Ischemic/Hemoragic Stroke Presentation

NPO

NPO

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Save you the sorry...

Do ischemic strokes present differently then hemoragic ?
 
I've heard nausea/vomiting is more specific for hemorrhage stroke, and the patient saying "this is the worst headache I've ever had", may describe the onset as a thunder clap for subarachnoid hemorrhage. At The EMT Spot, it says pontime hemorrhage will sometimes cause pinpoint pupils (miosis). I think an ischemic stroke sometimes self resolves without treatment within 24 hours, but the odds of them having another stroke within the next couple of days to weeks is really high.
 
If your getting a BP that is crazy high (280/170 or something) odds are hemorrhagic. BP presents higher in hemorrhagic then ischemic. Also if you get rapid deterioration of mental status it is more likely to be a bleed.
 
They may present with Cushing's Triad (bradycardia, widening pulse pressure, irregular respiration) or have a CGS of 3 with normal BP and HR, but this is dependent of the bleed's location.
 
tchristifulli said:
Peaked T waves are also a rare finding in Hem strokes.
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Hemorrhagic Strokes can present with "Cerebral T waves" which are deep inverted T waves with a prolonged QT similar to Wellen's T waves. They can also present with diffuse non-specific ST elevation, which I just posted an example of in another thread.

Here is an example of Cerebral T waves
SAH1.jpg



There really is no fool proof way of distinguishing the type of stroke based on symptoms alone. You can get a pretty good idea based history, events leading up to, and initial presentation.
 
NPO said:
Save you the sorry...

Do ischemic strokes present differently then hemoragic ?
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Sure they present differently... on CT. In most cases.

The only clinical manifestation of a hemorrhagic CVA that is not ischemic is when you see signs of uncal herniation. You're only going to see that when there is more mass in the cranial vault than the cranial vault will allow.

Signs of uncal herniation: widening pulse pressure (i.e. 268/42), bradycardia. And then there are the irradict VS, hypertension with tachycardia followed by hypotension with bradycardia and going back and forth. These people are dead. Their bodies just don't know it yet.
 
What everyone else said...you must have a CT, according to ASLS, to confirm and differentiate them.
 
OK now let me give some background to see if it changes things.

Patient was a mid 40s male, approximately 400lbs. No CT available because he was over weight for the CT machine at sending.

Pt was awake and, per yes/no type questions was oriented. Left sided facial droop, left side hemiplagia. Patient would go between in fully responsive and limited levels of response.

Bp 160s/90s hr 90 snoring respirations. Transported code 3 to higher level care.
 
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NPO said:
OK now let me give some background to see if it changes things.

Patient was a mid 40s male, approximately 400lbs. No CT available because he was over weight for the CT machine at sending.

Pt was awake and, per yes/no type questions was oriented. Left sided facial droop, left side hemiplagia. Patient would go between in fully responsive and limited levels of response.
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Take a guess, 50/50 chance of being right.
 
npo said:
ok now let me give some background to see if it changes things.

Patient was a mid 40s male, approximately 400lbs. No ct available because he was over weight for the ct machine at sending.

Pt was awake and, per yes/no type questions was oriented. Left sided facial droop, left side hemiplagia. Patient would go between in fully responsive and limited levels of response.

Bp 160s/90s hr 90 snoring respirations. Transported code 3 to higher level care.
Click to expand...

bgl?
 
Take any blood thinners or anti-platelet meds?
 
NPO said:
OK now let me give some background to see if it changes things.

Patient was a mid 40s male, approximately 400lbs. No CT available because he was over weight for the CT machine at sending.

Pt was awake and, per yes/no type questions was oriented. Left sided facial droop, left side hemiplagia. Patient would go between in fully responsive and limited levels of response.

Bp 160s/90s hr 90 snoring respirations. Transported code 3 to higher level care.
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In regards to the bolded part of your statement, I have never seen a bleed affect someone enough for them to lose some level of response only to regain it. I have only seen deteriorating mental orientation in bleeds that leads to failed airway generally. If this person was able to go back and forth between responsiveness and limited response I would think Ischemic is vastly more likely (or possibly a bad, and early caught TIA). With a bleed deterioration is going to be fairly permanent, I would suspect you would not see someone with a bad bleed go unconscious and then pop back up and be able to answer some questions but not others.

The majority of presentations of bleeds that I have seen in the hospital ER either involve BP's over 260 systolic, seizures, or rapidly deteriorating mental capacity that results in intubation shortly.



Chase said:
Take a guess, 50/50 chance of being right.
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actually I think ischemic strokes account for 87-90% of all strokes, so if asked to guess, ischemic :p
 
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Rialaigh said:
In regards to the bolded part of your statement, I have never seen a bleed affect someone enough for them to lose some level of response only to regain it. I have only seen deteriorating mental orientation in bleeds that leads to failed airway generally. If this person was able to go back and forth between responsiveness and limited response I would think Ischemic is vastly more likely (or possibly a bad, and early caught TIA). With a bleed deterioration is going to be fairly permanent, I would suspect you would not see someone with a bad bleed go unconscious and then pop back up and be able to answer some questions but not others.

The majority of presentations of bleeds that I have seen in the hospital ER either involve BP's over 260 systolic, seizures, or rapidly deteriorating mental capacity that results in intubation shortly.
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Thank you that's what m kinda looking for. I hadn't had a confirmed hemoragic strokev yet so I don't know what they look like. And since this guy was going back end forth on mentation levels and I had never seen that before either I wondered if that could be an effect of a bleed.
 
NPO said:
OK now let me give some background to see if it changes things.

Patient was a mid 40s male, approximately 400lbs. No CT available because he was over weight for the CT machine at sending.

Pt was awake and, per yes/no type questions was oriented. Left sided facial droop, left side hemiplagia. Patient would go between in fully responsive and limited levels of response.

Bp 160s/90s hr 90 snoring respirations. Transported code 3 to higher level care.
Click to expand...

Well my guess would be Ischemic. Since he is 400lbs I would say it is a safe bet that he has a great deal of fatty build up in his arteries, which would increase his risk of Ischemic strokes and ACS; the fact that he can answer questions and has left sided hemiplegia just screams ischemic to me. If it was hemorhagic I don't think he would be doing much talking, and like others have said would more than likely present with the cushings triad. So if I had to bet on it I would put my money on Ischemic. On the other hand I could be wrong, just putting in my two cents hope it helped.
 
Gastudent said:
lOn the other hand I could be wrong, just putting in my two cents hope it helped.
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All input is appreciated. There is no 'wrong' answer because I wasn't around when a ct was finally do e.
 
Subdural bleeds can present with changing levels of consciousness as blood build then redistribute.
 
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