STROKE

DIAGNOSIS

For any neurological emergency first secure airway, check BP and calculate NIHSS. National institute of health stroke scale value > 5 confirms stroke
Best initial step: Head CT without contrast to differentiate ischemic from hemorrhagic stroke and identify potential candidates for thrombolytic therapy. If CT head is normal and no evidence of CNS bleed in present in symptomatic patient it implies Acute ischemia stroke
Labs to draw immediately, in case thrombolytic therapy or intervention may be required, include CBC, Random blood sugar, coagulogram, cardiac biomarkers and KFT
CTA is done after fibrinolysis to determine opening of large vessel occlusion

Investigations

Common Stroke Symptoms by Vessel Territory

VESSEL TERRITORY	Characteristic features
Middle cerebral artery	Patient looks towards the side of lesion Contralateral paresis and sensory loss in the face and arm Homonymous hemianopsia Global Aphasia for dominant lobe lesion Neglect and constructional apraxia for non-dominant lobe lesion
Anterior cerebral artery	Contralateral paresis and sensory loss in the leg Aggressive behavior with personality changes Abulia Urinary incontinence
Posterior cerebral artery	P1 PCA: Weber syndrome I/L 3^rd nerve palsy with contralateral hemiparesis P1 PCA: Nothnagel syndrome I/L 3^rd nerve palsy with contralateral limb ataxia
Lacunar	Pure motor paralysis due to damage to posterior limb of internal capsule Pure sensory stroke Ataxic hemiparesis, dysarthria, or clumsy hand Strokes affecting the thalamus may cause thalamic pain syndrome several weeks after the event, patient complaints of burning pain over hand, arm, leg on even touch
Transient ischemic attack	Any 1 of the symptoms above depending on location of vascular lesion and 1. Neurologic deficit lasts < 24 hours (most last < 1 hour) 2. DW MRI will be normal
Wallenberg syndrome due to vertebral artery involvement	Loss of pain and temperature sensation on ipsilateral face and contralateral body Ipsilateral bulbar weakness Ipsilateral Horner syndrome Vertigo Nystagmus
Carotid artery dissection	Sudden headache, neck pain, Horner syndrome

Treatment of acute ischemic stroke

< 6 hours

6 -24 hours

Fibrinolysis but BP should be less than < 185/110 mm Hg

If BP remains more than the cut off mentioned then Schedule thrombectomy

Thrombectomy after conventional cerebral angiography

Ideal window period for acute ischemic stroke is 4.5 hours but can be done up to 6 hours

Treat fever and hyperglycemia as both are associated with poorer prog- noses in the setting of acute stroke.
Monitor for signs and symptoms of brain swelling, raised intracranial pressure and herniation. Treat acutely with mannitol and
Prevent and treat poststroke complications, such as aspiration pneumonia, urinary tract infection (UTI), and deep vein thrombosis (DVT).

Contraindications to fibrinolysis

Stroke or head trauma within the last 3 months

Anticoagulation with INR > 1.7

MI in past 3 months

Prior intracranial hemorrhage

Elevated BP: Systolic > 185 mm Hg or diastolic 110 mm Hg

Major Surgery in the past 14 days

On discharge the following measures are to be introduced –

Hypertension treatment with target BP of < 130/80 mm Hg
Keep HbA1c < 7%
Statins
Acetylsalicylic acid and ticagrelor (dual antiplatelet therapy)
For cardioembolic strokes due to atrial fibrillation, target INR is 2-3.
In Cases in India involving a prosthetic valve deployed for calcified mitral valve, the target INR is 2.5-3.5.
Carotid endarterectomy: If stenosis is > 60% in symptomatic patients or >70% in asymptomatic patients (contraindicated in complete occlusion)

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