Now, acute stroke evaluation and workup.
How are you going to work up your patient
as you go through and you suspect stroke?
ABCs, we’ll talk about these.
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.
Do not spend time memorizing every
single line of that particular scale.
Don’t worry, I’ll walk you through that.
Other workups that you
want to keep in mind,
glucose, CBC, PT/PTT, giving
you your hemodynamic status.
And you always want to
make sure is your patient
on some type of drug such
as heroine, cocaine?
Pregnancy test, troponins.
These all then gives you perhaps where
the acute stroke is coming from.
ECG is always
important as I said.
The heart could be very much
involved in developing a stroke.
On a head CT, what
are you looking for?
Well, maybe look for hemorrhage.
And 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.
I’ll talk to you about
this in a second.
Clues about the ischemia.
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.
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.
And just to be clear with the head CT, if
you find minimal involvement of the brain.
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.
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.
And usually indicates that the issue
has taken place very recently,
maybe about an hour or so.
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.
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?
usually early, acute,
or within 24 hours.
You’re thinking about hyperdense areas and
what does hyperdense look like on a CT?
And MRI and MRA, which is magnetic
resonance imaging or angiography.
This will be DW imaging
and this gives you a little bit
more detail about the tissue.
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.
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.
It’s not important that you
memorize every single line.
That is never going to be asked.
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.
Now, what you’ll notice here on
the CT is an area of hyperdense.
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.
And so therefore, it should clue you in
that the middle cerebral
artery is in fact the culprit.
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.
So you’re thinking about the
face and arms and such.
And then you know that it’s
probably more of the dominant side.
you should be thinking more or less
of what’s known as your hemineglect.
It literally means that the other half
of anything that you’re able to see
or should perceive is
not being digested.
A non-dominant side of the brain that
has been affected or hemineglect
if you remember that
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.
And you’ll notice here that
within one hour, it’s a dot.
In other words, you don’t find
this extensive, hyperdense area
as what you’re seeing here
in approximately 24 hours.
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
type of ischemic stroke.
And so therefore the
brain is being affected.
And this is approximately 24 hours later.
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.
Post acute stroke workup.
Cholesterol levels, TSH,
syphilis, such as RPR.
Always keep in mind B12, homocysteine,
erythrocyte sedimentation rate.
Echocardiogram, as to whether or
not the issue was in the heart.
Remember that you could have some of
the issues that are taking place,
risk factors such as
We talked about those that more
or less would be the risk factors
such as tobacco versus genetic.
And if it was genetic,
such as your CADASIL,
an autosomal dominant type of
stroke-like issue, leukoencephalopathy,
then do a skin biopsy.
And this will then help you
with diagnosing CADASIL.
Or hypercoagulable workup.
What do I mean by this?
Remember we talked about
and so therefore, you’re looking
for that lupus anticoagulant.
You have a female, multiple miscarriages
or we talked about protein C
deficiency or the factor V Leiden.
It is the most common, hereditary,
genetic type of hypercoagulable state.
Keep all that in mind as
you go through your workup
so that you know exactly as to
how your stroke has developed.