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Cerebrovascular Accident G010

Document
Last amended 
30 June 2015

Current RMA Instruments:

Reasonable Hypothesis SOP
65 of 2015
Balance of Probabilities SOP
66 of 2015

Changes from Previous Instruments:

SOP Bulletin 183

ICD Coding:

  • Transient ischaemia attack (ICD-9 435; ICD-10 G45.0-.2,.8,.9)
  • Cerebral infarction (ICD-9 433.01,433.11,433.21,433.31,433.81,433.91,434.01,434.11,434.91434.01, 434.11; ICD-10 I63)
  • Intra-cerebral haemorrhage (ICD-9 431; ICD-10 I61)
Brief description:

A cerebrovascular accident (CVA) is an acute symptomatic neurological injury of the brain.  The symptoms may be temporary or permanent and are due to either cerebral ischaemia or haemorrhage (bleeding) into the brain.   The SOP does not cover: cerebrovascular disease that has not caused an acute symptomatic event; stroke due to other causes (e.g. subarachnoid haemorrhage); nor chronic disease of the brain such as vascular dementia.

Cerebral ischaemia means an interruption to the blood supply to the brain. If temporary, the resulting brain dysfunction may be reversible, with the process being a TIA (transient ischaemic attack).  If the ischaemia persists the process is a cerebral infarction (brain death). The ischaemic type of CVA is analogous to the angina pectoris and myocardial infarction in ischaemic heart disease.

In the case of intracerebral haemorrhage, brain damage occurs as a result of the compression of the brain surrounding the haematoma, and due to the loss of blood flow to the brain tissue distal to the haemorrhaging vessel.

Confirming the diagnosis

The diagnosis of an ischaemic stroke (cerebral infarction) or cerebral haemorrhage requires both acute neurological symptoms and signs and confirmation by a brain CT [computerised tomography] scan or MRI [Magnetic Resonance Imaging] scan.

A transient ischaemic attack (TIA) is a clinical diagnosis and needs to be differentiated from other causes of acute transient neurological symptoms such as an epileptic attack, a migraine variant, the onset of another neurological disease such as multiple sclerosis or Parkinson’s disease, a hypoglycaemic attack, syncope due to cardiac disease or hypoxic attack from respiratory disease.

The relevant medical specialist is a neurologist or general physician.

Additional diagnoses covered by these SOPs
  • Brain stem stroke
  • Cerebral artery syndrome
  • Cerebral caused amaurosis fugax
  • Cerebral haemorrhage
  • Cerebral infarction
  • CVA [cerebrovascular accident]
  • Lacunar syndrome
  • TIA [transient ischaemic attack]
  • Vertebrobasilar artery syndrome or insufficiency
Conditions not covered by these SOPs   
  • Cerebral atherosclerosis#
  • Cerebral aneurysm#
  • Complicated migraine* - migraine
  • Concussion*
  • Epilepsy*
  • Extradural haematoma#
  • hypoxia not due to impairment of the blood supply#
  • Moderate to severe traumatic brain injury*
  • Silent stroke#
  • Subarachnoid haemorrhage*
  • Subclinical or asymptomatic cerebrovascular disease#
  • Subdural haematoma*                            
  • Vascular dementia*                                  

* another SOP applies  - the SOP has the same name unless otherwise specified

# non-SOP condition

Clinical onset

CVAs are acute events with generally clear cut clinical onsets.  The clinical onset will be when the neurological symptoms and signs, subsequently confirmed by imaging to be a cerebral infarction or haemorrhage, or confirmed on clinical grounds and by exclusion of other pathologies to be a TIA, first manifest.

Clinical worsening

A CVA may naturally progress over 48-72 hours in the acute phase but subsequently should peak in impairment and then subsequently lessen in impairment over a period of 18 months, with the speed of improvement highest at the beginning (first 3-6 months).

Further comments on diagnosis

Note that a CVA is an injury episode similar in analogy to a sprained ankle. As such the liability for a CVA is limited to the single episode and does not cover subsequent episodes which may relate to different aetiology.

The TIA on the other hand can be an episodic condition and hence recurrences should be covered by the same determination.

In most cases the term “stroke” will refer to a cerebrovascular accident.  However, the term may also be used to describe subarachnoid or other intracranial haemorrhage not covered by the cerebrovascular accident SOPs.  Therefore, “stroke” is insufficiently precise for diagnostic purposes and further information as to the type of stroke will be required.