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Acute hemorrhagic stroke
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Acute ischemic stroke
Glioblastoma multiforme
Subdural hematoma
Partial seizure
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The patient has acute left-sided facial paralysis and hyperdensity on non-contrast CT of the head consistent with acute hemorrhagic stroke. Initial work-up of a patient with concern for stroke is a non-contrast head CT in order to rule out a hemorrhage before consideration of tPA, as distinction between ischemic and hemorrhagic strokes can be difficult based on symptoms alone. If hemorrhage is identified, tPA is contraindicated. If an ischemic stroke is suspected clinically and CT is negative for evidence of a hemorrhagic stroke, the recommended treatment is to give IV tPA if the presentation is within 3-4.5 hours. For embolic disease and hypercoagulable states, give warfarin or aspirin only once the hemorrhagic stroke has been ruled out. Yew and Cheng discuss strokes, which can be classified as ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The classic presentation of an ischemic stroke is awakening with or the abrupt onset of focal neurologic deficits, the most common being difficulty with speech and weakness on one half of the body. Postictal states following seizures and hypoglycemia may mimic an ischemic stroke. Nentwich and Veloz discuss neuroimaging in the setting of an acute stroke, in which non-contrast brain CT should be the first study. Because CT functions to rule out a hemorrhagic stroke, further studies should be undertaken if the CT is negative. MRI, specifically diffusion-weighted imaging and others, are the most widely used. MR studies may show which brain regions are already infarcted and which are at risk of infarction if perfusion is not restored. Figure A shows a non-contrast CT of a hemorrhagic stroke. Note the hyper-dense blood. An infarct would be hypo-dense. Illustration A displays a hypodense ischemic stroke on head CT for comparison. Incorrect Answers: Answer 2: An acute ischemic stroke would not show up on CT for at least 24 hours. Answer 3: This presentation is not consistent with a GBM. Answer 4: A subdural hematoma would be seen as crescentic lesion extending from the skull. Answer 5: A partial seizure can result from brain lesions but is not the most likely cause of this patient's symptoms.
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