00:01
Now, acute stroke evaluation and workup.
00:04
How are you going to work up your patient
as you go through and you suspect stroke?
ABCs, we’ll talk about these.
00:12
And in the NIH, they have
laid out a stroke scale
and there’s a particular chart and table
that I’m giving you with that scale,
just have a general overlook and you’ll see
what I’m referring to when I get to it.
00:26
Do not spend time memorizing every
single line of that particular scale.
00:31
Don’t worry, I’ll walk you through that.
00:33
Others.
00:34
Other workups that you
want to keep in mind,
glucose, CBC, PT/PTT.
00:39
On the head CT,
what are you looking for?
Well, maybe look for hemorrhage.
00:43
And we're here, once again,
you try not to use contrast,
if you already know
that there's a possibility
of increased intracranial pressure,
then you don't want
to use contrast, please.
00:52
MRI, I'll talk
about this in a second.
00:55
Clues about the ischema.
00:57
A good example would be the middle cerebral artery dot sign,
Edema, could you find edema
with your head CT?
And here with the
middle cerebral artery,
I'm going to
quickly walk you through
what becomes important for you
is a little bit of a timeline.
01:13
And just to be clear,
with the head CT,
if you find minimal
involvement of the brain,
let's say that your patient
has having aphasia, okay.
01:22
And you're suspecting
that the middle cerebral artery
is the issue
and your patient has a history
of hyperlipidemia diabetes,
so on and so forth.
01:32
The MCA consists of
different segments.
01:35
More inferior,
the M2 segment of the MCA
can be viewed longitudinally
in a single axial slice
on a CT scan.
01:44
If the thromboembolus takes
place in that segment,
then hyperdense MCA will be seen.
01:51
If the occlusion occurs on a
more superior segment of the MCA,
the part that goes to the insula,
then you will see the dot sign.
01:59
This happens because
now you are seeing
a cross sectional section
of the MCA segment
that is perpendicular to the
axial orientation of the CT slices.
02:10
Both signs are seen in the first
90 minutes post stroke.
02:15
Both of them appear
as hyperdense and white.
02:19
Rush, ischemic stroke treatment.
02:24
Now, here, this is important,
time to tPA administration,
less than 4.5 hours from
the onset of the symptoms.
02:34
So this is where
your imaging studies
are going to become
incredibly crucial.
02:39
Granted, in current day practice,
there are many, many advancements
in imaging and such.
02:45
But at this point,
something that I walked you through
is the noncontrast CT.
02:50
And where for example,
I gave you middle cerebral artery
type of stroke,
and what it means for one hour.
02:57
So really pay attention to
4.5 hours, please, with TPA.
03:03
An MRI and MRA,
which is Magnetic Resonance
Imaging, or angiography.
03:08
This would be DW-Imaging
or diffuse weighted.
03:11
And this gives you a little bit
more detail about the tissue.
03:14
But at this point, it is important
that you pay attention to the CT
with the quick little timeline that
I'm going to provide for you.
03:22
So as I was saying earlier,
with the NIH stroke scale,
I want to give you this table
so that you have it
readily available.
03:30
And just go through the first
column here on your own time,
and ever so often
just come back and refer to this,
it's not important that you
memorize every single line
that is never going to be asked.
03:41
But in general,
you know, when is the
loss of consciousness taking place?
What are the risk factors,
and so on and so forth?
And this then gives you a scale
for that type of stroke
that the NIH has provided.
03:56
Now, what you'll notice here on
the CT is an area of hyperdense.
04:00
And you'll notice that it is the
parietal lobe or lateral hemisphere
that is affected.
04:05
And so therefore,
it should clue you in
that the middle cerebral artery
is in fact the culprit.
04:10
And if it is atherosclerosis,
that setting in here, shall we say,
then a patient presents with
aphasia, or motor type of issues.
04:19
And it's the,
remember the upper extremities
so you're thinking about
the face, and arms, and such,
then you know that it
probably more of the dominant side.
04:28
Non-dominant side,
you should be thinking more like
more or less of what's known
as your hemineglect.
04:33
Quickly here, all that I wish
to show you upon, noncontrast CT.
04:39
These are noncontrast CT images
that I'm giving you only.
04:42
The MCA dot sign, seen here in the Sylvian fissure, is the cross-sectional equivalent of the hyperdense MCA sign.
04:50
In 24 hours,
you will notice please
on the lateral hemisphere
of the brain,
that there is a large area
in which
it has undergone
your atherosclerotic
type of ischemic stroke.
05:02
And so, therefore, the brain
is being affected, is hypodense,
and this is approximate
24 hours later.
05:09
Now, what you also
want to keep in mind
as you go through the timeline
is, well, how did this occur?
Was it atherosclerosis?
Also keep in mind
that with MCA,
if you're adjoining or if you're
coming to your entry supraartery,
and you have a tissue in
which both the blood vessels
are supplying
that part of the brain,
this is then referring
to your watershed area.
05:32
Things that you want
to keep in mind.
05:35
Post-Acute Stroke Workup.
05:36
MRI/MRA, cholesterol levels,
TSH, syphilis, such as RPR.
05:43
Always keep in mind
B12, homocysteine
or erythrocyte
sedimentation rate.
05:48
Echocardiogram as to whether or not
the issue was in the heart,
carotid ultrasound.
05:53
Specialized tests,
remember, that you could have
some of the issues
that are taking place
risk factors such as
hypertension, diabetes.
06:01
We talked about those
that more or less would be
the risk factors such as
tobacco versus genetic.
06:09
And if it was genetic,
such as your CADASIL,
an autosomal dominant
type of stroke like issue
leukoencephalopathy,
then do a skin biopsy.
06:18
And this will then help you
with diagnosing CADASIL,
or hypercoagulable workup.
06:24
What do we mean by this?
Remember, we talked about
antiphospholipid syndrome,
and so therefore, you're looking
for that lupus anticoagulant.
06:32
You have female,
multiple miscarriages.
06:34
Or we talked about
potency deficiency
or Factor V Leiden,
a very, very, it is the most common
hereditary genetic type
of hypercoagulable state.
06:43
Keep all that in mind
as you go through workup
so that you know exactly
as to how your stroke is developed.