Hemorrhagic vs Ischemic Stroke Indicators?

[CWATT]

Preface: This question has been bugging me for a while now. If I'm honest, I've been afraid to put myself out there as to not look foolish, but if someone can benefit from this then I'm okay with a little criticism.

When I wrote my EMT licensing exam there was a question that asked you to differientiate between hemorrhagic vs. Ischemic stroke based on a case scenario. I've since completed ACLS and they cite only a non-contrast CT scan will determine this. Are there any symptomatic indicators like focal neurological signs that are unique to one type of stroke vs the other?


Thanks in advance,

- C

 

[E tank]

Preface: This question has been bugging me for a while now. If I'm honest, I've been afraid to put myself out there as to not look foolish, but if someone can benefit from this then I'm okay with a little criticism.

When I wrote my EMT licensing exam there was a question that asked you to differientiate between hemorrhagic vs. Ischemic stroke based on a case scenario. I've since completed ACLS and they cite only a non-contrast CT scan will determine this. Are there any symptomatic indicators like focal neurological signs that are unique to one type of stroke vs the other?


Thanks in advance,

- C

Since one involves an intracerebral bleed, I guess symptoms of increased ICP would be a differential, but the reality is that you need a CT to tell for sure.

Some embolic strokes can lead to hemorrhagic strokes, just to confuse the picture. Hemorrhagic strokes make up less than 20 % of CVA's and if a child or healthy young person presents with serious neurologic symptoms, you might include intracerebral bleed/tumor in the diff.

But, odds are, if you see someone with a stroke, it's embolic.

Oldish smokers and a fib patients are at biggest risk for embolic strokes so odds are, for them, that's it. It really doesn't matter though. Part of the brain isn't getting blood either way.

 

[CALEMT]

Since one involves an intracerebral bleed, I guess symptoms of increased ICP would be a differential, but the reality is that you need a CT to tell for sure.

We were just talking about this in lecture today. E tank is right, theres really no way to differentiate out in the field if its hemorrhagic or ischemic. The increased ICP with hemorrhagic is the main difference between the two. With that increased ICP you may have a headache associated with it. Really the only way to know for sure is a CT scan. You're going to treat both in the same manner out in the field.

 

[SpecialK]

If you are keen you can attempt to ascertain which part of the brain has lost its blood supply by relating it to changes in vision, motor power, speech, gait etc. The limitations are (a) it only works for ischaemic strokes, (b) it is not at all sensitive and only kind of specific and (c) in no way shape or form clinically significant so don't even bother.

Positive FAST test and less than four hours onset? Take urgently to a hospital with CT scanner and thrombolysis is about the gist of it.

 

[EpiEMS]

No evidence based way to differentiate prehospitally that I'm aware of.

 

[Summit]

Indicator is the rapid interpretation of the CT scan

 

[EpiEMS]

This is the only prehospital indicator...if you can afford it.

 

[Carlos Danger]

Preface: This question has been bugging me for a while now. If I'm honest, I've been afraid to put myself out there as to not look foolish, but if someone can benefit from this then I'm okay with a little criticism.

When I wrote my EMT licensing exam there was a question that asked you to differientiate between hemorrhagic vs. Ischemic stroke based on a case scenario. I've since completed ACLS and they cite only a non-contrast CT scan will determine this. Are there any symptomatic indicators like focal neurological signs that are unique to one type of stroke vs the other?

As the others have said, there's no way to tell for sure without a scan.

That said, the "classic" ischemic stroke is painless and presents with unilateral focal neurologic deficits, such as weak grip and facial droop. Coordination and balance may or may not be affected. The patient may be perfectly lucid or mildly confused and/or dysphasic. Symptoms can be subtle, even subclinical, or they can be dramatic.

By contrast, the textbook hemorrhagic stroke patient presents with signs of increased ICP and looks much sicker. With an intracerebral (subarachnoid) bleed, severe head pain is common and often progresses to loss of consciousness. Epidural bleeds almost almost always result from trauma and usually progress pretty quickly. Subdural bleeds are usually traumatic as well, and can also progress quickly, or can remain subclinical.

 

[ParamedicStudent]

Increased ICP and projectile vomiting are indicators of a hemorrhagic stroke. Also complain of "worst" headache of their life.

 

[StCEMT]

SpecialK kind of reminded of something. Maybe one of the other members with more first hand experience can chime in on this, but I'd venture to say it might be more worth your time brushing up on signs of anterior vs posterior stroke.

 

[EpiEMS]

SpecialK kind of reminded of something. Maybe one of the other members with more first hand experience can chime in on this, but I'd venture to say it might be more worth your time brushing up on signs of anterior vs posterior stroke.

Interesting idea - looked it up quickly, and unfortunately:

Inaccurate localization would occur commonly if clinicians relied on the clinical neurological deficits alone to differentiate PCI from ACI. Neuroimaging is vital to ensure accurate localization of cerebral infarction.

 

[StCEMT]

Interesting idea - looked it up quickly, and unfortunately:

Guess I should clarify. Not necessarily to roll in and say with certainty it's a PCI, but just recognizing other signs associated with it. There are others that go beyond the FAST signs we use for anterior strokes. So being familiar with some of the signs associated with a PCI, that way a stroke isn't ruled out prematurely on our end is more what I was getting at.

 

[EpiEMS]

So being familiar with some of the signs associated with a PCI, that way a stroke isn't ruled out prematurely on our end is more what I was getting at.

Ah, gotcha - I was thinking more about distinguishing them. It seems to me, at least, based on what I have found, that the usual signs (unilateral deficits) are predominant, though the so-called 5-Ds ("dizziness, diplopia, dysarthria, dysphagia, and dystaxia") also appear. I would say that those all cause me enough concern for stroke or other acute neurological problem to strongly advise transport - though I don't think I could call a stroke alert per my protocols based solely on dizziness, diplopia, or dysphagia.