Clinical Pathway for Management of Acute Ischemic Stroke After the 3-Hour Time Window
July 20, 2021

Posted by Andy Jagoda MD in: Feature Update , add a comment

Acute ischemic stroke is a leading cause of morbidity and mortality in the United States, and a majority of acute ischemic stroke patients are evaluated for the first time by a clinician in the emergency department. Our recent issue Acute Ischemic Stroke: Emergency Department Management After the 3-Hour Window presents evidence-based guidelines for the diagnosis and treatment of acute ischemic stroke in patients who present more than 3 hours after their last known well time. read more

Current Topics in Acute Stroke Care: Clinical Pathway for Acute Management of Central Retinal Artery Occlusion
August 10, 2020

Posted by Andy Jagoda MD in: Feature Update , 1 comment so far

Clinicians are highly likely to encounter patients with stroke in the emergency department and must be able to diagnose and manage stroke in a timely and effective manner to optimize patient outcomes. Emergency department management of stroke includes utilizing imaging appropriately based on the type of stroke, assessing patient risk for additional cardiovascular or stroke events, and recognizing subtle or different forms of stroke, such as patients who have normal initial imaging or patients who present with a central retinal artery occlusion.  read more

Test Your Knowledge: Evaluation and Management of Life-Threatening Headaches in the ED
February 6, 2020

Posted by Andy Jagoda, MD in: Brain Tease , 1 comment so far

Emergency Medicine Practice Blog Brain Teaser

Though patients often present to the ED seeking relief from headaches that cause significant pain and suffering, 90% of them can be considered ?benign.? It is essential to identify the 10% of headache patients who are in danger of having a life-threatening disorder presenting with a sudden and severe headache to ensure that they are treated quickly and effectively. read more

How to unlock 40% more LLSA options
January 29, 2020

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You just finished a rewarding but intensely grueling day.

Caseloads were high, patients were demanding, and time to JUST BREATHE was scarce.

You give your inbox a quick glance before going home to get some sleep so you can do it all again tomorrow, and one email yells for your attention: ?REMINDER! LLSA requirement for your ABEM certification.? Yikes. Just what you need? one more thing on your plate. You buckle down to fork out $$ and precious time to meet your ABEM certification requirement.

Unlock more LLSA options read more

Risk Management Pitfalls in the Management of Pediatric Stroke
January 21, 2020

Posted by Andy Jagoda, MD in: Feature Update , 1 comment so far

Stroke is a leading cause of morbidity and mortality in children. The etiologies, risk factors, and presentation of stroke differ from those of adults, and the diagnosis of stroke is often delayed in children. The management of pediatric stroke can be challenging because there are few data to support the efficacy of interventions. read more

What’s Your Diagnosis? Patient With Acute Dizziness
November 29, 2019

Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case, on Pain Management: Beyond Opioids, right. Click here to check out the answer! read more

Test Your Knowledge: Pediatric Stroke: Diagnosis and Management in the ED
November 21, 2019

Posted by Andy Jagoda, MD in: Brain Tease , add a comment

Stroke is a leading cause of morbidity and mortality in children. The etiologies, risk factors, and presentation of stroke differ from those of adults, and the diagnosis of stroke is often delayed in children. The management of pediatric stroke can be challenging because there are few data to support the efficacy of interventions.

Test your knowledge and see if you’d spot stroke in a pediatric patient!

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$( ".question22" ).click(function() { //When the question is clicked on. . .
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Review this Pediatric Emergency Medicine Practice issue to get up-to-date on the most common causes of pediatric stroke, provides guidance for distinguishing stroke from stroke mimics, discusses the indications for diagnostic studies, and offers evidence-based recommendations for treatment in the emergency department.

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What’s Your Diagnosis? a 7-year-old boy after a generalized seizure lasting 2 minutes
November 1, 2019

Posted by Andy Jagoda, MD in: What's Your Diagnosis , 4 comments

But before we begin, check out if you got last month’s case right, about the 9-month-old infant gasping for air. Click here to check out the answer! read more

Intravenous Thrombolysis in Acute Ischemic Stroke
July 17, 2019

Posted by Andy Jagoda, MD in: Feature Update , add a comment

Stroke is the fifth leading cause of death in the United States and an important cause of long-term disability. Approximately 795,000 people suffer from stroke each year (610,000 primary strokes and 185,000 recurrent strokes),1 with ischemic stroke representing the vast majority of all stroke types (87%).

The cornerstone of acute ischemic stroke treatment relies on rapid clearance of an offending thrombus in the cerebrovascular system. Advanced neuroimaging and clinical trials, together with continuous adjustments of inclusion/exclusion criteria, have helped emergency clinicians to rapidly and more accurately identify the patients who will benefit from acute stroke treatment.

Inclusion and Exclusion of Intravenous Thrombolysis: A Changing Landscape

The American Heart Association (AHA) recently published updated guidelines for stroke management. Table 1, summarizes the updated 2018 AHA indications and contraindications for treatment with IVT. Every patient presenting with symptoms of acute stroke within 4.5 hours of last known well or usual state should be triaged for potential IVT. Patients should be evaluated with computed tomography (CT) scan of the brain and systolic blood pressure (SBP) should be maintained at < 185 mm Hg and diastolic blood pressure (DBP) at < 110 mm Hg. Every eligible patient should receive IVT without delay. Changes and adjustments of inclusion/exclusion criteria (in order to minimize the risk of any complication) have been made and are discussed in following sections.

Table 1. Eligibility Criteria and Exclusion Criteria for Intravenous Thrombolysis
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It is Stroke Awareness Month!
May 16, 2019

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10 Risk Management Pitfalls For Cervical Artery Dissections

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained.

Use these risk management pitfalls to avoid unwanted outcomes when performing cervical artery dissections. Download now.

1. ?This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast CT head and it?s negative. The headache is probably just due to a hard game of basketball yesterday. I?m going to give him some IV ketorolac and send him out.?

Dissections can occur spontaneously or as a result of minor trauma, even from a basketball game. Failure to consider the diagnosis will result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; the radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome. Both of those are suspicious for carotid artery dissection and warrant further vascular imaging.

2. ?She has a history of migraines, and she says that this one is different from what she usually feels, but it definitely sounds like a migraine because it is unilateral, pulsatile, and she had a visual aura. I?m going to give her the usual migraine cocktail and see how she does.?

Not suspecting cervical arterial dissection in the beginning of the evaluation results in a significant delay to diagnosis. It can be many hours by the time she has a couple of migraine cocktails before you realize her headache isn?t better and you need to rethink your plan. Due to the risk of early stroke in these patients, a delay in diagnosis could lead to long-term neurological sequelae. Headaches in carotid dissections can be unilateral, pulsatile, and with an aura. Any time a patient with a history of migraines states that the symptoms are not typical, take note.

3. ?A 35-year-old woman was attacked by her boyfriend. He hit her on the right side of the neck near her jaw, causing her head to snap around to the left. Her neurological examination is completely normal. She is in a great deal of pain, but it seems to be related to the soft-tissue injury from the hit, because her noncontrast CT head and c-spine are negative. I?m going to treat her pain and see how she feels.?

Pain due to the trauma could mask specific signs or symptoms of dissection. In these patients, relying on the history to identify high-risk factors is important. Due to the location of the blow, it may have caused a hyperextension and rotation of her head in addition to direct trauma, which could have caused a dissection. Patients with risk factors should have advanced vascular imaging (CTA or MRA).

4. ?I couldn?t do a neurological examination because she was in too much pain. I?ll treat her headache and then try again later.?

Although it seems kind to give patients a little time to obtain comfort before performing an examination, a prompt neurological examination is absolutely necessary in order to determine any findings that need to be addressed immediately, such as an acute stroke.

5. ?A 12-year-old boy fell off of his bike after running into a parked car, and then he had a seizure. The noncontrast CT head and c-spine were normal. He is still in some pain, but I don?t see anything abnormal on his neuro examination, so I?m going to clear his c-spine.?

Pediatric patients with dissection have different symptoms from adults; seizure has been shown to be a presenting symptom in 12.5% of cases. The seizure, along with the mechanism, should prompt vascular imaging to assess for a cervical artery dissection before the cervical collar is removed.

6. ?I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I?ll just treat her pain and send her home.?

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or a slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

7. ?The CTA showed a dissection, so I gave him an aspirin and called neurology. However, he now says he doesn?t want to wait and wants to go home. His neuro examination is normal, so I was thinking of sending him out on aspirin.?

Sending the patient home in the acute setting without consultation is not a good idea. Due to high risk of stroke in the first 24 hours and the high incidence of progression of lower-grade dissections, these patients warrant close monitoring and early follow-up imaging to determine the need for escalation of care.

8. ?The intubated trauma patient had his noncontrast CT head and c-spine and the radiologist just called and said there is a temporal bone fracture through the carotid canal. I?m going to pass it along and let the trauma service finish the workup after he gets to the intensive care unit.?

This will lead to a significant delay in diagnosis, which could be devastating for the patient. Due to its sensitivity and availability in the ED, a CTA should be performed prior to the patient being transported upstairs, so treatment can be started immediately.

9. ?The CTA showed a vertebral artery dissection on that patient from the roller coaster ride, so I consulted the neurology service for admission. Her neuro examination is normal, so I?m going to wait to treat her and see what they recommend.?

An antithrombotic agent for stroke prevention needs to be started on this patient and can be started in the ED to avoid treatment delays. Studies in this population have not shown superiority of one over the other, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events if no contraindications exist.

10. ?The patient is a 42-year-old man presenting with an acute onset of right-sided hemiplegia and global aphasia that started 1 hour ago while at the grocery store. His CT head was negative for hemorrhage, but the CTA showed a dissection in his left carotid artery with about 50% vessel occlusion. Unfortunately, that excludes him from treatment with rtPA due to the risk of hemorrhage or intramural hematoma expansion.?

Data have shown rtPA to be as safe in patients with cervical dissections as with patients with strokes due to other causes. Therefore, this patient should be treated with rtPA as soon as possible if there are no contraindications. Endovascular treatment should also be considered if there are contraindications to IV rtPA or if he does not improve after treatment.

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