Stroke care begins with prevention by addressing modifiable risk factors such as inactivity, HLD, diet, HTN, obesity, DM, cigarette smoking, cardiac disease, carotid stenosis and managing sickle cell. Non-modifiable risk factors include older age, male, race, family history, genetics and low birth weight. Much of this will hopefully occur with the patient’s primary care physician prior to coming to the Emergency Department.

However once in the Emergency Department, we have several priorities when evaluating the potential stroke patient.

1. Determine time of onset (last known well, LKW)
2. Eliminate any contra-indications to thrombolytics
3. Rule out any stroke mimics

YouTube Videos on Stroke Care

Introduction to Ischemic Stroke

Stroke Anatomy

Stroke Evaluation

Stroke Treatment

primary survey

Of course, start with ABC’s. Medullary injury and bleeds can lead to loss of airway.

• take care of ABCs, glucose, temp
• permissive HTN: sBP < 220 to promote cerebral autoregulation and blood flow, if they got tPA then at or below 185/110
• avoid hyperthermia
• control sugars < 200
• keep sats at or above 94% (no supplemental O2 if ≥ 94%)

history

In addition to your normal history questions, focus on the following:

1. Last Known Well (LKW): Ask paramedics, patient, family the last time the patient was at their baseline level of functioning. You may have to call family at home. There are two times this may not be possible: the aphasic or obtunded patient or the patient who went to bed normal and woke up with symptoms (“wake-up strokes”).
2. Stroke risk factors: HTN, DM, AF, HLD, tobacco use, family history, CKD, sleep apnea
3. Meds: particularly any anticoagulants and the last time they took them.
4. Rule out stroke mimics: seizures (Todd’s paralysis or AMS can be confused as a stroke), migraines (can be hemiplegic and have brainstem aura that leads to dysarthria), Bell’s palsy (facial weakness due to CN7), HTN emergency (can have headache, AMS, blurred vision and even focal deficits), hypo and hyperglycemia, recrudescence (unmasking of old symptoms due to a stressor like infection, dehydration, fatigue), ingestions & tox (ASA, APAP, Li, dilantin, carbamazepine), degenerative neurological disorders (MS, MG, demyelinating diseases)

physical

We are very spoiled at Rush with Neurology residents who can perform the NIHSS quickly and report the score to us. In other places, you may be required to do this yourself. MDCalc has a calculator that can walk you through all the elements. If you log in, you can copy the results to your chart. It’s here if you need it as well.

NIH Stroke Scale

Feature	Symptoms	Score
1A: LEVEL OF CONSCIOUSNESS	Alert; keenly responsive	0
	Arouses to minor stimulation	1
	Requires repeated stimulation to arouse	2
	Movements to pain	2
	Postures or unresponsive	3
1B: ASK MONTH AND AGE	Both questions right	0
	1 question right	1
	0 questions right	2
	Dysarthric/intubated/trauma/language barrier	1
	Aphasic	2
1C: BLINK EYES & SQUEEZE HANDS	Performs both tasks	0
	Performs 1 task	1
	Performs 0 tasks	2
2: HORIZONTAL EXTRAOCULAR MOVEMENTS	Normal	0
	Partial gaze palsy: can be overcome	1
	Partial gaze palsy: corrects with oculocephalic reflex	1
	Forced gaze palsy: cannot be overcome	2
3: VISUAL FIELDS	No visual loss	0
	Partial hemianopia	1
	Complete hemianopia	2
	Patient is bilaterally blind	3
	Bilateral hemianopia	3
4: FACIAL PALSY	Normal symmetry	0
	Minor paralysis (flat nasolabial fold, smile asymmetry)	1
	Partial paralysis (lower face)	2
	Unilateral complete paralysis (upper/lower face)	3
	Bilateral complete paralysis (upper/lower face)	3
5A: LEFT ARM MOTOR DRIFT	No drift for 10 seconds	0
	Drift, but doesn’t hit bed	1
	Drift, hits bed	2
	Some effort against gravity	2
	No effort against gravity	3
	No movement	4
	Amputation/joint fusion	0
5B: RIGHT ARM MOTOR DRIFT	No drift for 10 seconds	0
	Drift, but doesn’t hit bed	1
	Drift, hits bed	2
	Some effort against gravity	2
	No effort against gravity	3
	No movement	4
	Amputation/joint fusion	0
6A: LEFT LEG MOTOR DRIFT	No drift for 5 seconds	0
	Drift, but doesn’t hit bed	1
	Drift, hits bed	2
	Some effort against gravity	2
	No effort against gravity	3
	No movement	4
	Amputation/joint fusion	0
6B: RIGHT LEG MOTOR DRIFT	No drift for 5 seconds	0
	Drift, but doesn’t hit bed	1
	Drift, hits bed	2
	Some effort against gravity	2
	No effort against gravity	3
	No movement	4
	Amputation/joint fusion	0
7: LIMB ATAXIA	No ataxia	0
	Ataxia in 1 Limb	1
	Ataxia in 2 Limbs	2
	Does not understand	0
	Paralyzed	0
	Amputation/joint fusion	0
8: SENSATION	Normal; no sensory loss	0
	Mild-moderate loss: less sharp/more dull	1
	Mild-moderate loss: can sense being touched	1
	Complete loss: cannot sense being touched at all	2
	No response and quadriplegic	2
	Coma/unresponsive	2
9: LANGUAGE/APHASIA	Normal; no aphasia	0
	Mild-moderate aphasia: some obvious changes, without significant limitation	1
	Severe aphasia: fragmentary expression, inference needed, cannot identify materials	2
	Mute/global aphasia: no usable speech/auditory comprehension	3
	Coma/unresponsive	3
10: DYSARTHRIA	Normal	0
	Mild-moderate dysarthria: slurring but can be understood	1
	Severe dysarthria: unintelligible slurring or out of proportion to dysphasia	2
	Mute/anarthric	2
	Intubated/unable to test	0
11: EXTINCTION/INATTENTION	No abnormality	0
	Visual/tactile/auditory/spatial/personal inattention	1
	Extinction to bilateral simultaneous stimulation	1
	Profound hemi-inattention (ex: does not recognize own hand)	2
	Extinction to >1 modality	2

do the symptoms match a particular vascular distribution?

The stroke should make sense with a particular artery being blocked. Stroke mimics can often cross distributions. The commonly blocked large vessel occlusions include the basilar artery, ICA, MCA and vertebral.

anterior circulation

• Anterior Cerebral Artery (ACA) 
  • frontal lobe: apathy, disinhibition, abulia (lack of will or initiative)
  • olfactory cortex: trouble with smell
  • leg motor cortex: contralateral motor/sensory loss
• Middle Cerebral Artery (MCA)
  • speech and language areas: aphasia
  • motor and sensory cortices: motor and sensation of contralateral arm and face
  • basal ganglia: motor control and coordination
  • internal capsule/corona radiata: motor and sensory pathways
  • →, neglect, forced eye deviation, contralateral homonymous hemianopsia,
• Posterior Cerebral Artery (PCA)
  • occipital lobe: visual field loss
  • midbrain: movements of the eye
  • thalamus: contralateral loss of pain and temperature
  • corpus callosum
• Posterior communicating Artery = common site for aneurysm = thalamus, hypothalamus, optic chiasm → headache, vision changes
• Anterior Communicating Artery = connects bilateral anterior circulations and another common site for aneurysms → visual symptoms due to proximity to optic nerve

posterior circulation

• Posterior Inferior Cerebellar Artery (PICA) = cerebellum, medulla, choroid plexus of 4th ventricle → ipsilateral limb ataxia, ↓pain and temp sensation contralaterally
• Anterior Inferior Cerebellar Artery (AICA) = cerebellum & pons → ipsi deafness, facial motor/sensory loss & limb ataxia, ↓pain and temp sensation contralaterally
• Basilar Artery = cerebellum, midbrain, pons, medial, thalamus, hypothalamus, inferior occipital and temporal lobes → ↓LOC, facial paresis, oculomotor difficulties, ataxia, quadraparesis

vascular distributions in much more details than you probably ever wanted to know

Artery	Structure Supplied	Associated Function	Associated Condition
Anterior Cerebral Artery (ACA)	Medial Frontal Lobe	Executive functions, decision-making, personality	Personality changes, impaired executive function, abulia
	Medial Primary Motor Cortex	Motor control for the lower limbs	Contralateral hemiparesis (lower limbs)
	Medial Parietal Lobe	Sensory processing (lower limb)	Contralateral sensory loss (lower limbs)
	Anterior Corpus Callosum	Interhemispheric communication	Split-brain syndrome
Middle Cerebral Artery (MCA)	Lateral Frontal Lobe	Motor control (face and upper limbs), cognition	Contralateral hemiparesis (face, upper limbs), Broca’s aphasia
	Lateral Temporal Lobe	Auditory processing, language comprehension	Wernicke’s aphasia
	Lateral Parietal Lobe	Sensory processing (face, upper limbs), spatial awareness	Contralateral sensory loss (face, upper limbs)
	Right Inferior Parietal Lobule	Spatial awareness, visual attention	Hemi-neglect (left side)
	Basal Ganglia	Motor control, coordination	Movement disorders (e.g., Parkinson’s, Huntington’s)
Posterior Cerebral Artery (PCA)	Occipital Lobe	Vision, visual processing	Contralateral homonymous hemianopia, cortical blindness
	Inferior Temporal Lobe	Memory, recognition (faces, objects)	Anomia, prosopagnosia
	Thalamus	Sensory relay, pain perception, consciousness	Thalamic pain syndrome, sensory loss
	Posterior Corpus Callosum	Interhemispheric communication	Visual and sensory deficits
Anterior Communicating Artery (AComA)	Optic Chiasm	Visual field processing, visual input coordination	Bitemporal hemianopia
	Hypothalamus	Autonomic functions, hormone regulation	Endocrine dysfunctions, sleep disturbances
Posterior Communicating Artery (PComA)	Optic Tract	Visual signal transmission, visual reflexes	Contralateral homonymous hemianopia
	Thalamus	Sensory integration, motor relay, consciousness	Thalamic pain syndrome, sensory loss
	Hypothalamus	Homeostasis, autonomic control, hormone regulation	Endocrine dysfunctions, autonomic issues
Internal Carotid Artery (ICA)	ACA and MCA Origin	Major supply to frontal, parietal, temporal lobes	Ischemic stroke (ACA, MCA territories)
Basilar Artery	Brainstem	Autonomic functions (breathing, heart rate), consciousness	Locked-in syndrome, respiratory failure
	Cerebellum	Balance, motor coordination	Ataxia, coordination deficits
Vertebral Artery	Medulla	Autonomic functions, respiration, heart rate	Respiratory arrest, cardiovascular dysfunction
	Inferior Cerebellum	Balance, fine motor coordination	Ataxia, vertigo
Anterior Choroidal Artery	Optic Tract, Lateral Geniculate Nucleus	Visual signal processing	Contralateral homonymous hemianopia
	Posterior Limb of Internal Capsule	Motor and sensory pathways	Hemiparesis, hemisensory loss
	Hippocampus	Memory formation and retrieval	Memory deficits
Posterior Inferior Cerebellar Artery (PICA)	Inferior Cerebellum	Balance, coordination	Ataxia, vertigo
	Lateral Medulla	Autonomic functions, reflexes	Wallenberg syndrome (lateral medullary syndrome)
Anterior Inferior Cerebellar Artery (AICA)	Inferior Cerebellum, Inner Ear	Balance, hearing	Ataxia, hearing loss, vertigo
Superior Cerebellar Artery (SCA)	Superior Cerebellum	Balance, coordination	Ataxia, dizziness
Lenticulostriate Arteries	Basal Ganglia, Internal Capsule	Motor control, coordination	Lacunar infarcts, movement disorders
Ophthalmic Artery	Retina	Vision	Vision loss (monocular blindness)
Pontine Arteries	Pons	Motor control, autonomic functions	Pontine stroke, locked-in syndrome