So I love mnemonics. Sue me.
We really tend to have problems with the myriad of possibilities for a stroke patient to deteriorate in the first – say – 72 hours. Even worse and more problematic if he chooses to decline in the first hours after thrombolysis, where everyone only thinks hemorrhage.
After a decade of juggling the options in my head, I came up with a reasonably simple mnemonic for the etiology of END – HEMODYNAMICS:
- H emorrhage – need a CT for this
- E mbolism from a proximal stenosis – need ultrasound or CTA for this
- M icroangiopathic: these tend to fluctuate a lot, but there is no proof. Think of it, if the same symptoms tend to progress or fluctuate from 100% to 0% and back
- O edema: early edema can pose problems in large strokes or if a microangiopathic lesion occurs near the capsule and swells; need a CT for this, better even: MRI
- D islocation: this is important in tPA patients – a well collateralized proximal embolus can shrink through thrombolysis and occlude a distal arterial segment where collateralization is not so good, thus increasing symptoms or even leading to new symptoms – need a CTA
- Y namics: both occlusions and high grade stenoses can lead to fluctuations along with blood pressure instability. Need an ultrasound or CTA for that, but a better proof is orthostatic increase of symptoms. What I really like is: raising the blood pressure by 50 mmHg to see whether the patient improves.
- M imics: think of migraine or encephalitis as the original cause of the stroke symptoms. As for diagnostics, probatory treatment with Metamizol+MCP and a spinal tap can help.
- I ctal: another mimic, requiring EEG to rule out or – if not possible – 1g of Levetiracetam
- C sf circulation problems – CT is enough
- S preading depression: after ruling out everything else, this is what remains. No proper diagnostics for that, but try Topiramate.
So here is our diagnostic algorithm:
- History – timecourse of deterioration, headache, other symptoms
- Examination – vital signs, neurological and internal
- Labs: routine labs + cTnI + EtOH
- Imaging: preferrably MRI, but if that is not acutely available: CT + CTA
- Ultrasound for hemodynamics
- EEG to rule out status, or 1g LEV
- Novalgin + MCP for Migraine
- Spinal tap to rule out encephalitis