MDM - Ischemic Stroke

[##]-year-old [male/female] with [headache/weakness/slurred speech] with history and exam consistent with [acute/subacute] ischemic stroke [involving NAME territory].

Initial considerations in this patient included cerebrovascular accident (CVA) from ischemic and hemorrhagic etiologies, metabolic etiologies including hypoglycemia, hyponatremia, and hyperglycemia amongst others, intracranial mass including tumor, seizure, systemic infectious processes, and conversion disorder among others.

Patient presented with complaint of [headache/weakness/slurred speech/facial droop/vision loss] with reported onset of symptoms [## hours prior to presentation/unknown].  Patient noted to have an NIH stroke scale of [##] on arrival in the ED.  Patient noted to be [out of/within] window for thrombolytics.  A Code Stroke was [not] activated in the ED.  A non-contrast CT scan of the head was obtained with no evidence of intracranial hemorrhage.  Additional imaging was obtained to include [a CTA of the head and neck/MRI] and was [notable for FINDINGS].

Patient noted to have symptoms consistent with likely [right/left anterior cerebral artery (ACA) distribution stroke based on contralateral sensory and motor symptoms in the lower extremities (sparing hands and face), gait apraxia (Left ACA: akinetic mutism, transcortical motor aphasia (similar to Broca’s aphasia); Right ACA: confusion, motor hemineglect)/right/left middle cerebral artery (MCA) stroke based on contralateral hemiparesis, facial plegia, and sensory loss with motor deficits affecting the face and upper extremities more than the lower extremities (dominant hemisphere involvement resulting in aphasia (Wernicke’s (receptive) aphasia or Broca’s (expressive) aphasia/non-dominant hemisphere involvement resulting in dysarthria (motor deficit of the mouth with understanding intact) and inattention and neglect on side opposite to lesion, agnosia (inability to recognize previously known objects)/right/left posterior circulation stroke based on dizziness, dysarthria, dystaxia, diplopia, and dysphagia].  Labs obtained to include point-of-care glucose, CBC, chemistry, coagulation panel [additional] and were [unremarkable/notable for leukocytosis and left shift].  We considered stroke mimics, including Todd’s paralysis after seizure, complex migraine, pseudoseizure and conversion disorder, unlikely based on history, exam, labs, and imaging.

Neurology was consulted on the patient and involved in the decision-making regarding administration of tPA.  We considered administration of tPA in this patient, and felt it was [indicated/contraindicated] based on [presentation within 3/4,.5 hours from onset of symptoms with no contraindications to treatment/presentation over 3/4.5 hours from onset of symptoms/absolute evidence of intracranial hemorrhage on CT/clinical presentation suggestive of subarachnoid hemorrhage (SAH)/neurosurgery, head trauma or stroke within the past 3 months/uncontrolled hypertension (≥185 mmHg systolic blood pressure or >110 mmHg diastolic blood pressure/history of intracranial hemorrhage/known intracranial arteriovenous malformation, neoplasm or aneurysm/active internal bleeding/suspected or confirmed endocarditis/known bleeding diathesis ((1)platelet count <100,000; (2)patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for lab); (3)current use of oral anticoagulants (e.g. warfarin) and INR >1.7; (4)current use of direct thrombin inhibitors or direct factor Xa inhibitors)/abnormal blood glucose (<50 mg/dL)/relative presence of only minor or rapidly improving symptoms/major surgery or serious non-head trauma in the previous 14 days/history of gastrointestinal or urinary tract hemorrhage within 21 days/seizure at stroke onset/recent arterial puncture at a non-compressible site/recent lumbar puncture/post myocardial infarction (MI) pericarditis/pregnancy].  We discussed risks, benefits and alternatives to administration of tPA with the [patient/family] and they [provided verbal/written consent/wished to refuse this treatment].

Prior to treatment with tPA, blood pressure was noted to be [less than 185 mmHg systolic and 110 mmHg diastolic/noted to be greater than 180 mmHg systolic/110 mmHg diastolic which prompted treatment with Nicardipine/Labetalol with/without noted improvement in blood pressure].  We monitored the patient for complications post-tPA administration, and discussed with ICU team for admission.

https://wikem.org/wiki/Ischemic_stroke
https://www.mdcalc.com/nih-stroke-scale-score-nihss
https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss
https://www.mdcalc.com/hat-hemorrhage-thrombolysis-score-predicting-post-tpa-hemorrhage
https://www.mdcalc.com/sedan-score-post-tpa-hemorrhage
https://www.mdcalc.com/tpa-tissue-plasminogen-activator-dosing-stroke-calculator