Diagnosis of

Acute Ischemic and Hemorrhagic

Stroke
Ischemic Stroke

Low blood flow to focal part of brain

Usually caused by thromboembolism
Acute therapy includes thrombolysis
2 prevention depends on source of
thromboembolus
Accounts for 85% of strokes
Transient Ischemic Attack (TIA)

Reversible focal dysfunction, usually

lasts minutes
Among TIA pts who go to ED:
5% have stroke in next 2 days
25% have recurrent event in next 3
months
Stroke risk decreased with proper
therapy
Intracerebral Hemorrhage

Bleeding into brain tissue

Usually caused by chronic
hypertension
Non-hypertension cause more likely if:
No past history of hypertension
Lobar (i.e., peripheral, not subcortical)
May require emergency surgery
Accounts for 10% of strokes
Subarachnoid Hemorrhage

Bleeding around brain

Usually caused by ruptured
aneurysm
Surgical emergency
Cerebral angiography
Aneurysmal clipping
Accounts for 5% of strokes
Five Major Stroke Syndromes
for Rapid Recognition in the ED
All Occur Suddenly in Stroke Patients
Left (dominant) cerebral hemisphere
Right (nondominant) cerebral hemisphere
Brainstem
Cerebellum
Hemorrhage

Note: The dominant cerebral hemisphere is the

side that controls language function.
Left (Dominant)
Cerebral Hemisphere
Aphasia
L gaze preference
R visual field deficit
R hemiparesis
R hemisensory loss
Right (Nondominant)
Cerebral Hemisphere
Neglect (= L hemi-inattention)
R gaze preference
L visual field deficit
L hemiparesis
L hemisensory loss
Brainstem

Hemi- or quadriparesis
Sensory loss in hemibody or all 4 limbs
Crossed signs (face 1 side, body other side)
Diplopia, dysconjugate gaze, gaze palsy
Vertigo, tinnitus
Nausea, vomiting
Hiccups, abnormal respirations
Decreased consciousness
Cerebellum

Truncal = gait ataxia

Limb ataxia
Hemorrhage
Symptoms only suggestive of hemorrhage.
CT or LP needed for definitive diagnosis.

Headache
Neck stiffness
Neck pain
Light intolerance
Nausea, vomiting
Decreased consciousness
Acute Stroke Scales
Most Commonly Used in the
U.S.
Glasgow Coma Scale ( LOC)
Hunt & Hess Scale (SAH)
NIH Stroke Scale (AIS)
 Glasgow Coma Scale
Add the 3 scores (1 from each category)

Eye Opening Best Motor Best Verbal

4 spontaneous 6 obeys commands 5 oriented
3 to speech 5 localizes pain 4 confused
2 to pain 4 withdraws to pain 3 inappropriate
1 none 3 abnl flexion to pain 2 incomprehensible
2 extension to pain 1 none
1 none

Quantifies deficits in pt w/ LOC:

GCS < 9 carries poor prognosis
 Hunt and Hess Scale
Choose the single-most-appropriate grade

Grade I: asx; mild HA; slight nuchal rigidity

Grade II: moderate-to-severe HA; nuchal rigidity;
no neuro deficit other than CN palsy
Grade III: drowsiness/confusion; mild focal deficit
Grade IV: stupor; moderate-to-severe hemiparesis
Grade V: coma; decerebrate posturing

Prognostic value in SAH pts:

Grades I-III better prognosis & surgical candidates
Urgent Evaluation of Patients
with Focal Neurologic Deficits

Complete neurologic exam

lengthy, variable, parts not reproducible
inappropriate in acute setting
Glasgow Coma Scale
valuable for pts w/ LOC
does not quantify focal neurologic deficit
Hunt & Hess Scale
value is specific to SAH pts
NIH Stroke Scale
Designed for acute ischemic stroke trials
Relatively quick (5-10 min) and reproducible
Requires speech-&-language cards, safety
pin, complex grading scale
Quantifies stroke deficit:
< 4 = mild stroke
> 15 = poor prognosis if no treatment
> 22 = risk for intracranial hemorrhage after t-PA
 NIH Stroke Scale:
Modified arrangement of items

Mental Cranial Nerves Limbs

Status Visual fields R/L arm motor
LOC Horizontal R/L leg motor
Questions gaze Coordination
Commands Face strength Sensation
Language Dysarthria
Neglect
NIH Stroke Scale:
Traditional order of items

1a. LOC 6a. Right leg motor

1b. LOC questions 6b. Left leg motor
1c. LOC commands 7.Limb ataxia
2.Best gaze 8.Sensory
3.Visual fields 9.Best language
4.Facial palsy 10. Dysarthria
5a. Right arm motor 11. Extinction/
5b. Left arm motor inattention
NIH Stroke Scale:
Caveats re: traditional version

Item 12Distal Motor Function

was never included in total NIHSS score
is supplemental and not necessary
Grades of 9Untestable
used only for motor, ataxia, and dysarthria
number 9 assigned for computer purposes
do NOT give 9 points for untestable items
Stroke Differential
Diagnosis:
Sudden Onset Persistent Focal
Deficit
Ischemic stroke
Intracerebral hemorrhage
Partial seizure with postictal (Todds) paralysis
Abscess with seizure
Tumor with bleed or seizure
Toxic-metabolic insult with old cerebral lesion
Hypoglycemia
Subdural hematoma (acute)
Multiple sclerosis
Cerebritis
Stroke Differential
Diagnosis:
Sudden Onset Transient Focal Deficit
Transient ischemic attack
Partial seizure
Migraine with aura

NOTE: AVMs can cause all three types

of transient focal neurologic
deficits.
Stroke Differential
Diagnosis:
Depressed LOC without Focal Deficit
Persistent LOC Transient
Subarachnoid hemorrhage LOC
Meningitis Seizure
Drug overdose Syncope
Toxic-metabolic insult
Seizure with postictal state
Subclinical status
epilepticus