Emergency Stroke Care: Advances & Controversies Volume III

Accreditation

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation

EB Medicine designates this enduring material for a maximum of 8 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Objectives

Upon completion of this article, you should be able to:

1. Identify the key elements of the history, physical examination, and laboratory testing in the initial evaluation of acute stroke patients
2. Describe the indications and contraindications for IV tPA and mechanical thrombectomy
3. Determine the imaging necessary prior to treating acute ischemic stroke with IV tPA or mechanical thrombectomy
4. Provide optimal management before and after treatment
5. List the risk factors for blunt cerebrovascular injury
6. Identify factors in the history and physical examination that can be indicative of a dissection
7. Perform appropriate emergency department workup for diagnosis of carotid and vertebral artery dissections
8. Initiate appropriate interventions to prevent stroke and to treat acute ischemic strokes due to blunt cerebrovascular injury.

Table of Contents

Acute Ischemic Stroke: Emergency Department Management After the 3-Hour Window (Stroke CME and Pharmacology CME)

1. Abstract
2. Introduction
3. Critical Appraisal of the Literature
4. Etiology and Pathophysiology
5. Outcome Measures
6. Time Windows for Treatment of Acute Ischemic Stroke
7. Prehospital Care
8. Emergency Department Management
   1. Initial Stabilization
   2. History
   3. Physical Examination
   4. Blood Pressure Management
   5. Laboratory Testing
   6. Intravenous tPA Administration Within the 3- to 4.5-Hour Time Window
      1. Imaging in the 3- to 4.5-Hour Time Window
   7. Mechanical Thrombectomy in the 0- to 6-Hour Time Window
      1. Imaging in the 0- to 6-Hour Time Window
   8. Mechanical Thrombectomy in the 6- to 24-Hour Time Window
      1. Imaging in the 6- to 24-Hour Time Window
   9. IV tPA in Patients With Unknown Time of Onset
      1. Imaging in Patients With Unknown Time of Onset
9. Disposition
10. Summary
11. Clinical Pathway for Management of Acute Ischemic Stroke After the 3-Hour Time Window
12. Tables and Figures
    1. Table 1. Modified Rankin Scale
    2. Table 2. Contraindications to the Use of IV tPA for Acute Ischemic Stroke
    3. Table 3. Eligibility Criteria for Treatment of Acute Ischemic Stroke with IV tPA
    4. Table 4. Eligibility Criteria for Treatment of Acute Ischemic Stroke with Mechanical Thrombectomy
    5. Figure 1. Left Middle Cerebral Artery Occlusion on Computed Tomographic Angiography of the Head
    6. Figure 2. Right Middle Cerebral Artery Occlusion Seen on CTA and CTP With Resolution After Mechanical Thrombectomy Seen on Cerebral Angiogram
13. References

Blunt Cerebrovascular Injuries: Early Recognition and Stroke Prevention in the Emergency Department (Stroke CME)

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Spontaneous Cervical Artery Dissections
   2. Traumatic Cervical Artery Dissections
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History and Physical Examination
   2. Spontaneous Cervical Artery Dissections
      1. Pain Characteristics
      2. Compressive Symptoms
      3. Transient Ischemic Attack or Stroke
   3. Traumatic Cervical Artery Dissections
9. Diagnostic Studies
   1. Computed Tomographic Angiography
   2. Magnetic Resonance Imaging
   3. Ultrasound
   4. Digital Subtraction Angiography
10. Treatment
    1. Stroke
    2. Medical Therapies for Stroke Prevention
       1. Antiplatelet Medications Versus Anticoagulant Medications
       2. Customization of Treatment
       3. Timing of Treatment
       4. Follow-Up Imaging
       5. Length of Treatment
    3. Endovascular Therapy
11. Special Populations
    1. Intracranial Dissections
    2. Pregnancy and Puerperium
    3. Cervical Artery Dissection in the Pediatric Population
12. Controversies and Cutting Edge
    1. Timing Of Antithrombotic Therapy
    2. Blood Pressure Management
13. Disposition
    1. Prognosis
    2. Consultation
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Management of Cervical Artery Dissections in the Emergency Department
17. Case Conclusions
18. Clinical Pathway for Diagnosis and Treatment of Cervical Artery Dissection
19. Tables and Figures
    1. Table 1. Guidelines Related to the Treatment of Carotid or Vertebral Artery Dissections
    2. Table 2. Clinical Presentations of Cervical Artery Dissection
    3. Table 3. Screening Criteria for Blunt Cervical Artery Dissection Injuries
    4. Figure 1. Mechanism of Cervical Artery Dissection
    5. Figure 2. Common Sites of Carotid and Vertebral Artery Dissection
    6. Figure 3. Double Lumen in Carotid Artery Dissection on Computed Tomographic Angiography
    7. Figure 4. Magnetic Resonance Imaging Compared to Computed Tomographic Angiography in Cervical Artery Dissection
    8. Figure 5. Carotid Artery Dissection on Ultrasound
    9. Figure 6. Pseudoaneurysm On Digital Subtraction Angiography
20. References