CVA/TIA

• CVA Risks


  • HTN
  • dyslipidemia
  • DM
  • smoking
  • physical inactivity
  • afib
  • diet/nutrition
  • obesity
  • alcohol consumption
  • substance abuse
• Unmodifiable CVA Risks


  • older (>80yo)
  • race and ethnicity (black > white)
  • family history and genetic conditions
  • sex (generally M > F)
• CVA Symptoms


  • Mental status change/confusion
  • dysarthria
  • receptive or expressive aphasia
  • New paresthesias/weakness (usually unilateral)
  • Severe HA w/o known cause
  • Acute vision change in one/both eyes
  • New gait abnormality, coordination or balance issue
  • dizziness
• CVA Assessment


  • rapid hx
  • vitals
  • POC glucose
  • CT
  • time of onset/last known well
• CVA Physical Exam


  • detailed neuro exam
  • rapid initial focused exam
  • POC glucose then immediately CT scanner
  • vitals
  • CT head, non-contrast (r/o hemorrhage)
  • CTA head/neck (critical stenosis, obvious LVO)
  • EKG
  • CBC, BMP, Trop, coags (pt/inr, ptt)
  • hcg maybe UA
  • brain MRI w diffusion sequence
• Ischemic CVA Treatment Options

  • Symptom onset <4.5 hours- option for TPA
  • Symptom onset <24 hours- possible mechanical thrombectomy if LVO
  • Symptom onset >24 hours- generally supportive care and secondary
  • "Wake-up stroke" or unwitnessed symptom onset- may be candidate for MT w appropriate imaging based criteria (e.g. MRI demonstrating acute ischemic lesion, diffusion positive, FLAIR negative) at an expert stroke center
• Secondary Prevention for All CVA Patients

  • BP mngent- treat if >220/>120, goal of <185/<110 if initiating TPA (<180/<105 for 24 hours after TPA), aspiration risk? Admit
• tPA Inclusion/Exclusion Criteria


  • need clin dx of ischemic stroke
  • sig neuro defects
  • onset sx <4.5hrs before tx
  • older than 18
  • Sx of subarachnoid hemorrhage
  • bp elevation
  • active internal bleed
  • infective endocarditis
  • stroke from aortic arch dissection
  • acute bleeding diathesis
• Prognosis


  severity of stroke at neuro exam predict short/long term outcomes, <6 is good, >16 is bad
• Factors Associated with Worse CVA Outcomes

  • LVO
  • older/larger infarct
  • LOW BMI
• Diffusion-perfusion mismatch on MRI


  may indicate risk of lesion progression
• Women tend to have lower mortality, higher morbidity than men
• Low income/socioeconomic status, living situations have worse outcomes
• Sx improvement by 12hrs, and takes up to 18mo. Most ppl improve mostly by 2-5mo
• Neurologic Conditions to Compare and Contrast

  • CVA
  • TIA
  • Bell 's palsy
  • Seizure disorder
  • Movement disorders
• Underlying Causes of Ischemic vs Hemorrhagic CVA

  • Ischemic= thrombotic, ischemic, hypoxic
  • Hemorrhagic= intracerebral or subarachnoid
• CT Findings for Ischemic CVA

  • Hyperdense Artery Sign
  • Loss of Grey-White Matter Differentiation
  • Sulcal Effacement
  • Hypodensity in the affected area
  • Insular Ribbon Sign
• CT Findings for Hemorrhagic CVA

  • Hyperdense Area-indicating acute blood
  • Intraventricular Hemorrhage
  • Subarachnoid Hemorrhage
  • Mass Effect (midline shift, ventricular compression)
  • Perihematomal Edema
• Focal Neurologic Deficits and Lesion Locations

  • Middle cerebral artery (MCA)= Contralateral paresis (esp. Face, arm), sensory deficit; inability to understand, produce speech (left hemisphere); hemispatial neglect (right hemisphere); homonymous hemianopsia; deviation of eye to damaged side
  • Anterior cerebral artery (ACA)= Contralateral hemiparesis (esp., leg, face), sensory deficit; inability to understand, produce speech (left hemisphere); impaired judgment; inconsistency
  • Posterior cerebral artery (PCA)= Homonymous hemianopsia, cortical blindness (bilateral lesion), Midbrain: oculomotor, trochlear palsy → dilated pupil, Thalamus: sensory loss, impaired memory, altered consciousness
  • Posterior cerebellar artery syndrome (PICA): AKA "Wallenberg" syndrome, Dizziness, nystagmus; speech, swallowing Difficulties, Ipsilateral: facial sensory loss, Horner's sign, Ataxia, Contralateral: loss of pain, temperature sensation in limbs
  • Basilar/vertebral arteries= Dizziness; gait, vision disorders; dysarthria, dysphagia, Locked-in syndrome: thrombosis/embolism of basilar artery, Plegia of head, body muscles, except eye; only blinking, vertical eye movement possible