Stroke resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Definitions

The term 'stroke' is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013), the updated definitions are:

Ischemic Stroke

This is defined as an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction.

CNS Infarction

CNS infarction is brain, spinal cord, or retinal cell death attributable to ischemia, based on:

1. Pathological, imaging, or other objective evidence of cerebral, spinal cord, or retinal focal ischemic injury in a defined vascular distribution; or

2. Clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting ≥24 hours or until death, and other etiologies excluded.

Hemorrhagic Stroke

This is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma.

Time of Onset

This is defined as when the patient was last awake and symptom-free or known to be “normal".

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• All the causes of stroke are life-threatening.

Common Causes

Ischemic Stroke

• Embolic causes - Cardiac arrhythmias, infective endocarditis, left atrial myxoma, cardiomyopathy, atrial or ventricular thrombus

• Thrombotic causes - Atherosclerosis of large vessels, arteritis/vasculitis, dissection, Takayasu arteritis

• Systemic hypoperfusion (Watershed stroke) - Myocardial infarction, cardiac arrhythmias, pericardial effusion, pulmonary embolism

Hemorrhagic Stroke

• Hypertension
• Bleeding disorders
• Illicit drug use (e.g., amphetamines or cocaine)
• Trauma
• Vascular malformations
• Rupture of arterial aneurysms

Management

Evaluation Check vitals ABCs Rapid Hx - time of onset, time of arrival at the ED, medications (especially anticoagulants) Rapid physical exam - neuro exam, NIHSS Activate stroke team Stat fingerstick Labs EKG, troponin, CXR NPO Obtain stroke protocol

Rule out DD Seizure, syncope, migraine, hypoglycemia

Non-contrast enhanced CT (or MRI) to r/o hemorrhage

Bleed positive

Hemorrhagic stroke

Bleed negative

Hemorrhagic stroke algorithm

Acute ischemic stroke

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Time of onset

<3 hours

3 -4.5 hours

>4.5 hours

Eligibility criteria for IV rTPA

Consider rTPA

Eligible

Not eligible

Blood pressure control algorithm Treat fever with IV antipyretics

BP≤180/110

BP≥180/110

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IV rTPA 0.9 mg/kg (maximum of 90 mg) with 10% given as intravenous bolus over 1 minute and the rest as IV infusion over 1 hour

Commence IV antihypertensives

Admit ICU for BP monitoring + bleeding complications Vitals Neurocheck hourly Aspiration precautions

After 24 hours post rTPA or no rTPA

Follow-up head CT/MRI before commencing antiplatelets

ASA 325 mg (if no contraindication) Statins DVT prophylaxis

PTOT evaluation Speech and swallow evaluation

Investigate the cause MRA/CTA/carotid duplex Venous doppler USS Echocardiography

Exclusion Criteria for IV Recombinant TPA Treatment

Less than 3 hours of onset

• Significant head trauma or prior stroke in previous 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
• Intracranial neoplasm, arteriovenous malformation, or aneurysm
• Recent intracranial or intraspinal surgery
• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
• Active internal bleeding
• Acute bleeding diathesis, including but not limited to
• Platelet count <100,000/mm³
• Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
• Current use of anticoagulant with INR >1.7 or PT >15 seconds
• Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and

ECT; TT; or appropriate factor Xa activity assays)

• Blood glucose concentration <50 mg/dL (2.7 mmol/L)
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative exclusion criteria

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Pregnancy
• Seizure at onset with postictal residual neurological impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)

Between 3 and 4.5 hours of onset

• Aged >80 years
• Severe stroke (NIHSS>25)
• Taking an oral anticoagulant regardless of INR
• History of both diabetes and prior ischemic stroke

Management of Blood Pressure

Blood Pressure Management

Review Exclusion Criteria for IV rTPA Administration

Eligible

Not eligible

Before treatment

During/After treatment

BP <220/120 mmHg

BP >220/120 mmHg

BP>185/110 mm Hg Labetalol 10–20 mg IV over 1–2 minutes, may repeat 1 time; or nicardipine 5 mg/h IV infusion; titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or other agents (hydralazine, enalaprilat, e.t.c.) may be considered when appropriate

Observe unless evidence of end-organ damage is present (e.g., acute myocardial infarction, aortic dissection, pulmonary edema, hypertensive encephalopathy) Conservative management - treat fever, pain, headaches, nausea, vomiting

Labetalol 10–20 mg IV over 1–2 minutes, may repeat or double every 10 minutes (maximum dose of 300 mg); or nicardipine 5 mg/h IV infusion; titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h Aim at 15% reduction during the first 24 hours afte stroke onset

SBP>180–230 mm Hg or DBP >105–120 mm Hg

BP not controlled or DBP >140 mm Hg

Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h

Sodium nitroprusside 0.5 mcg/kg/min IV infusion as initial dose, then titrate to desired blood pressure

Algorithm based on AHA/ASA guidelines for the early management of patients with acute ischemic stroke (2013)

Dos

• Review the criteria for the administration of IV rTPA to determine the patient's status of the patient.
• Order a limited number of investigation during the initial emergency evaluation. Only the estimation of blood glucose should precede the administration of IV rTPA.
• Cardiac monitoring for at least the first 24 hours to screen for atrial fibrillation.
• Ensure blood pressure of ≤180/110 mmHg before initiating IV rTPA, and maintain it below 180/105 mmHg for at least the first 24 hours post-IV rTPA.
• Give ASA 325 mg within 24 to 48 hours to most patients (except if contraindicated).
• Strict blood pressure monitoring for the first 24 hours, especially if rTPA was administered - every 15 minutes for 2 hours, then every 30 mins for 6 hours, and every hour for the next 16 hours.

Don'ts

• Do not treat hypertension except the blood pressure is >220/120 mmHg, and not until CT/MRI have been performed.
• Do not initiate anticoagulation treatment within the first 24 hours.
• Do not commence oral administration of medications before speech and swallow evaluation.
• Do not delay sending the patient to CT for any reason.