Case A 59 year old female who came in for left sided weakness
Ictus 0550H
Patient was noted to be lying on her left
side with noted slurring of speech. No fever, vomiting, chest pain ,incontinence, trauma or loss of consciousness noted Antecedents Patient is a known hypertensive and diabetes exact onset of the condition is unknown and poorly compliant with medications.
Non smoker, non alcoholic beverage
drinker, denies illicit drug use. Approach History Time of symptom onset (or time the patient was last normal) Initial symptoms and progression of symptoms Vascular risk factors(Hypertension, diabetes, hypercholesterolemia, and smoking) Medications(Anticoagulants, antiplatelet agents ) Recent trauma or surgery Liver or hematologic disorders Neurologic Examination in the ER Traditional neurologic formulation follows a three-tiered approach: (1) Is there a lesion of the nervous system? (2) Where is the lesion? and (3) What is the lesion? ORGANIZATIONAL FRAMEWORK 1. Mental status testing 2. Higher cerebral functions 3. Cranial nerves 4. Sensory examination 5. Motor system 6. Reflexes 7. Cerebellar testing 8. Gait and station ORGANIZATIONAL FRAMEWORK Higher Cerebral Mental status testing Functions
Is the patient is Speech and Language
awake, alert, and Primary sensory conversant? modalities (sharp, Thought content, light touch, etc.) attention and memory Spatial assessment ORGANIZATIONAL FRAMEWORK 3. Cranial nerves 4. Sensory examination 5. Motor system 6. Reflexes 7. Cerebellar testing 8. Gait and station Differential Diagnosis Ischemic stroke Intracranial hemorrhage Subarachnoid hemorrhage Drug toxicity Ischemic stroke Encephalitis Intracranial hypotension Venous thrombosis Metabolic derangements Work Up CT Scan of the head
(CT is optimal for demonstrating
hemorrhage extension into the ventricles, whereas MRI is superior for demonstrating underlying structural lesions.) Work Up CT angiography and contrast-enhanced CT may be considered to help identify patients at risk for hematoma expansion
CT angiography, CT venography, contrast-enhanced
CT, contrast-enhanced MRI, magnetic resonance angiography, and magnetic resonance venography can be useful to evaluate for underlying structural lesions, including vascular malformations and tumors when there is clinical or radiological suspicion Management Attention to the patient's airway, monitoring of neurologic status, Management of hyperthermia with antipyretics Administration of antiepileptic medications if seizures occur Aggressive management of hyperglycemia Blood pressure management Reversal of coagulopathy if present. Management Coagulopathy should be reversed. If the coagulopathy is related to heparin use, protamine should be administered at approximately 1 milligram per 100 units of heparin, adjusted based on the time since the heparin was last given. For patients taking warfarin, reversal should be done no matter what the international normalized ratio. Several options exist for reversing warfarin-induced coagulopathy. Vitamin Kn can be administered IV, SC, or PO but takes several hours to be effective. Fresh frozen plasma has a faster onset of effects but contains variable amounts of clotting factors and may result in the infusion of a large volume of fluid. Type AB fresh frozen plasma can be given without typing and cross-match of blood when delays in preparation and administration must be minimized. Management Management of elevated intracranial pressure (ICP) should include raising the head of the bed 30 degrees and providing appropriate analgesia and sedation. If more aggressive reduction of ICP is requiredsuch as administration of osmotic diuretics or intubation with Neuromuscular blockade and mild hyperventilationinvasive ICP monitoring is generally indicated. Management Disposition and Follow Up All patients diagnosed with ICH should be admitted to an intensive care unit in consultation with a neurosurgeon.
A higher GCS score is associated with a
better outcome. Factors that predict a worse outcome are increasing age, diabetes, and previous anticoagulation therapy. Prevention Prevention of ICH: Summary and Recommendations Treatment of hypertension is strongly recommended as the most effective means to decrease morbidity and mortality due to ICH Careful control of the anticoagulation level in patients prescribed warfarin decreases risk of subsequent ICH Careful selection of patients for thrombolytic treatment for acute myocardial infarction and acute ischemic stroke should result in a decline in ICH rates . Increased consumption of fruits and vegetables and avoidance of heavy alcohol and use of sympathomimetic drugs may decrease risk of ICH.