Suspected Acute Ischemic Stroke/TIA Please view our disclaimer. Reviewed: Aneesh Singhal, M.D. on 12/26/07
DAY 1: The first 24 hrs Initial Management • •
• •
History and Physical Blood tests (CBC, Plt, ESR, PT, PTT, Glucose, Chem-7, CPK, LFT, Optional Hypercoagulation Panel) ECG and Chest X-ray CT or MRI brain; consider CTA/MRA or carotid ultrasound TCD to evaluate large cerebral vessel patency
Presumed Pathophysiological Dx If < 12hrs from symptom onset, page Acute Stroke Team beeper #34282
Stroke Mimic
Hemorrhagic
Tumor Ischemic Stroke Migraine Seizures Demyelination
Brain Imaging
Acute Ischemic Stroke
(ALL STROKES < 12 hrs after symptom onset) Consider CT and/or MRI • If < 3 hrs and no CT exclusion, consider iv t-PA with contrast agent • If < 6 hrs in carotid territory or < 12 hrs in Consider EEG, basilar territory, no CT exclusion, and CTA LP, Toxicology evidence of large vessel occlusion, consider IA Screen thrombolysis
SAH ICH TBI
Brain Imaging CTA, MRI/A, Angiography Consider admission to NeuroCritical Care Unit
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Strokes up to 36 hrs after onset may be eligible for neuroprotective trials
Confirm the presumed pathophysiologic diagnosis with the following tests/procedures •
• • •
Evaluate cerebrovascular pathology with Carotid Ultrasound, TCD, CTA, Perfusion MR/MRA of Conventional Transfemoral Angiography consider cardiac echo (see Cardiac echo utilization for stroke/TIA) Consider IV Heparin in non-lacunar or noninfectious stroke Consider admission to Stroke Unit
Stroke Type
ThromboEmbolic Large Vessel
Source
Emboli from Left Heart, Great Vessels, Paradoxical, or Cryptogenic
Mechanisms
Embolism
Atherosclerosis of Internal Carotid, Middle Cerebral or Vertebrobasilar Arteries
Lacunar
Other Mechanism
Lipohyalinosis of Lenticulostriate, Brainstem, Variable Cerebellar or locations Thalamogeniculate Arteries Dissection Vasculitis, Complicated migraine, Low flow or Cerebral venous Artery-to-artery Thrombosis in situ sinus Embolism thrombosis, Infection, Mitochondrial, Genetic