Week 40: Stroke Me

Transient ischemic attack is defined as a transient neurologic deficit that has complete resolution within 24 hours. The ABCD2 score can be used to predict likelihood of subsequent stroke within 2 days. Low risk patients (scores of 0-3) may be discharged home if they have reliable follow-up within two days, whereas moderate risk (4-5 points) and high risk (6-7 points) patients should be admitted for echocardiography, carotid dopplers, and likely carotid endarterectomy.

The scoring system is as follows:

Age of 60 years or greater = 1 point
Initial SBP of 140 or greater OR DBP of 90 or greater = 1 point
Clinical features (Unilateral weakness = 2 points; Speech disturbance without weakness = 1 point; Other symptoms = 0 points)
Duration of symptoms (<10 minutes = 0 points; 10-59 minutes = 1 point; 60 minutes or greater = 2 points)
History of diabetes = 1 point

This patient’s score = 4. He receives 1 point for age and 2 points for unilateral weakness as well as 1 point for history of diabetes.

The patient had a transient ischemic attack. Two interventions that reduce mortality in patients with TIA are anticoagulation for patients with atrial fibrillation or LV thrombus, and carotid endarterectomy for carotid stenosis > 70%. The patient only has 65% stenosis, thus anticoagulation is the better answer choice. While long-term blood pressure control is important in decreasing morbidity and mortality for this patient, emergent blood pressure control has not been shown to decrease the immediate morbidity of this patient. Long-term blood glucose control is also important in decreasing morbidity and mortality for this patient, emergent blood glucose control has not been shown to decrease the immediate morbidity of this patient

When a patient presents with vertigo, it is imperative that a central cause of vertigo is excluded. Central vertigo is caused by disorders affecting the brainstem and cerebellum (i.e. hemorrhage, dissection, vascular insufficiency, etc). Disorders causing peripheral vertigo include benign paroxysmal positional vertigo (BPPV), meniere’s disease, labyrinthitis, vestibular neuronitis, and ototoxicity, to name a few. This question describes a peripheral process, specifically vestibular neuronitis. Vestibular neuronitis is characterized by gradual onset vertigo that lasts for hours. It is commonly preceded by a viral illness. Diagnosis is supported by a positive head impulse test (sudden turning of the head elicits nystagmus of peripheral vertigo). Nystagmus of peripheral vertigo is horizontal and rotational, lessens or disappears when the patient focuses the gaze, and usually is triggered by some provoking factor. Treatment of vestibular neuronitis includes corticosteroids. The Epley maneuver treats BPPV, antibiotics are reserved for bacterial labyrinthitis, and acyclovir is for Bell’s palsy and possibly Ramsey Hunt syndrome (controversial).

Cortical strokes affect large arteries, like the MCA and ACA. They are characteristically large infarcts that have a progressively worsening course. Patients typically have loss of consciousness/executive function and a poor prognosis. They include motor AND sensory findings, along with cortical signs, such as aphasia and neglect. Inability to write and dysarthria describes the dysarthria/clumsy hand syndrome (a lacunar stroke syndrome), which can be localized to the: basilar pons, anterior limb of the internal capsule, corona radiata, basal ganglia, thalamus, or cerebral peduncle. Isolated hemiparesis of left face, arm, and leg describes a pure motor stroke (the most common lacunar stroke syndrome), localized often to the posterior limb of the internal capsule, basilar pons or corona radiata. Pain and tingling to right face, arm, and leg describes a pure sensory stroke (a lacunar stroke syndrome), localized to the contralateral thalamus, internal capsule, corona radiata, or midbrain.

The contraindication is a sustained blood pressure > 185/110. Antihypertensives can be administered, however a blood pressure at this level is currently a contraindication to TPA. tPA can be administered within 4.5 hours of onset of stroke symptoms according to the most current guidelines. There is no age cut off for administration of tPA. A contraindication to use of tPA in prior guidelines was a blood sugar > 400 mg/dl or 22.2 mmol/L or less than 50 mg/dl (2.8 mmol/L). However current recommendations have revised this recommendation to only include the less than 50 mg/dl (2.8 mmol/L) as a contraindication. Indications for tPA include age > 18, onset < 4.5 hours, and a negative head CT.

Sickle cell disease is the most common cause of ischemic stroke in children. Patients with homozygous hemoglobin-SS are at greatest risk, but all genotypes have increased risk. Patients with sickle cell disease are also more likely than the general population to have cerebral aneurysms and cerebral arterial abnormalities. Infants and children with sickle cell disease are more likely to have ischemic strokes while hemorrhagic stroke is more common in adults. Patients may present with focal neurologic deficits, seizure, altered mental status and headache. Patients should be managed with conventional therapies for sickle cell disease, including oxygen, analgesia, and hydration. Exchange transfusion is indicated for acute ischemic stroke, which is a unique difference in management compared to the general population. The goal is to reduce hemoglobin S levels to < 30%.

Factor V Leiden (A) is the most common inherited hypercoagulable disorder and occurs predominantly in patients of European descent. Patients are more at risk for venous thromboembolic disease than for acute stroke. Hypertension (B) is a significant risk factor in cerebrovascular disease, including subarachnoid hemorrhage and lacunar infarcts. However, this is not the most common cause of pediatric strokes. Kawasaki disease (C) is a microvasculitis that may cause coronary artery aneurysms but does not cause cerebral vascular abnormalities or strokes.

This patient has a carotid artery dissection. This is the most frequent cause of stroke in patients < 45 years old. Risk factors include minor neck trauma (cervical manipulation in this patient), family history of arterial disease, and connective tissue disorders. The most common presenting symptoms are unilateral neck pain or headache around the eye or frontal area. The pain is classically abrupt in onset. Carotid artery dissection is associated with a partial ipsilateral Horner’s syndrome of miosis and ptosis without facial anhidrosis. Horner’s syndrome results from a disruption of sympathetic innervation anywhere along the sympathetic chain. A carotid bruit may be heard on exam. The diagnostic study of choice is a MRI/MRA. If left untreated, it can lead to cerebral ischemia or retinal artery infarction and vision loss.

Carotid Artery Dissection
• Most common cause of stroke in patients < 45 years
• Connective tissue disorders, neck trauma
• Abrupt unilateral neck pain or headache around the eye/frontal area, partial ipsilateral Horner’s syndrome (miosis/ptosis)
• MRI/MRA
• Anticoagulation

Cluster headaches (B) are typically unilateral and characterized by severe orbital, supraorbital, or temporal pain lasting 15–180 minutes, and recurring throughout the day. It is also associated with ipsilateral red conjunctiva, lacrimation, nasal congestion, and rhinorrhea. Seventy percent of the time these headaches resolve with oxygen administration. Based on presenting headache features, distinguishing vertebral from carotid artery dissection can be difficult. However, dissection of the vertebral artery (E) is typically associated with marked occipital or posterior neck pain and may be accompanied by focal neurological deficits, including ipsilateral facial numbness and contralateral pain and temperature sensory loss. Retinal artery occlusion (C) is painless and is associated with loss of vision. Fundoscopic exam reveals a pale retina with cherry red macula. Temporal arteritis (D) tends to occur in patients over 50 years of age and involves severe, throbbing, frontotemporal pain and jaw claudication. On exam, there is tenderness or decreased pulse in the temporal artery. ESR measurement is a useful screening test, but the final diagnosis is made by arterial biopsy

MRI brain is correct. This patient’s normal head impulse test is concerning for central vertigo. In peripheral vertigo, typically the patient’s eyes will travel with the head as it is turned, and reflex saccadic movements will occur bring the eyes back to midline. The absence of this sign is suggestive of a central process such as a cerebellar stroke and should prompt further workup. The Dix-Hallpike maneuver is useful for peripheral vertigo due to BPPV. This patient’s head impulse test is more suggestive of central vertigo.

The correct answer is MRI brain and neurology consultation. Bidirectional nystagmus (like vertical nystagmus) is suggestive of central vertigo and a cerebellar stroke. While this patient’s other symptoms are suggestive of peripheral vertigo, an abnormal neurologic exam should prompt further testing.

Alternative physical exam features that can help distinguish central from peripheral vertigo are the Dix-Hallpike maneuver as well as the HINTS exam. In the HINTS exam, the patient is focused on your nose as you turn the head left and right. In a normal exam, the patient’s eyes remain fixed on your nose. In an abnormal exam (which suggests peripheral vertigo) the patient has trouble keeping his or her eyes on you and there is compensatory nystagmus towards the midline.

A. CT head followed by lumbar puncture
This patient’s history is suggestive of cluster headache. CT scan is not unreasonable as some patients with these symptoms can have structural abnormalities, but the daily quality of the headache makes subarachnoid unlikely and lumbar puncture is not necessary.

B. High flow oxygen
The correct answer is high flow oxygen. This patient’s history and exam is classic for cluster headaches. Cluster headaches are characterized by attacks of unilateral pain and are relatively short-lived. Physical exam can demonstrate ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, or nasal congestion. This should occur only during headache and be ipsilateral to the pain. Initial treatment is with high flow oxygen which can abort the headache.

C. Metoclopramide
This patient’s history is suggestive of cluster headache. Metoclopramide is more effective in the treatment of migraine headaches.

D. Pilocarpine
This patient’s history is suggestive of cluster headache. While acute glaucoma is part of the differential diagnosis, the intermittent, short duration of symptoms with spontaneous resolution, makes glaucoma less likely.