Disease modifying treatment available:
Time critical diagnosis and management:
Lateralising:
| Supercategory | |||||
|---|---|---|---|---|---|
| Stroke |
| Subclassifications | Epidemiology | Clinical features |
|---|---|---|
| Posterior inferior cerebellar artery occlusion | None | |
| Anterior inferior cerebellar artery occlusion | None | Vertigo Sensorineural hearing loss |
| Anterior cerebral artery occulsion | None |
| Disorder | Clinical features | Associated features | Investigations | Disease modifying treatment available | Time critical |
|---|---|---|---|---|---|
| Atrial fibrillation | |||||
| Hypertension |
Chronic kidney disease Headache |
Posterior reversible encephalopathy syndrome |
|||
| Acute promyelocytic leukemia |
Splenic infarction |
||||
| Arterial dissection | |||||
| Aortic dissection |
Abdominal pain Chest pain Seizure Cardiogenic syncope |
Ischaemic stroke may cause the following:
In people presenting with acute ischaemic stroke the most important initial decision is regarding if a reperfusion therapy (thrombolysis or thrombectomy) is likely to be of benefit.
Pharmacological thrombolysis should be considered in those with acute ischaemic stroke with a deficit for less than 4.5 hours. Thrombolysis is not offered to those who are already therapeutically anticoagulated. If the blood pressure is 185/110mmHg or greater this should be lowered before giving thrombolysis. Meta-analysis has confirmed that even patients with a low NIHSS benefit from thrombolysis.
Mechanical thrombectomy should be considered in those presenting with a deficit of less than 6 hours. This time windows extends to 24 hours if there is basilar occlusion or favourable neuroimaging. Typically a reasonable pre-morbid baseline is required (e.g. mRS 0-2) and an NIHSS score > 6. The initial CT brain should not show any haemorrhage or evidence of major ischaemic changes (eASPECTS >= 6). CT angiogram should demonstrate a large vessel occlusion.
In those presenting within 6 - 24 hours, mechanical thrombectomy can be considered in those with significant salvageable tissue on CT perfusion.
Blood glucose should be tested as soon a neurological deficit is identified and treated if low.
Lots of questions remain about the optimal management of ischaemic stroke secondary to arterial dissection:
- Are anticoagulant and antiplatelet therapy equivalent in terms of risk and do individual drugs within these classes offer any advantage?
- What is the optimal duration for pharmacological therapy?
- If aneurysmal outpouching develops post dissection does this have implications for the nature or duration of treatment?
- Is thrombolysis safe and effective?