A 68-year-old man is brought to the emergency department for acute right-sided hemiplegia,
headache, and impaired consciousness. His symptoms started an hour ago and are
progressively getting worse. He has no prior history of transient ischemic attack. His medical
problems include obesity, gout, benign prostatic hyperplasia, benign essential tremor,
hypertension, and hypercholesterolemia The patient’s medications include allopurinol,
tamsulosin, propranolol, amlodipine, and simvastatin. He has smoked a pack of cigarettes daily
for 15 years. Neurological examination shows right-sided weakness and hemi-sensory loss.
There is a carotid bruit on his left side. Which of the following is the most appropriate next step in
management?
ID A Anticoagulation with heparin
6 B. Carotid Doppler
ID C. CT angiography of the head and neck
6 D. CT of the head without contrast
® E. Echocardiogram
e; F. MRI of the brain
0 G. Treatment with aspirin
This patient likely has stroke due to spontaneous intracerebral hemorrhage (ICH). Stroke can be
ischemic or hemorrhagic, and the latter is subcategorized into subarachnoid hemorrhage (SAH)
and ICH. ICH is characterized by acute focal neurologic deficits that gradually worsen over
minutes to hours. As the hemorrhage expands, symptoms of elevated intracranial pressure (eg,
headache, vomiting, a~e ed mental status) may develop. Hypertension is the most important risk
factor.
Conversely, SAH classically presents with the sudden onset of severe headache that may be
associated with brief loss of consciousness, nausea/vomiting, and meningismus Patients with
ischemic stroke usually have an abrupt onset of focal neurologic deficits but lack headache and
impaired consciousness. A previous history of transient ischemic attack is also characteristic of
ischemic stroke.
Patients with suspected acute stroke should initially receive a CT scan of the head without
contrast to rule out hemorrhage (highly sensitive) Although MRI can detect hemorrhage, CT is
preferred due to its widespread availability, acquisition speed, and lower cost (Choice F)
Neurovascular imaging can be done with CT angiography to detect abnormalities of the
intracranial and extracranial arteries (eg, aneurysm, stenosis) but should be considered after a
non-contrast study (Choice C)
(Choices A and G) Secondary prevention with aspirin is indicated in most patients with acute
ischemic stroke, and anticoagulation with heparin can be considered in those with acute
cardioembolism (eg, due to atrial fibrillation). CT should be performed prior to initiating either of
these agents to rule out hemorrhage
(Choices B and E) Carotid Doppler and echocardiogram may be considered after head CT to
~
evaluate for possible embolic sources in patients with ischemic stroke.
Conversely , SAH classically presents with the sudden onset of severe headache that may be
associated with brief loss of consciousness, nausea/vomiting, and meningismus. Patients with
ischemic stroke usually have an abrupt onset of focal neurologic deficits but lack headache and
impaired consciousness. A previous history of transient ischemic attack is also characteristic of
ischemic stroke.
Patients with suspected acute stroke should initially receive a CT scan of the head without
contrast to rule out hemorrhage (highly sensitive) Although MRI can detect hemorrhage, CT is
preferred due to its widespread availability, acquisition speed, and lower cost (Choice F)
Neurovascular imaging can be done with CT angiography to detect abnormalities of the
intracranial and extracranial arteries (eg, aneurysm, stenosis) but should be considered after a
non-contrast study (Choice C)
(Choices A and G) Secondary prevention with aspirin is indicated in most patients with acute
ischemic stroke, and anticoagulation with heparin can be considered in those with acute
cardioembolism (eg, due to atrial fibrillation) CT should be performed prior to initiating either of
these agents to rule out hemorrhage
(Choices B and E) Carotid Doppler and echocardiogram may be considered after head CT to
evaluate for possible embolic sources in patients with ischemic stroke.
Educational objective:
Intracranial hemorrhage classically presents with acute focal neurologic deficits that gradually
worsen over minutes to hours and can be associated with symptoms of elevated intracranial
pressure (eg, headache, vomiting, altered mental status) Patients with suspected acute stroke
should initially receive a head CT without contrast to rule out hemorrhage