze preference
  • L visual field deficit
  • L hemiparesis
  • L hemisensory loss
  • Hemi- or quadriparesis
  • Sensory loss in hemibody or all 4 limbs
  • Crossed signs (face 1 side, body other side)
  • Diplopia, dysconjugate gaze, gaze palsy
  • Vertigo, tinnitus
  • Nausea, vomiting
  • Hiccups, abnormal respirations
  • Decreased consciousness
  • Truncal = gait ataxia
  • Limb ataxia
hemorrhage symptoms only suggestive of hemorrhage ct or lp needed for definitive diagnosis
Hemorrhage Symptoms only suggestive of hemorrhage. CT or LP needed for definitive diagnosis.
  • Headache
  • Neck stiffness
  • Neck pain
  • Light intolerance
  • Nausea, vomiting
  • Decreased consciousness
acute stroke scales most commonly used in the u s
Acute Stroke ScalesMost Commonly Used in the U.S.
  • Glasgow Coma Scale ( LOC)
  • Hunt & Hess Scale (SAH)
  • NIH Stroke Scale (AIS)
glasgow coma scale add the 3 scores 1 from each category
Glasgow Coma ScaleAdd the 3 scores (1 from each category)

Best Verbal

5 oriented

4 confused

3 inappropriate

2 incomprehensible

1 none

Eye Opening

4 spontaneous

3 to speech

2 to pain

1 none

Best Motor

6 obeys commands

5 localizes pain

4 withdraws to pain

3 abnl flexion to pain

2 extension to pain

1 none

Quantifies deficits in pt w/ LOC:

GCS < 9 carries poor prognosis

hunt and hess scale choose the single most appropriate grade
Hunt and Hess ScaleChoose the single-most-appropriate grade
  • Grade I: asx; mild HA; slight nuchal rigidity
  • Grade II: moderate-to-severe HA; nuchal rigidity;
  • no neuro deficit other than CN palsy
  • Grade III: drowsiness/confusion; mild focal deficit
  • Grade IV: stupor; moderate-to-severe hemiparesis
  • Grade V: coma; decerebrate posturing
  • Prognostic value in SAH pts:
  • Grades I-III better prognosis & surgical candidates
urgent evaluation of patients with focal neurologic deficits
Urgent Evaluation of Patients with Focal Neurologic Deficits
  • Complete neurologic exam
    • lengthy, variable, parts not reproducible
    • inappropriate in acute setting
  • Glasgow Coma Scale
    • valuable for pts w/  LOC
    • does not quantify focal neurologic deficit
  • Hunt & Hess Scale
    • value is specific to SAH pts
nih stroke scale
NIH Stroke Scale
  • Designed for acute ischemic stroke trials
  • Relatively quick (5-10 min) and reproducible
  • Requires speech-&-language cards, safety pin, complex grading scale
  • Quantifies stroke deficit:

< 4 = mild stroke

> 15 = poor prognosis if no treatment

> 22 = risk for intracranial hemorrhage after t-PA

nih stroke scale modified arrangement of items
Mental Status






Cranial Nerves

Visual fields

Horizontal gaze

Face strength


NIH Stroke Scale:Modified arrangement of items
  • Limbs
  • R/L arm motor
  • R/L leg motor
  • Coordination
  • Sensation
nih stroke scale traditional order of items
1a. LOC

1b. LOC questions

1c. LOC commands

2. Best gaze

3. Visual fields

4. Facial palsy

5a. Right arm motor

5b. Left arm motor

6a. Right leg motor

6b. Left leg motor

7. Limb ataxia

8. Sensory

9. Best language

10. Dysarthria

11. Extinction/


NIH Stroke Scale:“Traditional” order of items
nih stroke scale caveats re traditional version
NIH Stroke Scale:Caveats re: “traditional” version
  • Item 12—Distal Motor Function
    • was never included in total NIHSS score
    • is supplemental and not necessary
  • Grades of “9”—Untestable
    • used only for motor, ataxia, and dysarthria
    • number 9 assigned for computer purposes
    • do NOT give 9 points for untestable items
stroke differential diagnosis sudden onset persistent focal deficit
Stroke Differential Diagnosis:Sudden Onset Persistent Focal Deficit
  • Ischemic stroke
  • Intracerebral hemorrhage
  • Partial seizure with postictal (Todd’s) paralysis
  • Abscess with seizure
  • Tumor with bleed or seizure
  • Toxic-metabolic insult with old cerebral lesion
  • Hypoglycemia
  • Subdural hematoma (acute)
  • Multiple sclerosis
  • Cerebritis
stroke differential diagnosis sudden onset transient focal deficit
Stroke Differential Diagnosis:Sudden Onset Transient Focal Deficit
  • Transient ischemic attack
  • Partial seizure
  • Migraine with aura

NOTE: AVMs can cause all three types of transient focal neurologic deficits.

stroke differential diagnosis depressed loc without focal deficit
Persistent  LOC

Subarachnoid hemorrhage


Drug overdose

Toxic-metabolic insult

Seizure with postictal state

Subclinical status epilepticus

Transient  LOC



Stroke Differential Diagnosis:Depressed LOC without Focal Deficit