Seeing a Stroke
Developed by:
K. Banasky, RN, BSN
Educator
GCH Emergency Services
What we know…
There are two types of stroke/brain attack:
• Ischemic
• Hemorrhagic
Treatment is based on the type of brain attack a
person is having.
Efforts by the American Stroke Association,
National Stroke Association, and American
Heart Association include mass education to
the public on brain attack and response.
ACT F.A.S.T.
• ACT F.A.S.T. is a public education campaign
on recognition of Stroke symptoms as an
emergency.
• ACT F.A.S.T. stands for
– F Face: Facial Droop, Uneven Smile
– A Arm: Arm numbness, Arm Weakness
– S Speech: Slurred speech, Difficulty speaking or
understanding
– T Time: Call 911 and get to the hospital
immediately
ACTING FAST
When a patient arrives to the Emergency
Department with symptoms of a
stroke…OR…an admitted patient exhibits
symptoms of a stroke, time is critical in
determining if a Cerebral Vascular Accident
aka CVA is occurring.
Obtaining a CT Scan of the Brain is one of the
most important evaluation tools for
determination of treatment.
Why?
Time is Tissue
CT scan of the brain helps to determine if there is a
bleed within the brain.
• Evidence of blood, or an active bleed within the brain
immediately contraindicates administration of tPA
(tissue Plasminogen Activator)
• If blood is present, a Neurosurgery consult of the
patient is necessary to determine course of care as
there is risk of herniation from increased pressures.
• If NO blood is evident on the CT scan, treatment
commences to reverse the effects of stroke.
What Happens
The patient is transported to CT via cart/stretcher with
RN present. Upon completion, radiology immediately
evaluates scan for the presence of blood.
If NO evidence of blood exists, the finding is termed
“CT Negative”, meaning CT is negative for
hemorrhage. Initially a CT may be read as
“Negative”; however, ischemia eventually appears.
KEYPOINTS:
• This indicates ONLY, that the patient does not have
evidence of hemorrhage.
• CT must be completed within 25 minutes of arrival in
the ED or within 25 minutes of recognition of StrokeLike Symptoms.
How do we know it is a stroke?
• Diagnosis is based on clinical assessment
findings and Negative for Hemorrhage Scan.
– Clinical diagnosis of Stroke with a measurable
deficit
– Timeline of events
– History by patient or individuals present prior to
and during event (i.e. family, friends, staff)
– There is no evidence of improvement or reversal of
symptoms
• KEYPOINT: A CT Scan of the brain will
eventually demonstrate signs of Ischemia.
Figure 1. Drawings (top) illustrate the territories (blue) of the ACA, middle cerebral artery
(MCA) , and posterior cerebral artery.
The CT Scan
below each
drawing shows
an infarction of
the artery.
de Lucas E M et al. Radiographics 2008;28:1673-1687
©2008 by Radiological Society of North America
Figure 12. Hypertension-related macrohemorrhage in an 80-year-old woman with right-sided
weakness and a blood pressure of 160/85 mm Hg.
The White area
showing up within the
CT scan of this brain is
evidence of
hemorrhage. This
patient would NOT be
a candidate for tPA
Chao C P et al. Radiographics 2006;26:1517-1531
©2006 by Radiological Society of North America
Figure 6. CAA-related macrohemorrhage with associated subdural hemorrhage in a 77-yearold man with severe headache and difficulty walking.
This patient was
documented as
having a severe
headache and
difficulty walking.
The large white area
indicates
Hemorrhage.
Chao C P et al. Radiographics 2006;26:1517-1531
©2006 by Radiological Society of North America
Figure 2. Determination of ICH location in a 74-year-old man with acute onset of expressive
aphasia, confusion, and a right-sided facial droop.
This area within the brain is
white and demonstrates
hemorrhage. This patient
would NOT be a candidate
for tPA as the scan
demonstrates blood present.
Chao C P et al. Radiographics 2006;26:1517-1531
©2006 by Radiological Society of North America
Figure 2a. Early ischemic CT signs.
Early ischemic CT signs. CT
scans show subtle
hypoattenuation and sulcal
effacement in the right MCA
territory (arrows in 2a)
This infers that the
area supplied by the
MCA is changing
due to the lack of
nutrient rich blood.
de Lucas E M et al. Radiographics 2008;28:1673-1687
©2008 by Radiological Society of North America
Figure 1b. Early infarct in the territory of the left middle cerebral artery in a 52-year-old man.
This is an un-enhanced
image of a ischemic stroke
caused by a thrombus.
This would be considered a
negative CT meaning
“negative for hemorrhage”;
however, ischemia is
present.
Provenzale J M Radiographics 1999;19:1323-1331
©1999 by Radiological Society of North America
Ischemic Stroke
Hyperdense MCA Sign
Notice the area of brain is not
white, but the Middle Cerebral
Artery is white, (aka. MCA sign)
indicative of an Ischemic Stroke.
This CT Scan would be
“negative for hemorrhage”;
however ischemia is present
within this scan.
Figure 4a. Acute stroke (2.5 hours evolution) in a 55-year-old man with right hemiplegia.
Can you see the
stroke?
The arrows indicate
changes within the
brain matter from lack
of Oxygen and
Glucose rich blood
de Lucas E M et al. Radiographics 2008;28:1673-1687
©2008 by Radiological Society of North America
Figure 4e. Acute stroke (2.5 hours evolution) in a 55-year-old man with right hemiplegia.
This is the same patient.
What changed?
e) Follow-up CT scan
obtained 24 hours later
shows hemorrhagic
transformation. An extensive,
established infarcted core
poses the major risk for
hemorrhagic complications
after thrombolysis.
de Lucas E M et al. Radiographics 2008;28:1673-1687
©2008 by Radiological Society of North America
So what does this mean for us?
• When a patient arrives to our hospital or ED, is
admitted and experiences Stroke-Like
Symptoms, we must ACT F.A.S.T.
• CT scan is the most effective and rapid way to
evaluate if there is indication of hemorrhage.
• Acting FAST can save brain and allow for
administration of time sensitive medication or
intervention.
• Time is Tissue
Please complete test after viewing this
Demonstration.
The test will submit electronically.
No need to print…GO GREEN!
Special Thanks
• Thank you to Dr. Dan Wale PGY3, Radiology
Resident at Garden City Hospital for his time
and assistance
• Garden City Hospital Radiology Department
• Garden City Hospital Radiology
Administration
• Dr. Brian Kim, Chair of GCH Emergency
Services
References
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American Stroke Association
American Heart Association
American College of Radiology
Chao C P et al. Radiographics 2006;26:1517-1531
Dr. Dan Wale, PGY 3, Garden City Hospital Department of
Radiology
Dr. Brian Kim, Chair Emergency Services Garden City
Hospital
de Lucas E M et al. Radiographics 2008;28:1673-1687
National Stroke Association
Provenzale J M Radiographics 1999;19:1323-1331
Radiological Society of North America