eMedicine Specialties > Emergency Medicine > Neurology

Stroke, Ischemic: Differential Diagnoses & Workup

Author: Joseph U Becker, MD, Fellow, Global Health and International Emergency Medicine, Stanford University
Coauthor(s): Charles R Wira, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale School of Medicine; Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Feb 26, 2010

Differential Diagnoses

Acute Coronary Syndrome
Hypoglycemia
Alcohol and Substance Abuse Evaluation
Hyponatremia
Anemia, Acute
Hypothyroidism and Myxedema Coma
Atrial Fibrillation
Labyrinthitis
Bell Palsy
Myocardial Infarction
Benign Positional Vertigo
Neoplasms, Brain
Brain Abscess
Status Epilepticus
CBRNE - Botulism
Stroke, Hemorrhagic
Delirium, Dementia, and Amnesia
Subarachnoid Hemorrhage
Dissection, Carotid Artery
Subdural Hematoma
Dissection, Vertebral Artery
Syncope
Epidural Hematoma
Transient Ischemic Attack
Hypernatremia
Hyperosmolar Hyperglycemic Nonketotic Coma

Other Problems to Be Considered

Guillain-Barre syndrome

Workup

Laboratory Studies

  • CBC, basic chemistry panel, coagulation studies, and cardiac biomarkers should be obtained in most patients.
    • CBC serves as a baseline study and may reveal a cause for the stroke (eg, polycythemia, thrombocytosis, thrombocytopenia, leukemia) or provide evidence of concurrent illness (eg, anemia).
    • Chemistry panel serves as a baseline study and may reveal a stroke mimic (eg, hypoglycemia, hyponatremia) or provide evidence of concurrent illness (eg, diabetes, renal insufficiency).
    • Coagulation studies may reveal a coagulopathy and are useful when thrombolytics or anticoagulants are to be used. In patients who are not anticoagulated and in whom there is no suspicion for coagulation abnormality, administration of rt-PA should not be delayed awaiting laboratory studies.
    • Cardiac biomarkers are important because of the association of cerebral vascular disease and coronary artery disease. Additionally, several studies have indicated a link between elevations of cardiac enzyme levels and poor outcome in ischemic stroke.
  • Toxicology screening may be useful in selected patients in order to assist in identifying intoxicated patients with symptoms/behavior mimicking stroke syndromes. Urine pregnancy test should be obtained for all women of childbearing age with stroke symptoms. rt-PA is Pregnancy Class C.

Imaging Studies

  • Noncontrast head CT scan
    • Emergent noncontrast head CT scanning is mandatory for rapidly distinguishing ischemic from hemorrhagic infarction and may help determine the anatomic distribution of stroke.
    • Head CT scan is a fundamental branch point in the evaluation of stroke, since patients with acute ischemic stroke may be triaged to receive thrombolytic therapy, whereas patients with hemorrhagic stroke are best served via a completely different diagnostic and therapeutic pathway.
    • CT scan may also rule out other life-threatening processes, such as hematoma, neoplasm, and abscess.
    • The changes in CT scan over the time course of acute cerebral infarction must be understood. The sensitivity of standard noncontrast head CT increases 24 hours after ischemic event.11 After 6-12 hours, sufficient edema is recruited into the stroke area to produce a regional hypodensity on CT scan.18 A large hypodense area present on CT scan within the first 3 hours of reported symptom onset should prompt careful review regarding the time of stroke symptom onset (eg, determining when the patient was last seen in usual health). The presence of CT evidence of infarction early in presentation has also been associated with poor outcome and increased propensity for hemorrhagic transformation after thrombolytics.19,20,21
    • Other radiologic clues to acute ischemic infarction include the insular ribbon sign, the hyperdense MCA sign (MCA occlusion), obscuration of the lentiform nucleus, sulcal asymmetry, and loss of gray-white matter differentiation.11
    • Unfortunately, as many as 5% of patients with subarachnoid hemorrhages also have a normal CT scan, making lumbar puncture or other imaging (MR or CTA) imperative when subarachnoid hemorrhage is suspected. CT scan may also fail to demonstrate some parenchymal hemorrhages smaller than 1 cm.16
  • CT perfusion: CT perfusion is a novel modality potentially useful in identifying early areas of ischemia. By continuing to scan through the brain after an initial bolus of intravenous contrast dye, perfusion of different brain regions can be measured. Areas of hypoattenuation on CT perfusion imaging correspond well with ischemia and allow some determination of viability and as a result the ischemic penumbra.22,23
  • CT angiography
    • Noncontrast CT may be followed by a CT angiography (CTA) in certain centers. CTA may identify a filling defect in a cerebral artery, thus localizing the lesion to a specific portion of the causative vessel. In addition, CTA can provide an estimation of perfusion because poorly perfused cerebral tissue appears as hypodense areas of tissue. Noncontrast head CT in combination with CT angiography and CT perfusion imaging has been shown to have increased sensitivity for detecting small ischemic lesions when compared with any of the individual imaging modalities alone. CTA also has a higher sensitivity than standard noncontrast CT for detecting subarachnoid hemorrhage.11,24,25
    • CT scanning utilizing all 3 of these CT modalities (CT perfusion, angiography and noncontrast CT) are being studied in acute stroke imaging. This technology may offer improved detection of early stroke signs, small hemorrhagic strokes, and subarachnoid hemorrhages and as well allow for calculation of perfusion. These studies have the disadvantage of requiring further expense, radiation exposure, and the administration of intravenous contrast dye. It is unclear to what extent earlier detection of ischemia via newer imaging modalities will impact current treatment algorithms and the administration of thrombolytics.11
  • Magnetic resonance imaging
    • A variety of MRI protocols have utility in acute stroke.
      • Standard MR T1 and T2 sequences may be combined with other imaging protocols such as diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) to yield improved sensitivity for the detection of acute ischemic and hemorrhagic strokes over standard noncontrast CT. Further, subacute intracerebral hemorrhage, while difficult to diagnose via standard noncontrast CT, can be detected with reliability approaching 100%.
      • DWI can detect ischemia much earlier than standard CT or MRI and provides useful data in stroke and TIA patients outside of the initial management window.11,26,27 DWI MRI can detect small areas of ischemia, particularly in regions poorly visualized by noncontrast CT scanning such as the cerebellum and the brain stem.11 Acute stroke volume, as measured on DWI MRI, correlates well with final lesion volume and clinical stroke severity scales, suggesting a possible role in prognostication.28,29
    • PWI MRI directly measures perfused areas of brain in a manner similar to CT perfusion. A contrast bolus is given, and multiple images over time are obtained, providing a comparative measure of perfused versus nonperfused tissue regions. PWI MRI may have utility in acute stroke patients.30
    • MR angiography (MRA) has also been shown to have efficacy in the early identification of vascular lesions and blockages in acute stroke.31
    • Disadvantages of MRI imaging in acute stroke include its high cost, lack of ready availability at most centers, complexity, time required for transport and obtaining the study (15-20 minutes minimum with most scanners), and significant contraindication in patients with metallic implants. Despite the significant improvements in CT and MRI technology, differentiation and thus measurement of infarcted core tissue and ischemic and potentially rescuable penumbra tissue is still not possible acutely. It is likely that a combination of CT and/or MRI modalities will be necessary to fully assess the patient with acute stroke for hemorrhage and stroke mimics, and to quantify the area of infarcted versus ischemic tissue. These data will be useful in allowing the extension of the therapeutic window for thrombolysis in certain cases where large areas of rescuable tissue are identified and in preventing symptomatic intracranial hemorrhage in those patients in whom bleeds are identified.
  • Further imaging: The ultrasonography studies below are usually reserved for further evaluation outside of the ED.
    • Carotid duplex scanning is reserved for patients with acute ischemic stroke in whom carotid artery stenosis or occlusion is suspected.
    • Transcranial Doppler ultrasonography is useful for evaluating more proximal vascular anatomy, including the MCA, intracranial carotid artery, and vertebrobasilar artery.32
    • Echocardiography is obtained in all patients with acute ischemic stroke in whom cardiogenic embolism is suspected. Transesophageal echocardiography is necessary for detecting thoracic aortic dissection and more accurate for identification of thrombi in the left atrial appendage from atrial fibrillation. A certain proportion of patients with strokes may have underlying systolic dysfunction, diastolic dysfunction, or concentric hypertrophy. Echocardiography is also a modality to identify the presence of a patent foramen ovale.
  • Chest radiography: Chest radiography has potential utility for patients with acute stroke; however, obtaining a chest radiograph should not delay the administration of rt-PA, and it has not been shown to alter the clinical course or decision making in most cases.33

Other Tests

  • Electrocardiography
    • ECG should be obtained for all patients with acute stroke because as many as 60% of all cardiogenic emboli are associated with atrial fibrillation or acute MI.
    • Some reports have also recommended continuous cardiac monitoring for all patients, since 4% of patients have a life-threatening arrhythmia during the course of their illness and 3% have concurrent MI. Acute ischemic stroke has been associated with acute cardiac dysfunction and arrhythmia, which then correlate with worse functional outcome and morbidity at 3 months.34,35

Procedures

  • Angiography
    • Angiography is useful for patients with acute ischemic stroke in whom characterization of the cerebrovascular anatomy might lead to change in medical or surgical management, such as patients with subtle occlusive diseases (eg, fibromuscular dysplasia, vasculitis) or arterial dissection.
    • Angiography continues to play an important role in the preoperative evaluation of carotid artery disease.

More on Stroke, Ischemic

Overview: Stroke, Ischemic
Differential Diagnoses & Workup: Stroke, Ischemic
Treatment & Medication: Stroke, Ischemic
Follow-up: Stroke, Ischemic
References
[ CLOSE WINDOW ]

References

  1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. Dec 14 1995;333(24):1581-7. [Medline].

  2. Hacke W, Kaste M, Bluhmki E, et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. Sep 25 2008;359(13):1317-29. [Medline].

  3. [Guideline] Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator. A Science Advisory From the American Heart Association/American Stroke Association. Stroke. May 28 2009;[Medline]. [Full Text].

  4. American Heart Association. Economic Cost of Cardiovascular Diseases. Available at Http://www.americanheart.org/scientific/Hsstats98/10econom.html. Accessed June 2005.

  5. Witt BJ, Ballman KV, Brown RD Jr, Meverden RA, Jacobsen SJ, Roger VL. The incidence of stroke after myocardial infarction: a meta-analysis. Am J Med. Apr 2006;119(4):354.e1-9. [Medline].

  6. Kasner SE, Grotta JC. Emergency identification and treatment of acute ischemic stroke. Ann Emerg Med. Nov 1997;30(5):642-53. [Medline].

  7. American Heart Association. 2002 Heart and Stroke Facts Statistical Update. Dallas: American Heart Association; 2001.

  8. U.S. Centers for Disease Control and Prevention and the Heart Disease and Stroke Statistics - 2007 Update, published by the American Heart Association. Available at http://www.strokecenter.org/patients/stats.htm.. Accessed September 2008.

  9. [Guideline] Adams HP Jr. Guidelines for the management of patients with acute ischemic stroke: a synopsis. A Special Writing Group of the Stroke Council, American Heart Association. Heart Dis Stroke. Nov-Dec 1994;3(6):407-11. [Medline].

  10. Flynn RW, MacWalter RS, Doney AS. The cost of cerebral ischaemia. Neuropharmacology. Sep 2008;55(3):250-6. [Medline].

  11. [Guideline] Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. May 2007;38(5):1655-711. [Medline].

  12. Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke. May 2006;37(5):1248-53. [Medline].

  13. Huff JS. Stroke mimics and chameleons. Emerg Med Clin North Am. Aug 2002;20(3):583-95. [Medline].

  14. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. Nov 1995;52(11):1119-22. [Medline].

  15. National Institutes of Health Stroke Scale. Available at http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf. Accessed October 2008.

  16. Tintinalli J, Kellen G, Stapczynski J. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: American College of Emergency Physicians. McGraw Hill; 2004:1382-1390.

  17. Leira EC, Chang KC, Davis PH, et al. Can we predict early recurrence in acute stroke?. Cerebrovasc Dis. 2004;18(2):139-44. [Medline].

  18. Wardlaw JM, Mielke O. Early signs of brain infarction at CT: observer reliability and outcome after thrombolytic treatment--systematic review. Radiology. May 2005;235(2):444-53. [Medline].

  19. The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. Dec 14 1995;333(24):1581-7. [Medline].

  20. von Kummer R, Allen KL, Holle R, et al. Acute stroke: usefulness of early CT findings before thrombolytic therapy. Radiology. Nov 1997;205(2):327-33. [Medline].

  21. Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. Oct 4 1995;274(13):1017-25. [Medline].

  22. Klotz E, Konig M. Perfusion measurements of the brain: using dynamic CT for the quantitative assessment of cerebral ischemia in acute stroke. Eur J Radiol. Jun 1999;30(3):170-84. [Medline].

  23. Wintermark M, Reichhart M, Thiran JP, et al. Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients. Ann Neurol. Apr 2002;51(4):417-32. [Medline].

  24. Wildermuth S, Knauth M, Brandt T, Winter R, Sartor K, Hacke W. Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke. Stroke. May 1998;29(5):935-8. [Medline].

  25. Verro P, Tanenbaum LN, Borden NM, Sen S, Eshkar N. CT angiography in acute ischemic stroke: preliminary results. Stroke. Jan 2002;33(1):276-8. [Medline].

  26. Sorensen AG, Buonanno FS, Gonzalez RG, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology. May 1996;199(2):391-401. [Medline].

  27. Gonzalez RG, Schaefer PW, Buonanno FS, et al. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology. Jan 1999;210(1):155-62. [Medline].

  28. Barber PA, Darby DG, Desmond PM, et al. Identification of major ischemic change. Diffusion-weighted imaging versus computed tomography. Stroke. Oct 1999;30(10):2059-65. [Medline].

  29. Lovblad KO, Baird AE, Schlaug G, et al. Ischemic lesion volumes in acute stroke by diffusion-weighted magnetic resonance imaging correlate with clinical outcome. Ann Neurol. Aug 1997;42(2):164-70. [Medline].

  30. Neumann-Haefelin T, Wittsack HJ, Wenserski F, et al. Diffusion- and perfusion-weighted MRI. The DWI/PWI mismatch region in acute stroke. Stroke. Aug 1999;30(8):1591-7. [Medline].

  31. Lee LJ, Kidwell CS, Alger J, Starkman S, Saver JL. Impact on stroke subtype diagnosis of early diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Stroke. May 2000;31(5):1081-9. [Medline].

  32. Camerlingo M, Casto L, Censori B, Ferraro B, Gazzaniga GC, Mamoli A. Transcranial Doppler in acute ischemic stroke of the middle cerebral artery territories. Acta Neurol Scand. Aug 1993;88(2):108-11. [Medline].

  33. Sagar G, Riley P, Vohrah A. Is admission chest radiography of any clinical value in acute stroke patients?. Clin Radiol. Jul 1996;51(7):499-502. [Medline].

  34. Sirna S, Biller J, Skorton DJ, Seabold JE. Cardiac evaluation of the patient with stroke. Stroke. Jan 1990;21(1):14-23. [Medline].

  35. Adams RJ, Chimowitz MI, Alpert JS, et al. Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Stroke. Sep 2003;34(9):2310-22. [Medline].

  36. Handschu R, Poppe R, Rauss J, Neundorfer B, Erbguth F. Emergency calls in acute stroke. Stroke. Apr 2003;34(4):1005-9. [Medline].

  37. Williams JE, Rosamond WD, Morris DL. Stroke symptom attribution and time to emergency department arrival: the delay in accessing stroke healthcare study. Acad Emerg Med. Jan 2000;7(1):93-6. [Medline].

  38. Zweifler RM, Mendizabal JE, Cunningham S, Shah AK, Rothrock JF. Hospital presentation after stroke in a community sample: the Mobile Stroke Project. South Med J. Nov 2002;95(11):1263-8. [Medline].

  39. Lacy CR, Suh DC, Bueno M, Kostis JB. Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke. Jan 2001;32(1):63-9. [Medline].

  40. Milhaud D, Popp J, Thouvenot E, Heroum C, Bonafe A. Mechanical ventilation in ischemic stroke. J Stroke Cerebrovasc Dis. Jul-Aug 2004;13(4):183-8. [Medline].

  41. Krieger D, Hacke W. The intensive care of the stroke patient. In: Stroke: Pathophysiology, Diagnosis and Management. 3rd ed. New York, NY: Churchill Livingstone; 1998.

  42. Oppenheimer SM, Hachinski VC. The cardiac consequences of stroke. Neurol Clin. Feb 1992;10(1):167-76. [Medline].

  43. Kolin A, Norris JW. Myocardial damage from acute cerebral lesions. Stroke. Nov-Dec 1984;15(6):990-3. [Medline].

  44. Bruno A, Levine SR, Frankel MR, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. Sep 10 2002;59(5):669-74. [Medline].

  45. Bruno A, Biller J, Adams HP Jr, et al. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology. Jan 15 1999;52(2):280-4. [Medline].

  46. Baird TA, Parsons MW, Phanh T, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke. Sep 2003;34(9):2208-14. [Medline].

  47. Paula WK. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology. Nov 8 2005;65(9):1514; author reply 1514. [Medline].

  48. Castillo J, Leira R, Garcia MM, Serena J, Blanco M, Davalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. Feb 2004;35(2):520-6. [Medline].

  49. Johnston KC, Mayer SA. Blood pressure reduction in ischemic stroke: a two-edged sword?. Neurology. Oct 28 2003;61(8):1030-1. [Medline].

  50. Marion DW. Controlled normothermia in neurologic intensive care. Crit Care Med. Feb 2004;32(2 Suppl):S43-5. [Medline].

  51. Olsen TS, Weber UJ, Kammersgaard LP. Therapeutic hypothermia for acute stroke. Lancet Neurol. Jul 2003;2(7):410-6. [Medline].

  52. [Best Evidence] den Hertog HM, van der Worp HB, van Gemert HM, Algra A, Kappelle LJ, van Gijn J, et al. The Paracetamol (Acetaminophen) In Stroke (PAIS) trial: a multicentre, randomised, placebo-controlled, phase III trial. Lancet Neurol. May 2009;8(5):434-40. [Medline].

  53. Albers GW, Clark WM, Madden KP, Hamilton SA. ATLANTIS trial: results for patients treated within 3 hours of stroke onset. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Stroke. Feb 2002;33(2):493-5. [Medline].

  54. Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. Oct 17 1998;352(9136):1245-51. [Medline].

  55. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. Mar 6 2004;363(9411):768-74. [Medline].

  56. Wahlgren N, Ahmed N, Davalos A, Hacke W, Millan M, Muir K, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet. Oct 11 2008;372(9646):1303-9. [Medline].

  57. Graham GD. Tissue plasminogen activator for acute ischemic stroke in clinical practice: a meta-analysis of safety data. Stroke. Dec 2003;34(12):2847-50. [Medline].

  58. Donnan GA, Hommel M, Davis SM, McNeil JJ. Streptokinase in acute ischaemic stroke. Steering Committees of the ASK and MAST-E trials. Australian Streptokinase Trial. Lancet. Jul 1 1995;346(8966):56. [Medline].

  59. The Multicenter Acute Stroke Trial-Europe Study Group. Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial--Europe Study Group. N Engl J Med. Jul 18 1996;335(3):145-50. [Medline].

  60. Chalela JA, Katzan I, Liebeskind DS, et al. Safety of intra-arterial thrombolysis in the postoperative period. Stroke. Jun 2001;32(6):1365-9. [Medline].

  61. Ducrocq X, Bracard S, Taillandier L, Anxionnat R, Lacour JC, Guillemin F, et al. Comparison of intravenous and intra-arterial urokinase thrombolysis for acute ischaemic stroke. J Neuroradiol. Jan 2005;32(1):26-32. [Medline].

  62. Macleod MR, Davis SM, Mitchell PJ, et al. Results of a multicentre, randomised controlled trial of intra-arterial urokinase in the treatment of acute posterior circulation ischaemic stroke. Cerebrovasc Dis. 2005;20(1):12-7. [Medline].

  63. Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. Nov 18 2004;351(21):2170-8. [Medline].

  64. Tsivgoulis G, Eggers J, Ribo M, Perren F, Saqqur M, Rubiera M, et al. Safety and efficacy of ultrasound-enhanced thrombolysis: a comprehensive review and meta-analysis of randomized and nonrandomized studies. Stroke. Feb 2010;41(2):280-7. [Medline].

  65. Wright WL, Geocadin RG. Postresuscitative intensive care: neuroprotective strategies after cardiac arrest. Semin Neurol. Sep 2006;26(4):396-402. [Medline].

  66. Muir KW, Lees KR, Ford I, Davis S. Magnesium for acute stroke (Intravenous Magnesium Efficacy in Stroke trial): randomised controlled trial. Lancet. Feb 7 2004;363(9407):439-45. [Medline].

  67. Gobin YP, Starkman S, Duckwiler GR, et al. MERCI 1: a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia. Stroke. Dec 2004;35(12):2848-54. [Medline].

  68. Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. Jul 2005;36(7):1432-8. [Medline].

  69. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. Dec 1 1999;282(21):2003-11. [Medline].

  70. Berlis A, Lutsep H, Barnwell S, et al. Mechanical thrombolysis in acute ischemic stroke with endovascular photoacoustic recanalization. Stroke. May 2004;35(5):1112-6. [Medline].

  71. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet. May 31 1997;349(9065):1569-81. [Medline].

  72. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet. Jun 7 1997;349(9066):1641-9. [Medline].

  73. Padma V, Fisher M, Moonis M. Role of heparin and low-molecular-weight heparins in the management of acute ischemic stroke. Expert Rev Cardiovasc Ther. May 2006;4(3):405-15. [Medline].

  74. Abciximab in acute ischemic stroke: a randomized, double-blind, placebo-controlled, dose-escalation study. The Abciximab in Ischemic Stroke Investigators. Stroke. Mar 2000;31(3):601-9. [Medline].

  75. Milionis HJ, Giannopoulos S, Kosmidou M, Panoulas V, Manios E, Kyritsis AP, et al. Statin therapy after first stroke reduces 10-year stroke recurrence and improves survival. Neurology. May 26 2009;72(21):1816-22. [Medline].

  76. Abciximab Emergent Stroke Treatment Trial (AbESTT) Investigators. Emergency administration of abciximab for treatment of patients with acute ischemic stroke: results of a randomized phase 2 trial. Stroke. Apr 2005;36(4):880-90. [Medline].

  77. [Guideline] Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke. Apr 2005;36(4):916-23. [Medline].

  78. [Guideline] Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke. Apr 2003;34(4):1056-83. [Medline].

  79. [Guideline] Adams HP Jr, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. Sep 1994;25(9):1901-14. [Medline].

  80. Albers GW. Medical treatment for acute ischemic stroke. Am J Med. 1996;3-9.

  81. Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM. Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology. Apr 24 2001;56(8):1015-20. [Medline].

  82. Barsan WG, Kothari R. Stroke. In: Emergency Medicine Concepts and Practices. Vol 3. 1998:2184-98.

  83. Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med. Nov 23 1995;333(21):1392-400. [Medline].

  84. Brott T, Bogousslavsky J. Treatment of acute ischemic stroke. N Engl J Med. Sep 7 2000;343(10):710-22. [Medline].

  85. Chan YF, Kwiatkowski TG, Rella JG, Rennie WP, Kwon RK, Silverman RA. Tissue plasminogen activator for acute ischemic stroke: a New York city emergency medicine perspective. J Emerg Med. Nov 2005;29(4):405-8. [Medline].

  86. Christensen H, Fogh Christensen A, Boysen G. Abnormalities on ECG and telemetry predict stroke outcome at 3 months. J Neurol Sci. Jul 15 2005;234(1-2):99-103. [Medline].

  87. Cocho D, Belvis R, Marti-Fabregas J, et al. Reasons for exclusion from thrombolytic therapy following acute ischemic stroke. Neurology. Feb 22 2005;64(4):719-20. [Medline].

  88. del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. Stroke. Jan 1998;29(1):4-11. [Medline].

  89. Fieschi C, Hacke W, Kaste M, Toni D, Lesaffre E. Thrombolytic therapy for acute ischaemic stroke. ECASS Study Group. Lancet. Nov 15 1997;350(9089):1476; author reply 1477. [Medline].

  90. Grotta J, Bratina P. Subjective experiences of 24 patients dramatically recovering from stroke. Stroke. Jul 1995;26(7):1285-8. [Medline].

  91. Gubitz G, Sandercock P, Counsell C. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev. 2004;CD000024. [Medline].

  92. Jones MM, Nogajski JH, Faulder K, Harrington T, Ng P, Storey CE. Intra-arterial thrombolysis in acute ischaemic stroke. Intern Med J. May 2005;35(5):300-2. [Medline].

  93. Kase CS, Wolf PA, Chodosh EH, et al. Prevalence of silent stroke in patients presenting with initial stroke: the Framingham Study. Stroke. Jul 1989;20(7):850-2. [Medline].

  94. Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med. Jun 10 1999;340(23):1781-7. [Medline].

  95. Lewandowski C, Barsan W. Treatment of acute ischemic stroke. Ann Emerg Med. Feb 2001;37(2):202-16. [Medline].

  96. Lyden PD, Lau GT. A critical appraisal of stroke evaluation and rating scales. Stroke. Nov 1991;22(11):1345-52. [Medline].

  97. National Institute of Neurological Disorders Stroke rt-PA Stroke Study Group. Recombinant tissue plasminogen activator for minor strokes: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study experience. Ann Emerg Med. Sep 2005;46(3):243-52. [Medline].

  98. National Stroke Association Consensus Group. Stroke: the first hours - emergency evaluation and treatment. Stroke Clin Updates. 1997;5-14.

  99. Noor R, Wang CX, Shuaib A. Hyperthermia masks the neuroprotective effects of tissue plaminogen activator. Stroke. Mar 2005;36(3):665-9. [Medline].

  100. Parnetti L, Caso V, Santucci A, et al. Mild hyperhomocysteinemia is a risk-factor in all etiological subtypes of stroke. Neurol Sci. Apr 2004;25(1):13-7. [Medline].

  101. Raco, et al. Management of acute cerebellar infarction: One institution's experience. Neurosurgery vol 53(5). Nov 2005;1061-1065.

  102. Ribo M, Molina CA, Rovira A, et al. Safety and efficacy of intravenous tissue plasminogen activator stroke treatment in the 3- to 6-hour window using multimodal transcranial Doppler/MRI selection protocol. Stroke. Mar 2005;36(3):602-6. [Medline].

  103. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med. Jun 23 2005;352(25):2618-26. [Medline].

  104. [Guideline] Schwamm LH, Pancioli A, Acker JE 3rd, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Circulation. Mar 1 2005;111(8):1078-91. [Medline].

  105. Tomson J, Lip GY. Blood pressure changes in acute haemorrhagic stroke. Blood Press Monit. Aug 2005;10(4):197-9. [Medline].

  106. Wechsler LR, Roberts R, Furlan AJ, et al. Factors influencing outcome and treatment effect in PROACT II. Stroke. May 2003;34(5):1224-9. [Medline].

  107. Wilterdink JL, Bendixen B, Adams HP Jr, Woolson RF, Clarke WR, Hansen MD. Effect of prior aspirin use on stroke severity in the trial of Org 10172 in acute stroke treatment (TOAST). Stroke. Dec 1 2001;32(12):2836-40. [Medline].

  108. Wyer PC, Osborn HH. Recombinant tissue plasminogen activator: in my community hospital ED, will early administration of rt-PA to patients with the initial diagnosis of acute ischemic stroke reduce mortality and disability?. Ann Emerg Med. Nov 1997;30(5):629-38. [Medline].

  109. Yundt KD, Diringer MN. The use of hyperventilation and its impact on cerebral ischemia in the treatment of traumatic brain injury. Crit Care Clin. Jan 1997;13(1):163-84. [Medline].

  110. Zweifler RM. Management of acute stroke. South Med J. Apr 2003;96(4):380-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Joseph U Becker, MD, Fellow, Global Health and International Emergency Medicine, Stanford University
Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Charles R Wira, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale School of Medicine
Charles R Wira, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.