Basic Clinical Syndromes and Definitions

The goal for neurological evaluation in the Emergency Department is to appropriately route potential acute stroke patients toward medical or surgical interventions in the most expedient manner possible. This chapter focuses on familiarizing the reader with main stroke subtypes and clinical manifestations associated with specific syndromes. Acute neurologic episodes being evaluated in the emergent setting for stroke workup can be divided into broad categories based on duration of symptoms, clinical presentation, and findings from basic imaging. This chapter explores the most common of these stroke syndromes and discusses the classification and clinical characteristics of transient ischemic attacks and ischemic and hemorrhagic strokes.

Surgical Treatment of Hemorrhagic Stroke

This chapter describes basic pathophysiology along with evidence-based indications for the decision-making process of medical versus surgical intervention in hemorrhagic strokes. Both the critical care management and surgical treatment of intracerebral and intraventricular hemorrhages, epidural and subdural hematomas, and subarachnoid hemorrhage are examined. The common completed landmark clinical trials, along with ongoing trials, of surgical treatment for intervention of hemorrhagic strokes are reviewed. The chapter concludes with two case-based treatment modalities and patient outcome. The following text is not a comprehensive guideline for the management of cerebral hemorrhages but rather a framework of principles supported through the literature for which to treat hemorrhagic stroke patients.

Intravenous Thrombolysis in Acute Ischemic Stroke

The only proven therapy for patients with acute ischemic stroke is early recanalization. The use of intravenous thrombolytic alteplase is the standard of care for patients presenting with ischemic stroke within the first 4.5 hours from symptom onset. This chapter reviews the indications and contraindications to alteplase including the 2015 American Heart Association guidelines and their relevance to clinical practice. Furthermore, emerging research and ongoing trials on expanding the time window for intravenous thrombolysis are discussed.

Telemedicine for Evaluation of Stroke Patients

Telemedicine uses video communication to evaluate patients at an originating site by a distant physician. Telestroke was developed to apply telemedicine for the delivery of stroke expertise to hospitals with limited or no available stroke capability. This chapter reviews the most commonly used models of telestroke networks. It discusses the evidence for telestroke, including its value in managing patients with ischemic stroke who are candidates for intravenous alteplase and endovascular thrombectomy, as well as patients with intracerebral hemorrhage. Economic, legislative, and legal issues of treating patients within a telestroke network are also reviewed. Future advances in telemedicine will continue to deliver expert care in a way that brings comprehensive care to patient’s doorstep.

Prehospital Triage of Stroke

Proper identification of patients with acute ischemic stroke in the prehospital setting can be challenging. This chapter reviews the most commonly employed prehospital stroke screening tools. Such tools were initially designed to optimize the timely detection of strokes in the field by the emergency medical personnel. However, in conjunction with the recent advances in endovascular stroke therapy, new field screens have been developed with the goal of identifying patients with higher likelihood of emergent large vessel occlusion strokes. These new screens can assist the emergency medical personnel with patient triage to the most appropriate facility within a regional stroke system of care.

Medical Management of Hemorrhagic Stroke

Since the management of hemorrhagic stroke differs from that of ischemic stroke, prompt, accurate, and early diagnosis is vital in the management of patients who present with acute onset of focal neurologic symptoms and/or with altered mental status. Diagnostic imaging in the form of computed tomography scan or magnetic resonance imaging and a vessel study is required to ascertain the bleeding characteristic, location, and etiology. A multidisciplinary approach is required in the management of hemorrhagic stroke. Early diagnosis and treatment of the hemorrhagic stroke impacts the long-term outcome of such patients. This chapter reviews the common clinical presentations, diagnostic imaging modalities and prehospital and emergency department medical management of the most common types of hemorrhagic stroke.

Care of Stroke Patients Post Intravenous Alteplase and Endovascular Thrombectomy

The last three decades have seen significant advances in stroke therapeutics that have resulted in the development of medical and endovascular interventions for acute revascularization. After acute treatment, it is recommended that patients are transferred to a stroke or intensive care unit for careful assessments. The goal of the immediate postoperative care is to provide continuous observation of vital signs, vascular access site checks, and cardiac monitoring and to administer uniform neurological evaluations to capture clinical fluctuations and/or complications. The purpose of this chapter is to provide a contemporary perspective based on recent data, along with the authors’ recommendations on the acute care and management of acute ischemic stroke patients post revascularization.

Stroke Systems of Care

Recent randomized controlled trials of stroke thrombectomy have led the American Heart Association to provide recommendations that thrombectomy be pursued in patients with large vessel occlusions who meet certain criteria. Evolving recommendations allow the Brain Attack Coalition to establish, update, and maintain a hierarchal system of care involving the proper management of different types of acute stroke. This chapter will outline various stroke systems of care and assist emergency medicine providers in evaluating, managing, and triaging patients with different types of stroke. The history behind the development of stroke centers as well as the qualifications for each level of care are discussed here alongside example cases of patients best managed at the various hospital subtypes.

Cerebral Venous Thrombosis

Establishing the diagnosis of cerebral venous thrombosis (CVT) can often be challenging to physicians. CVT presents with variable symptoms, resulting in delay in establishing the correct diagnosis and treatment. This chapter provides practical recommendations on the currently available diagnostic and treatment options in patients with suspected acute CVT. The diagnostic value of computed tomography, magnetic resonance imaging, and catheter angiography are also discussed. This chapter also includes recommendations for medical treatment with systemic anticoagulation, the role of endovascular therapy, and indications for surgical interventions including hemicraniectomy and control of intracranial pressure. Formal evidence-based guidelines released by the American Heart Association in 2011 are also outlined in this chapter.

Medical Management of Ischemic Stroke

This chapter reviews the main principles of the initial medical management of ischemic stroke. The fundamental principles of initial medical management of ischemic stroke are discussed. Based on the American Heart Association’s guidelines, these medical management standards include general supportive care (i.e., patient positioning, control of temperature, blood pressure), the use of antiplatelet and lipid-lowering agents, blood glucose control, dyslipidemia, and neuroprotection. This chapter also reviews and discusses the most recent data on the indication and timing of anticoagulation and the use of newer anticoagulation agents. Stroke clinical cases resulting from intracranial atherosclerosis, carotid and vertebral artery dissection, and fibromuscular dysplasia are presented.