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It is Stroke Awareness Month! May 16, 2019

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

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.

Need more information or Stroke CME?
Click here to review the issue and take the CME test, but hurry, CME expires August 1, 2019!

It is Stroke Awareness Month! Can you solve the stroke case below? May 10, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Was it a “mini stroke”? — ED Management of Transient Ischemic Attack

Case Recap:
A 59-year-old obese woman presents to your community hospital ED after experiencing a distinct episode in which her left hand felt “clumsy,” along with a left facial droop and left-sided numbness. She denies experiencing frank weakness and states that the symptoms resolved in less than 10 minutes. She mentions that she experienced a similar episode 2 weeks prior, and is concerned because both her parents and an older sibling experienced disabling ischemic strokes. Her vital signs and point-of-care glucose were normal, and her ECG showed sinus rhythm. Her physical examination, including a detailed neurologic examination, was largely unrevealing, with no facial asymmetry, unilateral weakness, sensory loss, or dysmetria appreciated. A noncontrast cranial CT scan of the brain was remarkable only for nonspecific subcortical and periventricular white matter changes without evidence of acute or old infarction, mass, or hemorrhage. Although she is relieved to learn that she has not had a stroke, she is concerned that this may be a precursor of a more serious event. She does not have a primary care physician and states that she has not seen a physician in several years. She asks whether this was a “mini stroke” and, if yes, what the chances are that she will have a stroke in the future?

Case Conclusion:
The 59-year-old obese patient’s detailed description of abrupt, negative symptoms appropriately raised your concern for a right anterior circulation TIA. You calculated her ABCD2 score as a 2, correctly counting her reported facial droop and unilateral weakness. Knowing recent risk stratification data, you counseled her that her 7-day stroke risk was very low; however, you also remembered that the periventricular white matter hypointensities on CT may be indicative of underlying small-vessel cerebrovascular disease, and her report of multiple recent episodes raised your concern. Since your observation unit was at capacity, you insisted on hospital admission. As an inpatient, she underwent MRI/MRA, revealing extensive small-vessel disease and multiple lacunar infarctions of varying ages. She was seen by a neurologist, started on antiplatelet therapy, and counseled on diet and exercise strategies. She remained stroke-free at a 3-month follow-up appointment.

Did you get it right?

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Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage February 17, 2019

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

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening.

This clinical pathway will help you improve care in the management of patients with subarachnoid hemorrhage. Download now.


Life-Threatening Headache. What do you do? February 12, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced…

Case Conclusion:
You recognize that this cancer patient’s change in mental status and severely elevated blood pressure was likely the result of PRES. You obtained a CT of the head, which revealed white-matter changes in the posterior cerebral hemispheres. Utilizing IV nicardipine, you lowered the patient’s MAP by 25% over the first hour. In addition, you temporarily discontinued his chemotherapy medication. He subsequently became more alert and responsive.

Would you have done it different? Tell us how you would have handled this case.

“High-risk of stroke…” Case Conclusion January 7, 2013

Posted by Andy Jagoda, MD in : Cardiovascular, Neurologic , add a comment

Case re-cap:

A 72-year-old woman with a history of hypertension, diabetes, coronary artery disease, and chronic kidney disease presents shortly after experiencing a 20-minute episode of slurred speech and right facial droop. She denies experiencing similar events in the past, but she does endorse a transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month. On exam, her blood pressure is 178/100 mm Hg, her heart rate is 80 beats per minute and regular, and the ECG shows a sinus rhythm. Her stroke scale is zero, and noncontrast cranial CT scan shows an old small cerebellar infarct. It is Friday evening, and you have no inhouse neurology and no MRI capabilities overnight. The patient attributes her symptoms to stress and states that she has experienced anxiety and palpitations recently. She asks if it is necessary for her to be admitted or whether she can seek follow-up with her primary care physician next week.

Case conclusion:

You correctly identified that the 72-year-old woman was at a high short-term risk of stroke with an ABCD2 score of 6 and multiple recent episodes in different vascular territories as well as evidence of an old infarct on CT scan. At your recommendation, she agreed to admission. You arranged expedited etiologic workup, including carotid duplex and transcranial Doppler ultrasound, which was initially unrevealing. She experienced a brief episode of atrial fibrillation, which was captured on the cardiac monitor, before leaving the ED. Knowing that cardioembolic causes correlate with increased stroke severity and stroke mortality, you arranged for transthoracic echocardiography the next morning, which revealed a left atrial thrombus. She was started on anticoagulation and was recurrence-free at 3 months.

Congratulations to Ramy Yakobi, Jim Mitch, Patrick Bruss, Michael Dawson, and CD  — this month’s winners of the exclusive discount coupon for Emergency Medicine Practice. For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Transient Ischemic Attack: An Evidence-Based Update, purchase the Emergency Medicine Practice issue on this topic.

High-risk of stroke… December 28, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Neurologic , 16comments

A 72-year-old woman with a history of hypertension, diabetes, coronary artery disease, and chronic kidney disease presents shortly after experiencing a 20-minute episode of slurred speech and right facial droop. She denies experiencing similar events in the past, but she does endorse a transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month. On exam, her blood pressure is 178/100 mm Hg, her heart rate is 80 beats per minute and regular, and the ECG shows a sinus rhythm. Her stroke scale is zero, and noncontrast cranial CT scan shows an old small cerebellar infarct. It is Friday evening, and you have no inhouse neurology and no MRI capabilities overnight. The patient attributes her symptoms to stress and states that she has experienced anxiety and palpitations recently. She asks if it is necessary for her to be admitted or whether she can seek follow-up with her primary care physician next week.

How would you handle this patient?

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Last Modified: 07-16-2019
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