Acute Stroke Management
A 72-year-old woman with a history of uncontrolled hypertension presents to the emergency room with a severe headache, blurry vision, and slurred speech. Initial blood pressure is 238/109 mm Hg. Emergent head CT shows a cerebellar vermal hemorrhage measuring 4 cm with significant compression of the brain stem and encroachment of the fourth ventricle. Coagulopathy studies and platelets are normal. The patient is not taking any antithrombotic therapies. Shortly thereafter she becomes obtunded requiring intubation. What should we do next?
Emergent posterior decompressive craniotomy
Urgent surgical evacuation with or without external ventricular drainage (EVD) is recommended to reduce mortality in patients with cerebellar ICH who have brain stem compression and/or hydrocephalus from ventricular obstruction, are deteriorating neurologically, or have a cerebellar ICH volume ≥15 mL. Limiting blood pressure variability and sustained blood pressure control appear to reduce hematoma expansion and yield better functional outcomes. Therapeutic hypothermia has not been proven effective in intraparenchymal hemorrhage. Platelet transfusion would not be indicated in someone with normal platelet levels, and evidence for empiric platelet transfusion is not supported even in patients on antiplatelet therapy. Hyperosmotic therapy may temporarily manage cerebral edema, but a more definitive intervention is needed.
A 38-year-old man with a history of a cervical spine injury secondary to a car accident with resultant spastic quadriplegia and autonomic instability is admitted to the hospital with a severe headache. His systolic blood pressure fluctuates between 120 and 210 mm Hg as a result of the autonomic instability. On hospital day 2, he began complaining of blurred vision and subsequently had a generalized tonic-clonic seizure. An MRI of the brain is obtained and demonstrated hyperintensity of the bilateral occipital lobes on the fluid-attenuated inversion recovery (FLAIR) sequence. The most likely diagnosis is: A. Bilateral posterior cerebral artery strokes B. Basilar artery occlusion C. Posterior reversible encephalopathy syndrome D. Occipital subdural hematomas E. Thrombosis of the vein of Labbe
C. Posterior reversible encephalopathy syndrome
Explanation:
The clinical symptoms of headaches, blurred vision, and seizures in the setting of severe hypertension are common in posterior reversible encephalopathic syndrome (PRES) or reversible posterior leukoencephalopathy syndrome. Characteristic MRI findings are consistent with focal regions of confluent symmetric hemispheric vasogenic edema most commonly in the occipital and parietal lobes. The cause remains poorly understood. Other conditions commonly associated with PRES include eclampsia, renal failure, sepsis, autoimmune disorders, transplantation, and immunosuppressive therapies. Thrombosis of the vein of Labbe often results in temporal lobe hemorrhage or infarction and is classically associated with headache and seizures. The fulminant, confluent, T2 hyperintense pattern on the MRI brain is inconsistent with an ischemic stroke. Subdural hematomas are extra-axial.
A 59-year-old African American man with a history of hypertension presents to the emergency room with acute onset of headache, nausea, vomiting, right-sided weakness, and numbness. Initial blood pressure is 201/103 mm Hg. Initial Glasgow coma scale is 14. Emergent CT of the head shows a left thalamic intraparenchymal hemorrhage with intraventricular extension and no hydrocephalus. The calculated volume of the hematoma is 8 mL (based on the ABC/2 formula). Based on the data provided, what is his ICH score?
1
Explanation:
The ICH score is a clinical grading scale and can be useful in estimating 30-day mortality. The scale ranges from 0 to 6 with 6 being associated with the highest mortality. One point is assigned for each: age >80 years old, ICH volume >30 mL, associated intraventricular hemorrhage, and infratentorial location. One point is given for a Glasgow coma scale (GCS) of 5 to 12 and two points are given for a GCS of 3 to 4. For this patient:
GCS = 14 (0 points)
ICH volume = 8 mL (0 points, since it's <30 mL)
Intraventricular hemorrhage = Yes (1 point)
Infratentorial origin = No (0 points)
Age = 59 (0 points, since it's <80 years old) Therefore, the total ICH score is 1.
A 62-year-old man with a history of atrial fibrillation presents to the emergency department with acute-onset right-sided weakness and inability to speak. His symptoms started 45 minutes prior to arrival. Initial blood pressure is 172/82 mm Hg. Neurologic examination is notable for moderate expressive aphasia, right face and arm greater than leg weakness, right visual field deficit, and left gaze preference. Emergent head CT shows no evidence of bleeding. NIHSS (National Institutes of Health Stroke Scale) is 8. He has no prior bleeding events. Which of the following is associated with improved functional outcomes? A. Aspirin B. CT angiogram C. Intravenous alteplase D. Intravenous heparin infusion E. Warfarin
C. Intravenous alteplase This is a classic presentation of a stroke affecting the left middle cerebral artery (left middle cerebral artery syndrome). There is no evidence of hemorrhage on the CT head and the NIHSS of 8 entails a moderate stroke burden. The patient is within the therapeutic window for systemic alteplase and should be treated with thrombolytics. This decision is supported by the NINDS trial, a randomized control trial comparing intravenous alteplase versus placebo. It showed that patients treated with intravenous alteplase within 3 hours of symptoms onset were 30% more likely to achieve minor or no disability on disability scales at 90 days compared to placebo. In 2008, the ECASS trial, another large randomized controlled trial, demonstrated improved functional outcomes in patients treated with intravenous tPA up to 4.5 hours of symptom onset with additional relative exclusion criteria of age <80 years old, lack of prior stroke and diabetes, and use of any anticoagulation. The routine use of therapeutic anticoagulation is not recommended in acute strokes and should be reserved for select cases. Warfarin would be a reasonable antithrombotic for secondary stroke prevention in the setting of atrial fibrillation but not in the acute setting. Early administration of aspirin in ischemic stroke has been associated with reduction in recurrent stroke but is not associated with specifically improved functional outcomes. CT angiogram would be useful to screen for endovascular therapy cases which could improve acute stroke patients' outcome in selected cases, but the CT angiogram alone does not improve functional outcomes
A 39-year-old woman with a history of systemic lupus erythematosus presents with new-onset psychosis. She is admitted to the medicine floor and shortly thereafter she was found to be minimally reactive, unable to move the left side more so than the right side of the body. She continues to worsen requiring intubation due to an inability to protect her airway. An emergent brain MRI shows multiple areas of subcortical ischemic stroke affecting the bilateral hemisphere with more predominant right-sided involvement. She is noted to have non-blanching, deep bluish-red reticular skin lesions on the legs and body. Blood work showed ESR 93, CRP 189, C3 and C4 less than 5, and ANA >1000. Which of the following antibodies is most commonly associated with this condition? A. Anti-RNP B. Anti-Ro and Anti-La C. Anti-Scl70 D. Antiphospholipid antibodies panel E. Anti-gliadin
D. Antiphospholipid antibodies panel
Explanation:
This is a case of Sneddon syndrome which is a rare noninflammatory thrombotic vasculopathy characterized by the combination of ischemic strokes with livedo racemosa. Livedo racemosa is defined as a dusky erythematous-to-violaceous, irregular, net-like pattern in the skin. Livedo racemosa may precede the onset of stroke by years and is located on limbs, trunk, buttocks, face, or the hands or feet. The cerebrovascular disease mostly occurs due to ischemia (transient ischemic attacks and cerebral infarct). The etiology is unknown, but it can be either primary idiopathic or associated with primary autoimmune disorders including systemic lupus erythematosus. Up to 78% of patients with Sneddon syndrome test positive for antiphospholipid antibodies. Anti-RNP antibodies are associated with mixed connective tissue disorders and SLE. Anti-Ro and La antibodies are associated with various autoimmune conditions, particularly Sjogren disease and SLE. Anti-Scl70 antibodies are commonly associated with diffuse scleroderma. Anti-gliadin antibodies are associated with celiac disease.
A 43-year-old man with a history of hypertension and atrial fibrillation was found in his apartment with left-sided weakness, rightward eye deviation, and severely slurred speech. He was last seen normal the day prior while leaving work. Initial blood pressure is 167/93 mm Hg. A CT of the head shows hypoattenuation involving the entire right middle cerebral artery territory with associated cerebral edema, mass effect, and resultant 9-mm midline shift. Which of the following therapeutic interventions has been proven to improve functional outcomes and reduce mortality in the current acute settings?
A. HMG-CoA reductase inhibitors B. Hyperosmolar therapy C. Decompressive hemicraniectomy D. Intravenous alteplase E. Intravenous heparin drip
C. Decompressive hemicraniectomy
Explanation:
The patient has suffered a malignant right middle cerebral artery stroke with subsequent ischemic cerebral edema and mass effect putting him in danger of transtentorial herniation and resultant death. Multiple randomized controlled trials (DESTINY, HAMLET, DECIMAL) show up to a 50% reduction in mortality when decompressive hemicraniectomy is performed within the first 48 hours compared to maximum medical therapy. Hyperosmolar therapy has not been proven to improve clinical outcomes.
A 42-year-old male with a history of hypertension presents to the emergency room after a focal seizure witnessed by his significant other at home. On further history taking, he notes that he has had episodes of hemiparesis, speech difficulties, and recurrent migraines in the past that resolved on their own. MRI brain revealed high signal on diffusion-weighted (DWI) MRI in the left parietal, right frontal, and left occipital lobe with decreased apparent diffusion coefficient (ADC). MR spectroscopy revealed a lactate peak and a decreased N-acetyl aspartate peak in the lesion areas. Which of the following treatments has shown promise in improving clinical symptoms associated with this entity? A. Arginine B. Sodium valproate C. Chloramphenicol D. Metformin E. Barbiturates
A. Arginine
Explanation:
The patient likely has MELAS (mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes). Arginine is a nitric oxide precursor and leads to increased blood flow and cerebral vasodilation. Administration of intravenous arginine has been shown to improve symptoms during stroke-like episodes. The severity and frequency of stroke-like episodes have also been suggested to decrease with oral arginine. Both the cerebral cortex and subcortex can be affected in MELAS. There is a predilection to the posterior brain with the most common lesions involving the parietal and occipital lobes. Deep structures such as the thalamus can also be affected. Patients typically present with multiple, asymmetric lesions. These lesions are characterized by high signal on DWI, but ADC values can vary significantly. It is recommended to avoid medications such as sodium valproate, chloramphenicol, barbiturates, and metformin as they interfere with the respiratory chain function.
A 62-year-old man is brought to the emergency department via ambulance with speech difficulties and right-sided weakness. His last known normal was 2 hours prior to presentation. His NIHSS was 14 and notable for aphasia, left gaze deviation, and right hemiplegia. A CT of the head is negative for hemorrhage. Blood pressure is 162/84 mm Hg. He is not on any antithrombotics. Intravenous alteplase is administered. A CTA of the head and neck was performed and showed a left M1 middle cerebral artery occlusion. What is the next best step in management?
Mechanical thrombectomy The patient has a left middle cerebral artery syndrome with evidence of a left M1 middle cerebral artery occlusion. Multiple randomized control trials support mechanical thrombectomy in patients with a large vessel occlusion. The AHA/ASA currently recommends considering patients for intervention who can undergo recanalization within 24 hours from symptom onset. Obtaining either CT or DW-MRI perfusion imaging is recommended when selecting patients with anterior circulation large vessel occlusions presenting between 6 and 24 hours of last known normal if they meet other eligibility criteria from one of the trials that have shown benefit from thrombectomy in this extended time window.
A 54-year-old woman with no medical history presents to the emergency department with acute-onset right-sided weakness which started 1 hour prior to arrival. Initial vitals are as follows: temperature 39.2∘C, blood pressure 172/98, heart rate 92, respiratory rate 12, 100% O2 saturations on room air. NIHSS is 6 for right-sided motor deficits. A CT head is negative for hemorrhage. Basic labs show a white blood cell of 12, hemoglobin of 7.2 g/dL, platelets 11, sodium 140, potassium 4.3, creatinine 3.1, and glucose 123. What is the most appropriate acute treatment? A. Administer intravenous alteplase B. Start intravenous fluids C. Plasma exchange transfusion D. Give 2 units of platelets E. Start a nicardipine drip
C. Plasma exchange transfusion
Explanation:
The patient is presenting with thrombocytopenic thrombotic purpura (TTP). The classic pentad consists of thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal failure, and fever but cases have been reported with isolated stroke as the presenting feature. ADAMTS13 activity can be measured and is reduced in TTP. The treatment for TTP is plasma exchange transfusion. Intravenous alteplase should not be administered because of the thrombocytopenia and high risk of bleeding. Platelet transfusion can potentially mediate pathologic thrombogenesis and should be avoided in most cases of TTP. Neither nicardipine nor intravenous fluids are immediately indicated in this case.
A 63-year-old woman with diabetes, hypertension, and smoking presents to the emergency department with right arm and leg weakness. Her symptoms started 2 days prior when she woke up. Her initial NIHSS is 3. An MRI of the brain was obtained, and it showed a small infarct in the left corona radiata. A CTA of the head and neck was obtained and showed a critically stenosed left internal carotid artery with an ulcerated heterogeneous plaque. Which treatment would be most appropriate for this patient? A. Start clopidogrel in addition to aspirin therapy (dual antiplatelet therapy) B. Start a heparin drip C. Proceed with a carotid endarterectomy D. Liberalize long-term blood pressure goals to >160/>100 E. Proceed with an extracranial-intracranial bypass surgery
C. Proceed with a carotid endarterectomy
Explanation:
The patient has a critically stenosed left ICA with an ulcerated heterogeneous plaque. She is an ideal candidate for carotid endarterectomy to prevent recurrent stroke based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST). The rationale of liberalizing blood pressure to prevent hypoperfusion-related stroke in the setting of carotid disease has never been proven to be an effective long-term treatment to reduce the risk of recurrent stroke. Extracranial-intracranial bypass has never been proven effective in preventing future stroke in carotid disease even in the setting of complete carotid occlusion and confirmed hemodynamic cerebral ischemia.
A 52-year-old patient with a history of recent dental surgery is brought in by EMS with acute onset right-sided weakness and confusion. General examination is notable for a fever, a prominent cardiac murmur, and multiple linear hemorrhages underneath his nail beds. Based on the most likely diagnosis what is the most appropriate treatment? A. Intravenous alteplase B. Aspirin C. Antibiotics D. Levetiracetam E. Intravenous immunoglobulin therapy
The patient in this vignette has infectious endocarditis. The majority of cases (80%) are caused by Streptococci and staphylococci, and initiation of antibiotics would be the most appropriate treatment. Common clinical findings included fever (80%), new murmur (48%), hematuria (25%), splenomegaly (11%), splinter hemorrhages (8%), Janeway lesions (5%), and Roth spots (5%). A randomized control trial studying aspirin 325 mg daily in patients with endocarditis showed no significant decrease in embolic events and there was a trend toward increased rate of cerebral hemorrhage. Endocarditis can result in both hemorrhagic and ischemic strokes. Additionally, the formation of mycotic aneurysms increases the risk of hemorrhage. Intravenous alteplase would not be appropriate in this setting. The patient has infective endocarditis as opposed to nonbacterial/sterile/marantic endocarditis; thus intravenous immunoglobulin therapy would not be appropriate therapy.