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Stroke and Transient Ischemic Attack
Questions and answers
1
What is a stroke?
A stroke, more formally termed a cerebrovascular accident (CVA), is any event that disrupts blood supply to the brain and causes neurologic compromise. It is important to diagnose and treat early as lack of blood supply to the brain equates to lack of oxygen and nutrients thus leading to irreversible cell death.
2
What is a transient ischemic attack (TIA)?
A TIA is as it sounds—a transient disruption in blood supply that causes neurologic injury. Classically, it had been defined as symptoms lasting less than 24 hours; however, evidence suggests that TIAs can lead to permanent brain injury.
3
Name some patient risk factors for CVAs.
CVA risk factors are very similar to those for coronary artery disease. These include advanced age, African American race, male gender, hypertension, diabetes mellitus, and hyperlipidemia. Patient lifestyle adds to risk if the patient is physically inactive and smokes. Atrial fibrillation and carotid artery stenosis also confer an added risk of stroke.
4
What is the critical first test to do before calling a stroke alert?
Hypoglycemia is one of the great stroke mimics where patients can be confused, altered, or have odd neurologic symptoms that can easily be mistaken for a CVA. A rapid point-of-care fingerstick blood glucose test at the scene can elucidate if this is the cause and be treated. If symptoms are related to hypoglycemia, then they should rapidly improve with normalization of the blood glucose.
5
What if you do not have capabilities to perform this critical first test?
If you cannot perform a fingerstick blood glucose (out of supplies, basic life support unit, etc.), you can try and ask the family who may be able to assist in this testing. However, given the potential devastating pathology a stroke can cause, rapid transport should not be delayed and the receiving facility should be made aware that this test was not yet performed to help in their management.
6
How are strokes classified?
All CVAs are related to blood supply in the brain and are classified as ischemic (90%) or hemorrhagic (10%) ( Table 23.1 ).
Table 23.1
Cerebrovascular Accident Classification
| ISCHEMIC (90%) | HEMORRHAGIC (10%) |
|---|---|
| Cardioembolic: thrombi originating from the heart as a result of atrial fibrillation or valvular heart disease | Most often from hypertension or cerebral amyloid angiopathy (in the elderly) leading to bleeding of small penetrating arteries. |
| Large vessel disease: occlusions often from hyperlipidemia | Aneurysm rupture leading to subarachnoid hemorrhage |
| Small vessel disease: occlusions often from hypertension or diabetes | |
| Other: ischemia from arterial dissections or hypercoagulable state |
7
What are common stroke symptoms?
CVAs can present in a variety of different manners, from unilateral facial droop and hemiparesis to dizziness or gait disturbance. It is important to keep a keen eye out for symptoms that seem out of the ordinary. Larger strokes may affect speech (aphasia), cause visual disturbances or gaze preference, and even unilateral neglect, where a patient has complete lack of awareness of an entire side of their body.
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