STROKE

Tick Tock You’re on the Clock

Hannah Maloney ACNP-BC

Vanderbilt University Medical Center

Anesthesia Critical Care Neurocare Unit

OBJECTIVES

• Diagnosis

– History, Physical exam findings and initial workup

• Types of stroke

– Ischemic vs hemorrhagic

• Initial treatment options

• Inpatient management

• Causes and risk factors

History

• ***Time of onset of symptoms or when last seen normal***

• Past medical history (more on stroke risk factors later)

• Differential diagnosis:

– Conversion disorder, hypertensive encephalopathy, hypoglycemia, complicated migraine, seizures

Physical Exam

• Stabilize ABC’s (this may preclude the history)

• Thorough but concise neurologic exam with the use of a formal stroke scale such as the National Institutes of Health Stroke Scale (NIHSS)

• Cardiac exam to include arrhythmia, murmur, carotid bruit and JVD

Neurologic exam

• Cranial Nerves

• Motor

• Sensory

• Gait/Ataxia

• Beware of the Basilar occlusion

Diagnostic Testing

• Non-contrasted head CT or MRI

• **Blood glucose**

• BMP/CBC with platelets

• Renal function

• ECG/Cardiac enzymes

• PT/PTT

Case Study

Mr. Garcia is a 42 yo Hispanic M who presents to the ED with acute onset of left sided paresis at 9:30. He is primarily Spanish speaking.

You first: Assess if he is protecting his airway

You second: Get a head scan

Further Diagnostic Imaging

• The initial CT/MRI is negative for bleed

– If rapidly available and Creatinine is normal perform a CT with angiography

– Do not delay treatment to obtain further imaging

• The initial CT head is positive for bleed

– Diagnosis Intracerebral Hemorrhage

Initial Treatment of Ischemic Stroke

• Timing is everything –Save the pneumbra

– Door to Physician < 10min

– Door to Stroke Team (or Telestroke) < 15min

– Door to CT initiation < 25min

– Door to CT interpretation < 45 min

– Door to Drug (>80% compliance) < 60 min

– Door to stroke unit < 3 hours

Treatment of Ischemic CVA • Blood pressure control < 185/110 mm hg

• rtPA administered with in 3 hours of symptom onset

• rtPA in specific patients with in 4.5 hours of symptom onset (less than 1/3 MCA territory, < 80 yrs

old, NIHSS<25, PMH negative for DM and prior CVA)

• Consider intra-arterial fibrinolysis and/or thrombectomy if symptoms onset is <6hrs

• Transfer to stroke unit

Inclusion criteria rtPA

• Diagnosis of stroke causing neurologic deficit

• Onset <3hrs or 4.5 hrs in specific pt

• Age >18

Exclusion criteria for rtPA

• Sustained SBP>185 or DBP>110

• Platelets <100,000 or HCT<25

• Blood glucose <50

• Coagulopathy-elevated PTT, INR>1.7 or use of direct thrombin or factor Xa inhibitors w/in 2 days

• Prior stroke or head injury in last 3 months

• Prior ICH ever

• Major surgery or bleeding in last 14 days

Continued Case study

Mr. Garcia’s CT Head is read as no acute bleed evolving right frontoparietal infarct. His family arrives clarifying the time of onset and his PMH. He became acutely plegic around 9:00. He has an extensive cardiac history including 2 valve replacements and hypertension. He is supposed to take warfarin but does not reliably take it.

Does he meet the criteria for rtPa? What else do we need to know?

Management post rtPA • Should occur in a Primary or Comprehensive Stroke Unit

• Blood pressure management SBP140-160 avoid SBP<100 or >180

• Telemetry

• Close neurologic monitoring (rtPA protocol)

• Glucose management (100-180 mg/dL avoid hypoglycemia)

• Euvolemia, isotonic fluid

• Supplemental O2 to maintain SaO2>94%

• No invasive lines or procedures for 24hrs

• Start antiplatelet (usually aspirin) within 24-48hrs

Prevention of Secondary Injury

• DVT prophylaxis

• Swallow evaluation

• Treat infections (UTI/Pneumonia)

• Start enteral nutrition

• Prevent constipation

• Early mobilization

• PT/OT

Complications from Stroke

• Extension of stroke- optimize blood pressure

• Hemorrhagic conversion

• Seizures-EEG, anti-epileptic

• Cerebral edema

Cerebral Edema

• Elevate HOB 30-45 degrees

• Airway management

• Mild hypocapnea (pCO2 30-35 mmHg)

• Hyperosmolar/Hypertonic therapy

• Decompressive craniotomy

Overview of Risk Factors

First world problems

• Hypertension

• Dyslipidemia

• Diabetes mellitus

• Obesity

• OSA

• Vascular disease

• Physical inactivity

Other Problems

• Atrial Fib, thrombus

• Valve disease

• PFO

• MI, cardiomyopathy

• Hypercoagulation, antiphsopholipid antibody

• Pregnancy/breastfeeding

Initial Management

• Close monitoring for neurologic decline (airway watch)

• Reverse coagulopathy (Vit K, FFP, PCC, platelets)

• SBP<160 DBP<110

• Admit to ICU with neuroscience specialization

• Neurosurgical intervention (EVD, ICP monitor, decompressive craniotomy with clot evac)

Inpatient Management

• Blood pressure <160/90

• DVT prophylaxis SCD’s, sq heparin 1-4 days after ICH stabilizes

• Otherwise similar to ischemic management

Causes

• Hypertension

• Coagulopathy

• AVM/Aneurysm

• Less common-Amyloid angiopathy, venous sinus thrombus, tumor, stimulants (cocaine, methamphetamines)

Overview

• Develop protocol for initial management to include

– immediate triage

– priority to CT/MRI

– consultation with stroke team

– Door to rtPA time <60 min (you only have to have BG >50 and BP<185/110 to give rtPA)

– transfer to stroke unit within 3 hrs

Sources

Jauch, E. C., Saver, J. L., Adams Jr., Harold P, Bruno, A., Connors, J. J., Demaerschalk, P. K.,. . . Yonas, H. (2013) Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 870-947

Murray, T. A., Kelly, N. R., Jenkins, S. The Complete Neurologic Exam. NP&PA’s.

http://nurse-practitioners-and-physician-assistants.advanceweb.com/article/the-complete-neurological-examination.aspx

Morgenstern, L. B., Hemphill III, C., Anderson, C., Becker, K., Broderick, J. P., Connolly Jr, E. S., Greenberg, S. M., . . . Tamargo, R. J. (2010) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2108-2129

Wijdicks, E. F. M., Sheth K. N., Carter, B. S., Greer, D. M., Kasner, S. E., Kimberly, W. T., Schwab, S., (2014) Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 1222-1238

Smith, W. S., Ischemia and Infarction. 2011 Neurocritical Care Society Review Course. http://www.dcprovidersonline.com/ncs/?event_id=NCS101