Template:Stroke workup - Revision history

ClaireLewis at 01:13, 2 October 2019

2019-10-02T01:13:20Z

← Older revision		Revision as of 01:13, 2 October 2019
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	***Determine if there is carotid stenosis that warrants endarterectomy urgently		***Determine if there is carotid stenosis that warrants endarterectomy urgently
	**Pregnancy test		**Pregnancy test
	**CXR (if infection suspected)		**[[CXR]] (if infection suspected)
	**UA (if infection suspected)		**[[UA]] (if infection suspected)
	**Utox (if ingestion suspected)		**[[Utox]] (if ingestion suspected)

	{{MR studies CVA/TIA}}		{{MR studies CVA/TIA}}

Kxl328: /* Stroke Work-Up */

2019-02-19T06:23:26Z

Stroke Work-Up

← Older revision		Revision as of 06:23, 19 February 2019
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	**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.</ref>		**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.</ref>
	*Also consider:		*Also consider:
	**CTA brain and neck ~~(to~~ check for large vessel occlusion for potential thrombectomy)		**CTA brain and neck
			***To check for large vessel occlusion for potential thrombectomy
			***Determine if there is carotid stenosis that warrants endarterectomy urgently
	**Pregnancy test		**Pregnancy test
	**CXR (if infection suspected)		**CXR (if infection suspected)

Kxl328: /* Large Vessel Occlusion - Thrombectomy */

2019-02-19T06:07:30Z

Large Vessel Occlusion - Thrombectomy

← Older revision		Revision as of 06:07, 19 February 2019
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	{{MR studies CVA/TIA}}		{{MR studies CVA/TIA}}

	~~===Large Vessel Occlusion - Thrombectomy===~~
	*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
	*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours<ref>Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.</ref>
	*If CT perfusion unavailable, use ASPECT score<ref>Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670-4.</ref>
	~~====VAN Score====~~
	*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>
	*VAN score is just as sensitive, but also may be more specific (~90%)
	**Weakness must be present, plus one or all of the VAN to be VAN positive
	***Weakness qualifying findings -- if no weakness, the pt is VAN negative
	****Mild (minor drift)
	****Moderate (severe drift—touches or nearly touches ground)
	****Severe (flaccid or no antigravity)
	***Visual disturbance qualifying findings
	****Field cut (which side) (4 quadrants)
	****Double vision (ask patient to look to right then left; evaluate for uneven eyes)
	****Blind new onset
	***Aphasia qualifying findings
	****Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
	****Receptive (not understanding or following commands) (close eyes, make fist)
	****Mixed
	***Neglect qualifying findings
	****Forced gaze or inability to track to one side
	****Unable to feel both sides at the same time, or unable to identify own arm
	****Ignoring one side
	**If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA

Kxl328: /* Large Vessel Occlusion -- Thrombectomy */

2019-02-19T05:57:26Z

Large Vessel Occlusion -- Thrombectomy

← Older revision		Revision as of 05:57, 19 February 2019
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	{{MR studies CVA/TIA}}		{{MR studies CVA/TIA}}

	===Large Vessel Occlusion -- Thrombectomy===		===Large Vessel Occlusion - Thrombectomy===
	*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy		*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
	*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours<ref>Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.</ref>		*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours<ref>Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.</ref>

Kxl328: /* Large Vessel Occlusion */

2019-02-19T05:57:08Z

Large Vessel Occlusion

← Older revision		Revision as of 05:57, 19 February 2019
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	{{MR studies CVA/TIA}}		{{MR studies CVA/TIA}}

	===Large Vessel Occlusion===		===Large Vessel Occlusion -- Thrombectomy===
	*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours		*"Cortical strokes" of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
			*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours<ref>Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718.</ref>
			*If CT perfusion unavailable, use ASPECT score<ref>Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670-4.</ref>
			====VAN Score====
	*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>		*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>
	*VAN score is just as sensitive, but also may be more specific (~90%)		*VAN score is just as sensitive, but also may be more specific (~90%)

Kxl328: /* Large Vessel Occlusion */

2019-02-19T05:52:42Z

Large Vessel Occlusion

← Older revision		Revision as of 05:52, 19 February 2019
Line 23:		Line 23:

	===Large Vessel Occlusion===		===Large Vessel Occlusion===
			*CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours
	*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>		*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>
	*VAN score is just as sensitive, but also may be more specific (~90%)		*VAN score is just as sensitive, but also may be more specific (~90%)

Kxl328: /* Stroke Work-Up */

2019-02-19T05:41:23Z

Stroke Work-Up

← Older revision		Revision as of 05:41, 19 February 2019
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	{{MR studies CVA/TIA}}		{{MR studies CVA/TIA}}

			===Large Vessel Occlusion===
			*NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy<ref>Teleb MS, Ver Hage A, Carter J, et al Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices Journal of NeuroInterventional Surgery 2017;9:122-126.</ref>
			*VAN score is just as sensitive, but also may be more specific (~90%)
			**Weakness must be present, plus one or all of the VAN to be VAN positive
			***Weakness qualifying findings -- if no weakness, the pt is VAN negative
			****Mild (minor drift)
			****Moderate (severe drift—touches or nearly touches ground)
			****Severe (flaccid or no antigravity)
			***Visual disturbance qualifying findings
			****Field cut (which side) (4 quadrants)
			****Double vision (ask patient to look to right then left; evaluate for uneven eyes)
			****Blind new onset
			***Aphasia qualifying findings
			****Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
			****Receptive (not understanding or following commands) (close eyes, make fist)
			****Mixed
			***Neglect qualifying findings
			****Forced gaze or inability to track to one side
			****Unable to feel both sides at the same time, or unable to identify own arm
			****Ignoring one side
			**If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA

TJYE: /* Stroke Work-Up */

2017-04-14T02:08:07Z

Stroke Work-Up

← Older revision		Revision as of 02:08, 14 April 2017
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	**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.</ref>		**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.</ref>
	*Also consider:		*Also consider:
			**CTA brain and neck (to check for large vessel occlusion for potential thrombectomy)
	**Pregnancy test		**Pregnancy test
	**CXR (if infection suspected)		**CXR (if infection suspected)

Rossdonaldson1: /* Stroke Work-Up */

2017-02-18T18:19:00Z

Stroke Work-Up

← Older revision		Revision as of 18:19, 18 February 2017
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	**In acute ICH the sensitivity is 95-100%<ref>Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.</ref>		**In acute ICH the sensitivity is 95-100%<ref>Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.</ref>
	**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.</ref>		**The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)<ref>Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.</ref>
	*[[MRI Brain]] DWI and cervical vascular imaging predict short-term risk for stroke in patients presenting with suspected TIA<ref name="ACEP">ACEP Clinical Policy: Suspected Transient Ischemic Attack[https://www.acep.org/Physician-Resources/Policies/Clinical-policies/Clinical-Policy-Suspected-Transient-Ischemic-Attack/ full text]</ref>. When feasible, physicians should obtain:
	**MRI with DWI/MRA in patients with high short-term risk for stroke (ACEP Level B)
	**Carotid US/CTA/MRA in patients with high short-term risk for stroke (ACEP Level B)
	***Carotid US is slightly less sensitive than MRA, but useful for carotid stenosis eval<ref>Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.</ref> (ACEP Level C)
	*Also consider:		*Also consider:
	**Pregnancy test		**Pregnancy test
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	**UA (if infection suspected)		**UA (if infection suspected)
	**Utox (if ingestion suspected)		**Utox (if ingestion suspected)

			{{MR studies CVA/TIA}}

Alvarez13 at 05:13, 2 September 2016

2016-09-02T05:13:14Z

← Older revision		Revision as of 05:13, 2 September 2016
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	**T&S		**T&S
	*[[ECG]]		*[[ECG]]
			**In large ICH or stroke, may see deep TWI and prolong QT, occ ST changes
	*[[Head CT]] (non-contrast)		*[[Head CT]] (non-contrast)
	**In ischemia stroke CT has sensitivity 42%, specificity 91%<ref>Mullins ME, Schaefer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology. 2002 Aug;224(2):353-60.</ref>		**In ischemia stroke CT has sensitivity 42%, specificity 91%<ref>Mullins ME, Schaefer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology. 2002 Aug;224(2):353-60.</ref>