DISEASE Hx, Clinical presentation, physical DX/ Labs tests Rx : 1) Health maintenance /2)disease prevention and BASIC S
examination and Etiologies 3)pharmacotherapy
STROKE AND Both → sudden onset of weakness on CT scan without contrast (best initial test) : Before giving the thrombolytics or any anticoagulation Cryptoge
TIA one side of the body + weakness of half sensitive for Hemorrhagic stroke → CT scan without contrast to rule out an hemorrhagic stenosis ,
of the face and aphasia ; partial or total stroke shows no
loss of vision may be present which may Need 3-5 days for non-hemorrhagic stroke You cannot even give an aspirin shows no
be transient to be detected with >95% Recall that Thrombolytics are indicated within at least the 1st
Difference is based on time 3-4.5 hours of the onset of the symptoms ( RX BASED ON
MRI : >95% sensitivity for TIME ELAPSED SINCE ONSET) The young
Stroke → >24 hours + permanent residual non-hemorrhagic stroke within 24 hours state
neurologic deficits ; ischemia (80%) or but recall that CT should be done 1st ABOUT DISEASE INTERVENTION/PHARMACOTHERAPY
hemorrhage (20%) ; upper ⅓ of the face, - Within the past 3 hours : tPA
from the eyes up ; Ischemic stroke form MRA (most accurately images for the - 3 - 4.5 hours ago Thrombolytics (tPA) Closure of
emboli (more sudden symptoms) or a brain) : positive within 30-60 minutes of If NIH stroke scale >25 AND the patient is <80, no 1)Embolic
thrombosis stroke diabetes with Hx of stroke , does not use R-to-L shu
anticoagulation 2)In conju
TIA→ <24 hours + resolve completely ; Indicated in all patients with stroke or TIA 3)Percuta
amaurosis fugax ; ophthalmic artery ; -Echo : anticoagulation for clots ; possible - ABSOLUTE CONTRAINDICATION
caused by emboli or thrombosis and surgery for valve vegetations - Hx of hemorrhagic stroke ABOUT H
NEVER by hemorrhage (hemorrhage do - Intracranial neoplasm/mass or -HTN → A
not resolve in 24 hours) -Carotid Doppler/duplex :endarterectomy bleeding disorder -Diabetes
for stenosis >70% but not if 100% AND - Active bleeding or surgery with 6 HbA1c <7
Only if patient is symptomatic weeks , cerebral trauma or brain -Hyperlip
surgery within 6 months or non-hemo
-EKG and Holter monitor if EKG is normal non-hemorrhagic stroke within 1
: DOAC are indicated for all stroke/TIA year
with A-fib or A-flutter - Suspicion of aortic dissection
In young patients age<50 with no past - >4.5 hours ago : catheter (up to 24 hours after
medical history (diabetes, HTN) → stroke onset)
Sedimentation rate , - For all non-hemorrhagic strokes → add statin
VDRL or RPR ,
ANA , ABOUT DISEASE INTERVENTION/PHARMACOTHERAPY
double-stranded DNA , After thrombolytic use : start antiplatelet therapy after 24
protein C , hours EVEN IF PREGNANT
protein S ,
factor V Leiden mutation , antiphospholipid -Small stroke (NIH stroke scale <6) or TIA :
syndromes - Aspirin and clopidogrel ; stop
clopidogrel after several weeks and
continue aspirin indefinitely
- DAPT is not for long term because
of risk of bleeding
, Cerebral venous Clotting in cerebral veins MRV (most accurate test) ABOUT DISEASE INTERVENTION/PLAN OF CARE Oral contr
thrombosis Headaches developing over several days LP is normal LMW heparin → DOAC (Apixaban, edoxaban, rivaroxaban,
Same weakness and speech difficulty dabigatran) for a few months
seen in stroke
Cerebral lesion Anterior cerebral artery → Profound contralateral extremity weakness + Mild Vertebro-basilar artery → Vertigo + Nausea and vomiting (+++) + Drop
contralateral upper extremity weakness + personality changes or psychiatric nystagmus + dysarthria + sensory changes in face and scalp + ataxia + bi
disturbance + Urinary incontinence
Posterior inferior cerebellar artery → Ipsilateral face + contralateral bod
Middle cerebral artery → Profound contralateral upper extremity weakness + Aphasia
+ Apraxia/neglect + eyes toward the side of the lesions + contralateral homonymous Lacunar infarct → Absence of cortical deficits + ataxia + Parkinsonian s
hemianopsia notable in the face) + possible bulbar signs
Both Anterior stroke and Middle cerebral artery stroke are managed the same Ophthalmic artery → amaurosis fugax
way
Posterior cerebral artery → Prosopagnosia (inability to recognize faces)
SEIZURES Some etiologies include : Sodium, calcium and magnesium ABOUT MIXED MANAGEMENT CCS tip :
Liver failure Glucose , oxygen, creatinine Only the management of status epilepticus is clear
Renal failure Head CT ; if negative , consider MRI later Benzodiazepine (lorazepam) Recall tha
Urine toxicology screen If persist → fosphenytoin
Liver and renal function If persist → levetiracetam , valproic acid or phenobarbital
ABOUT P
EEG only if other test do not reveal the e (interchangeable)
Carbamaz
tiology If persist → general anesthesia (pentobarbital, thiopental,
(Stevens-
midazolam, propofol)
Steven-Jo
ABOUT MIXED MANAGEMENT
Carbamaz
1)Single seizures → chronic antiepileptic drug are generally
NOT indicated unless :
Phenytoin
Strong family history ,
Abnormal EEG ,
OCPs incr
Status epilepticus that required benzodiazepine
ineffectiv
Uncorrectable precipitating cause (brain tumor)
2)Chronic seizures → no single agent is the best initial
therapy
1st line → levetiracetam , valproic acid , carbamazepine (all
equal in efficacy)
In pregnancy → levetiracetam or lamotrigine
examination and Etiologies 3)pharmacotherapy
STROKE AND Both → sudden onset of weakness on CT scan without contrast (best initial test) : Before giving the thrombolytics or any anticoagulation Cryptoge
TIA one side of the body + weakness of half sensitive for Hemorrhagic stroke → CT scan without contrast to rule out an hemorrhagic stenosis ,
of the face and aphasia ; partial or total stroke shows no
loss of vision may be present which may Need 3-5 days for non-hemorrhagic stroke You cannot even give an aspirin shows no
be transient to be detected with >95% Recall that Thrombolytics are indicated within at least the 1st
Difference is based on time 3-4.5 hours of the onset of the symptoms ( RX BASED ON
MRI : >95% sensitivity for TIME ELAPSED SINCE ONSET) The young
Stroke → >24 hours + permanent residual non-hemorrhagic stroke within 24 hours state
neurologic deficits ; ischemia (80%) or but recall that CT should be done 1st ABOUT DISEASE INTERVENTION/PHARMACOTHERAPY
hemorrhage (20%) ; upper ⅓ of the face, - Within the past 3 hours : tPA
from the eyes up ; Ischemic stroke form MRA (most accurately images for the - 3 - 4.5 hours ago Thrombolytics (tPA) Closure of
emboli (more sudden symptoms) or a brain) : positive within 30-60 minutes of If NIH stroke scale >25 AND the patient is <80, no 1)Embolic
thrombosis stroke diabetes with Hx of stroke , does not use R-to-L shu
anticoagulation 2)In conju
TIA→ <24 hours + resolve completely ; Indicated in all patients with stroke or TIA 3)Percuta
amaurosis fugax ; ophthalmic artery ; -Echo : anticoagulation for clots ; possible - ABSOLUTE CONTRAINDICATION
caused by emboli or thrombosis and surgery for valve vegetations - Hx of hemorrhagic stroke ABOUT H
NEVER by hemorrhage (hemorrhage do - Intracranial neoplasm/mass or -HTN → A
not resolve in 24 hours) -Carotid Doppler/duplex :endarterectomy bleeding disorder -Diabetes
for stenosis >70% but not if 100% AND - Active bleeding or surgery with 6 HbA1c <7
Only if patient is symptomatic weeks , cerebral trauma or brain -Hyperlip
surgery within 6 months or non-hemo
-EKG and Holter monitor if EKG is normal non-hemorrhagic stroke within 1
: DOAC are indicated for all stroke/TIA year
with A-fib or A-flutter - Suspicion of aortic dissection
In young patients age<50 with no past - >4.5 hours ago : catheter (up to 24 hours after
medical history (diabetes, HTN) → stroke onset)
Sedimentation rate , - For all non-hemorrhagic strokes → add statin
VDRL or RPR ,
ANA , ABOUT DISEASE INTERVENTION/PHARMACOTHERAPY
double-stranded DNA , After thrombolytic use : start antiplatelet therapy after 24
protein C , hours EVEN IF PREGNANT
protein S ,
factor V Leiden mutation , antiphospholipid -Small stroke (NIH stroke scale <6) or TIA :
syndromes - Aspirin and clopidogrel ; stop
clopidogrel after several weeks and
continue aspirin indefinitely
- DAPT is not for long term because
of risk of bleeding
, Cerebral venous Clotting in cerebral veins MRV (most accurate test) ABOUT DISEASE INTERVENTION/PLAN OF CARE Oral contr
thrombosis Headaches developing over several days LP is normal LMW heparin → DOAC (Apixaban, edoxaban, rivaroxaban,
Same weakness and speech difficulty dabigatran) for a few months
seen in stroke
Cerebral lesion Anterior cerebral artery → Profound contralateral extremity weakness + Mild Vertebro-basilar artery → Vertigo + Nausea and vomiting (+++) + Drop
contralateral upper extremity weakness + personality changes or psychiatric nystagmus + dysarthria + sensory changes in face and scalp + ataxia + bi
disturbance + Urinary incontinence
Posterior inferior cerebellar artery → Ipsilateral face + contralateral bod
Middle cerebral artery → Profound contralateral upper extremity weakness + Aphasia
+ Apraxia/neglect + eyes toward the side of the lesions + contralateral homonymous Lacunar infarct → Absence of cortical deficits + ataxia + Parkinsonian s
hemianopsia notable in the face) + possible bulbar signs
Both Anterior stroke and Middle cerebral artery stroke are managed the same Ophthalmic artery → amaurosis fugax
way
Posterior cerebral artery → Prosopagnosia (inability to recognize faces)
SEIZURES Some etiologies include : Sodium, calcium and magnesium ABOUT MIXED MANAGEMENT CCS tip :
Liver failure Glucose , oxygen, creatinine Only the management of status epilepticus is clear
Renal failure Head CT ; if negative , consider MRI later Benzodiazepine (lorazepam) Recall tha
Urine toxicology screen If persist → fosphenytoin
Liver and renal function If persist → levetiracetam , valproic acid or phenobarbital
ABOUT P
EEG only if other test do not reveal the e (interchangeable)
Carbamaz
tiology If persist → general anesthesia (pentobarbital, thiopental,
(Stevens-
midazolam, propofol)
Steven-Jo
ABOUT MIXED MANAGEMENT
Carbamaz
1)Single seizures → chronic antiepileptic drug are generally
NOT indicated unless :
Phenytoin
Strong family history ,
Abnormal EEG ,
OCPs incr
Status epilepticus that required benzodiazepine
ineffectiv
Uncorrectable precipitating cause (brain tumor)
2)Chronic seizures → no single agent is the best initial
therapy
1st line → levetiracetam , valproic acid , carbamazepine (all
equal in efficacy)
In pregnancy → levetiracetam or lamotrigine
