Acute Stroke: Evaluation and Workup

by Carlo Raj, MD

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    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, giving you your hemodynamic status.

    00:42 Electrolytes, toxicology.

    00:43 And you always want to make sure is your patient on some type of drug such as heroine, cocaine? Pregnancy test, troponins.

    00:51 These all then gives you perhaps where the acute stroke is coming from.

    00:56 ECG is always important as I said.

    00:59 The heart could be very much involved in developing a stroke.

    01:03 On a head CT, what are you looking for? Well, maybe look for hemorrhage.

    01:07 And here once again, you try not to use contrast if you already know that there’s a possibility of increased intracranial pressure.

    01:14 Then you don’t want to use contrast, please.

    01:16 MRI, I’ll talk to you about this in a second.

    01:20 Clues about the ischemia.

    01:21 You want to take a pretty good history from either the spouse, the friend or whatever, or if the patient is able to tell you, you know, what were the predisposing factors taking place, what’s the history of your patient that becomes important.

    01:35 Edema.

    01:36 Could you find edema with your head CT? And here, with the middle cerebral artery, I’m going to quickly walk you through.

    01:42 What becomes important for you is a little bit of a timeline.

    01:46 And just to be clear with the head CT, if you find minimal involvement of the brain.

    01:52 Let’s say that your patient is having aphasia, okay? 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.

    02:05 And at this point, you find that only part of the brain is affected, then this is called a dot sign for middle cerebral artery.

    02:12 And usually indicates that the issue has taken place very recently, maybe about an hour or so.

    02:18 Then if you allow for – or the patient has come in a little bit later and the stroke within the middle cerebral artery becomes more extensive, then the brain on the CT will then show you hyperdense.

    02:31 And I’m just going to show you that with the middle cerebral artery, keeping in mind that it's always going to be referring to the lateral hemisphere of your brain, okay? Dot, usually early, acute, or within 24 hours.

    02:45 You’re thinking about hyperdense areas and what does hyperdense look like on a CT? Blackish, okay? Darkish.

    02:54 Darkish, hyperdense.

    02:56 And MRI and MRA, which is magnetic resonance imaging or angiography.

    03:02 This will be DW imaging or diffuse-weighted and this gives you a little bit more detail about the tissue.

    03:08 But at this point, it is important that you pay attention to the CT, with a quick little timeline that I’m going to provide for you.

    03:15 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 and just go through the first column here on your own time and ever so often just come back and refer to this.

    03:30 It’s not important that you memorize every single line.

    03:33 That is never going to be asked.

    03:35 But in general, you know, when there’s a loss of consciousness taking place, whether risk factors and so on and so forth, and this then gives you a scale for that type of stroke that that the NIH has provided.

    03:50 Now, what you’ll notice here on the CT is an area of hyperdense.

    03:54 And this to you should mean that within 24 hours or 24 hours has elapsed, and you’ll notice that it is parietal lobe or lateral hemisphere that is affected.

    04:04 And so therefore, it should clue you in that the middle cerebral artery is in fact the culprit.

    04:09 And if it is atherosclerosis that’s setting in here, shall we say, then your patient presents with aphasia or motor type of issues and it’s the – remember, the upper extremities.

    04:21 So you’re thinking about the face and arms and such.

    04:24 And then you know that it’s probably more of the dominant side.

    04:27 Non-dominant side, you should be thinking more or less of what’s known as your hemineglect.

    04:32 It literally means that the other half of anything that you’re able to see or should perceive is not being digested.

    04:42 Amazing! A non-dominant side of the brain that has been affected or hemineglect if you remember that from neuroanatomy.

    04:49 Quickly here, all that I wish to show you upon non-contrast CT, these are non-contrast CT images that I’m giving you only.

    04:58 And you’ll notice here that within one hour, it’s a dot.

    05:02 In other words, you don’t find this extensive, hyperdense area as what you’re seeing here in approximately 24 hours.

    05:11 In 24 hours, you’ll 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.

    05:23 And so therefore the brain is being affected.

    05:26 Hyperdense.

    05:27 And this is approximately 24 hours later.

    05:30 Now, what you also want to keep in mind, as you go through the timeline is, well, how did this occur? What is it atherosclerosis? Also keep in mind that with the MCA, if you’re adjoining or if you're coming to your anterior cerebral artery 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, things that you want to keep in mind.

    05:56 Post acute stroke workup.

    05:57 MRI/MRA.

    05:59 Cholesterol levels, TSH, syphilis, such as RPR.

    06:04 Always keep in mind B12, homocysteine, erythrocyte sedimentation rate.

    06:09 Echocardiogram, as to whether or not the issue was in the heart.

    06:12 Carotid ultrasound.

    06:14 Specialized tests.

    06:15 Remember that you could have some of the issues that are taking place, risk factors such as hypertension, diabetes.

    06:22 We talked about those that more or less would be the risk factors such as tobacco versus genetic.

    06:30 And if it was genetic, such as your CADASIL, an autosomal dominant type of stroke-like issue, leukoencephalopathy, then do a skin biopsy.

    06:40 And this will then help you with diagnosing CADASIL.

    06:44 Or hypercoagulable workup.

    06:45 What do I mean by this? Remember we talked about antiphospholipid syndrome and so therefore, you’re looking for that lupus anticoagulant.

    06:53 You have a female, multiple miscarriages or we talked about protein C deficiency or the factor V Leiden.

    07:00 It is the most common, hereditary, genetic type of hypercoagulable state.

    07:04 Keep all that in mind as you go through your workup so that you know exactly as to how your stroke has developed.

    About the Lecture

    The lecture Acute Stroke: Evaluation and Workup by Carlo Raj, MD is from the course Stroke (Cerebrovascular Accident). It contains the following chapters:

    • Acute Stroke Evaluation and Workup
    • NIH Stroke Scale
    • Post-Acute Stroke Workup

    Included Quiz Questions

    1. D-Dimer
    2. EKG
    3. PT/APTT
    4. Head CT
    5. NIH stroke scale
    1. Contrast CT
    2. Non contrast CT
    3. Non contrast MRI
    4. EKG
    5. PT/PTT values
    1. Middle cerebral artery hyperdense sign
    2. Hypodense sign
    3. Bruzdenski's sign
    4. Kernigs sign
    5. Middle cerebral artery dot sign
    1. 1 hour
    2. 24 hours
    3. 6 hours
    4. 12 hours
    5. 48 hours

    Author of lecture Acute Stroke: Evaluation and Workup

     Carlo Raj, MD

    Carlo Raj, MD

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