1 Clinical Presentation and Acute Triage of Ischemic Stroke, Intracranial Hemorrhage, and Subarachnoid Hemorrhage

Devi P. Patra, Onur Açiş, Miles Hudson, Benzion Blech, Gyanendra Kumar, Vanesa K. Vanderhye, Lynda M. Christel, and Bernard R. Bendok

Abstract

Acute stroke management is challenging because patients can have varied presentation and multiple pathologies can present in a similar way. In this regard, it is critical to identify and triage stroke patients as the treatment paradigm can be significantly different. The triage begins in the field by the emergency medical services (EMS) in the prehospital setting and then in the emergency department, where ischemic stroke is primarily differentiated from a hemorrhagic stroke in addition to ruling out other pathologies like tumors, vascular malformations, and even other systemic conditions mimicking a stroke. The triage process starts with careful initial history and examination, and rapid laboratory tests including glucose and oxygen saturation, which in most of the cases gives a global impression regarding the etiology of the stroke. A rapid noncontrast computed tomography (CT) scan is the key differentiating imaging modality to differentiate an ischemic and hemorrhagic stroke. In the absence of hemorrhage or other obvious mass lesion, most patients receive thrombolytic therapy unless contraindicated. Further evaluation includes a CT or magnetic resonance (MR) angiogram with or without perfusion study based on the timing of presentation, which helps in detecting large vessel occlusion. Similarly, most patients with hemorrhagic stroke are further evaluated with an angiographic study to rule out structural lesions like aneurysms, arteriovenous malformations, etc. In an acute setting, a prompt differentiation of type of stroke in the emergency department is essential to institute rapid treatment to prevent irreversible brain damage.

Key words

acute stroke - ischemic stroke - hemorrhagic stroke - subarachnoid hemorrhage - triage - intracranial hemorrhage - intracerebral hemorrhage - thrombectomy - large vessel occlusion

• 1 Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke.. N Engl J Med 2015; 372 (1) 11-20 PubMed

• 2 Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial.. Lancet Neurol 2016; 15 (11) 1138-1147 PubMed

• 3 Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection.. N Engl J Med 2015; 372 (11) 1009-1018 PubMed

• 4 Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke.. N Engl J Med 2015; 372 (11) 1019-1030 PubMed

• 5 Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke.. N Engl J Med 2015; 372 (24) 2296-2306 PubMed

• 6 Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.. N Engl J Med 2015; 372 (24) 2285-2295 PubMed

• 7 Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.. Stroke 2018; 49 (3) e46-e110 PubMed

• 8 Chartrain AG, Shoirah H, Jauch EC, Mocco J. A review of acute ischemic stroke triage protocol evidence: a context for discussion.. J Neurointerv Surg 2018; 10 (11) 1047-1052 PubMed

• 9 Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.. N Engl J Med 2018; 378 (1) 11-21 PubMed

• 10 Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.. N Engl J Med 2018; 378 (8) 708-718 PubMed

• 11 Smith EE, Kent DM, Bulsara KR, et al. Accuracy of prediction instruments for diagnosing large vessel occlusion in individuals with suspected stroke: a systematic review for the 2018 guidelines for the early management of patients with acute ischemic stroke.. Stroke 2018; 49 (3) e111-e122 PubMed

• 12 Kettner M, Helwig SA, Ragoschke-Schumm A et al. Prehospital computed tomography angiography in acute stroke management.. Cerebrovasc Dis 2017; 44 (5–6) 338-343 PubMed

• 13 Rincon F, Lyden P, Mayer SA. Relationship between temperature, hematoma growth, and functional outcome after intracerebral hemorrhage.. Neurocrit Care 2013; 18 (1) 45-53 PubMed

• 14 Hemphill III JC, Greenberg SM, Anderson CS, et al. , , Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.. Stroke 2015; 46 (7) 2032-2060 PubMed

• 15 Douglas V, Shamy M, Bhattacharya P. Should CT angiography be a routine component of acute stroke imaging?. Neurohospitalist 2015; 5 (3) 97-98 PubMed

• 16 Hemphill III JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage.. Stroke 2001; 32 (4) 891-897 PubMed

• 17 Beck J, Raabe A, Szelenyi A et al. Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage.. Stroke 2006; 37 (11) 2733-2737 PubMed

• 18 Connolly Jr ES, Rabinstein AA, Carhuapoma JR, et al. , , , , Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.. Stroke 2012; 43 (6) 1711-1737 PubMed