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Subacute/Minor CVA


New and innovative, but it may also serve the grey area between TIA and conventional CVA



Inclusion Criteria

  • Non-disabling Stroke (i.e. unlikely to require nursing home/subacute rehab upon discharge)
    • Ambulatory
    • Independent with ADLs
    • NIHSS less than or equal to 3 (with individual components less than or equal to 1)
    • passing bedside dysphagia screen
  • At pre-stroke disability if disabled at baseline
    • No High-risk conditions:
    • Unstable deficit (waxing/waning)
    • Evidence of embolic pattern (Cortical strokes)
    • Acute infarcts larger than 2 cm
    • Presence of large artery stenosis (greater than 50%)
  • HCT negative for hemorrhage/mass
  • Seen by neurology in ED
  • Workup can be completed within ~18hrs

Exclusion Criteria

  • Disabling Stroke (new gait disturbance, unable to perform ADLs, NIHSS >3, fails dysphagia screen)
  • Presence of high-risk features:
    • Unstable deficit (waxing/waning)
    • Evidence of embolic pattern (Cortical strokes)
    • Acute infarcts larger than 2 cm
    • Presence of large artery stenosis (> 50%)
  • Altered/depressed mental status
  • Head CT imaging positive for bleed, mass, or acute infarction.
  • Known extra-cranial embolic source – history of atrial fibrillation, cardiomyopathy, artificial heart valve, endocarditis, known mural thrombus,
  • Non-focal symptoms – ie confusion, weakness, seizure, transient global amnesia
*Hypertensive encephalopathy
*Severe headache or evidence of cranial arteritis
*Acute medical or social (poor home support) issues requiring inpatient admission
*Prior large stroke - making serial neurological examinations problematic
*Pregnancy

Potential Interventions

  • Neuro checks Q-2hr
  • Neurology consult
  • Carotid imaging with MRI/MRA - to detect surgical carotid stenosis (>50%) and microinfarct
    • If contraindications to MRI/MRA and good renal function, then CTA of head and neck vessels
    • If contraindications to MRI/MRA and poor renal function, then carotid doppler
  • 2-D Echocardiography - to detect a cardioembolic source.
  • Cardiac monitoring – for at least 12 hours for paroxysmal atrial fibrillation
  • Appropriate antiplatelet therapy (Aspirin ⇒ If on ASA then Plavix OR Aggrenox)
  • TIA stroke preventive educational materials (lipids, smoking, DM, HT, obesity, alcohol, stroke)
  • Rehab consideration with outpatient treatment planning (orders placed for outpatient PT/OT if needed)

Discharge Criteria

Home

    • No recurrent deficits, negative workup
    • Clinically stable for discharge home (on Asa – 81mg/day)

Admit

    • Recurrent symptoms / worsening deficit
    • Evidence of treatable vascular disease - ie >50% stenosis of neck vessels
    • Evidence of embolic source requiring treatment (ie heparin / coumadin) - ie mural thrombus, Paroxysmal atrial fibrillation
    • Unable to complete workup or safely discharge patient within timeframe
    • Occupational or Physical Therapists recommend rehab
    • Provider (neurology or emergency) judgment


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