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→Stroke
=Brain=
=Brain=
==Stroke==
==Stroke==
*H&P: Ischemic stroke risk factors parallel ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent focal neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer. Different brain areas cause different stroke syndromes, such as thalamic strokes (pure sensory), insular strokes (pure motor), left MCA (dysphasia), right MCA (left arm and face), cerebellar (ataxia, poor coordination), posterior cerebral artery (homonymous hemianopsia), ACA (personality changes, leg weakness)
*H&P: Ischemic stroke risk factors parallel ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent focal neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer. Different brain areas cause different stroke syndromes, see table below:
{| class="wikitable"
|+ Stroke Syndromes
|-
! Artery !! Syndrome
|-
| Lacunar (thalamus) || pure sensory
|-
| Lacunar '''(internal capsule)''' || pure motor
|-
| ACA || contralateral leg weakness and sensory changes
|-
| left MCA || motor and sensory deficits in right arm, right face; aphasia
|-
| right MCA || motor and sensory deficits in left arm, left face; neglect
|-
| '''PCA (cerebellum, midbrain) || homonymous hemianopsia; ataxia, poor coordination; Weber syndrome: ipsilateral CN III palsy and contralateral arm/leg weakness.'''
|-
| '''AICA (pons) || Ipsilateral limb ataxia and contralateral hemiplegia and loss of pain/temperature.'''
|-
| '''PICA (medulla) || Wallenberg syndrome <u>(lateral medulla)</u>: nystagmus, vertigo, bulbar weakness (weak gag, dysphagia), Horner syndrome, loss of pain/temperature on ipsilateral face and contralateral body.'''
|}
*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. Prevention includes aspirin, statin, clopidogrel, blood pressure control, rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).
*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. Prevention includes aspirin, statin, clopidogrel, blood pressure control, rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).