Stroke






 

Treatment Overview: (NEW Guideline)
Age
< 80 yr
> 80 yr
< 4.5 hr > 4.5 hr > 3 hr < 3 hr

- rt-PA  0.9 mg/kg (max 90 mg) IV with 10% given as bolus over 1 min. remainder over 1 hr.
[Calculate]

- See rt-PA indication and contraindication below...

 

tPA Criteria:
1) CT reveals no evidence of hemorrhage
2) No hx of intracerebral hemorrhage
3) No seizure at onset of stroke
4) BP < 185/110
 

- rt-PA  0.9 mg/kg (max 90 mg) IV with 10% given as bolus over 1 min. remainder over 1 hr.
[Calculate]

- See rt-PA indication and contraindication below...


tPA Criteria:

1) CT reveals no evidence of hemorrhage
2) No hx of intracerebral hemorrhage
3) No seizure at onset of stroke
4) BP < 185/110
 

 

- CT head w/o contrast - r/o hemorrhage (repeat CT in 48hr OR get an MRI if no contraindication e.g; pacemaker)

- Carotid Doppler

- EKG -- r/o A-Fib
  • if (+) A-fib = Warfarin (recommended for long-term secondary prevention, but is generally begun 48–72 hours after the onset of the stroke)

- 2D Echo - r/o clot

  • if (+) clot = Warfarin (recommended for long-term secondary prevention, but is generally begun 48–72 hours after the onset of the stroke)
  • if Vegitation = Valvotomy
    • Aortic = Replace
      • INR 2.5-3.5
    • Mitral = Baloon

- Swallow study

- ASA (within first 48hr)  OR  Plavix  OR Aggrenox (aspirin/dipyridamole) 1 po bid.
 
DVT proph:
-
LMWH or Heparin to prevent DVT (DVT prophylaxis for at least 2 weeks)

Imaging:

- MRI within first 24 hours
- If cannot to MRI (Pacemaker etc.) -- Repeat CT Brain in 24-48 hrs.

BP Control:

- Ischemic Stroke: Permissive HTN in ischemic stroke (do not treat unless BP > 220/120, Goal: > 180/105)
- Acute (Hemorrhagic) CVA:  Patients with sBP 150-220, lowering of BP to 140 is “probably safe”
- Subarachnoid Hemorrhage:  Decrease sBP < 160
 

Algorithm

Ischemic Stroke

Source: Tarascon Hospital Medicine

Intracranial Hemorrhage


Source: Tarascon Hospital Medicine

Symptoms

Traditional symptoms Sudden numbness or weakness of face, arm, or leg—especially unilateral
Sudden confusion or aphasia
Sudden memory deficit or spatial orientation or perception difficulties
Sudden visual deficit or diplopia
Sudden dizziness, gait disturbance, or ataxia
Sudden severe headache with no known cause (More common in hemorrhagic stroke)
Nontraditional symptoms Loss of consciousness or syncope
Shortness of breath
Sudden pain in the face, chest, arms, or legs
Seizure (More common in hemorrhagic stroke)
Falls or accidents
Sudden hiccups
Sudden nausea
Sudden fatigue
Sudden palpitations
Altered Mental Status
 

DDx

Acute Stroke Syndrome

Stroke Mimic Distinguishing Clinical Features
Seizures/postictal paralysis
(Todd paralysis)
Transient paralysis following a seizure, which typically disappears quickly; can be confused with transient ischemic attack. Seizures can be secondary to a cerebrovascular accident.
Syncope No persistent or associated neurologic symptoms.
Brain neoplasm or abscess Focal neurologic findings, signs of infection, detectable by imaging.
Epidural/subdural hematoma History of trauma, alcoholism, anticoagulant use, bleeding disorder; detectable by imaging.
Subarachnoid hemorrhage Sudden onset of severe headache.
Hypoglycemia Can be detected by bedside glucose measurement, history of diabetes mellitus.
Hyponatremia History of diuretic use, neoplasm, excessive free water intake.
Hypertensive encephalopathy Gradual onset; global cerebral dysfunction, headache, delirium, hypertension, cerebral edema.
Meningitis/encephalitis Fever, immunocompromise may be present, meningismus, detectable on lumbar puncture.
Hyperosmotic coma Extremely high glucose levels, history of diabetes mellitus.
Wernicke encephalopathy History of alcoholism or malnutrition; triad of ataxia, ophthalmoplegia, and confusion.
Labyrinthitis Predominantly vestibular symptoms; patient should have no other focal findings; can be confused with cerebellar stroke.
Drug toxicity
(lithium, phenytoin, carbamazepine)
Can be detected by particular toxidromes and elevated blood levels. Phenytoin and carbamazepine toxicity may present with ataxia, vertigo, nausea, and abnormal reflexes.
Bell's palsy Neurologic deficit confined to isolated peripheral seventh nerve palsy; often associated with younger age.
Complicated migraine History of similar episodes, preceding aura, headache.
Ménière disease History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness.
Demyelinating disease
(multiple sclerosis)
Gradual onset. Patient may have a history of multiple episodes of neurologic findings in multifocal anatomic distributions.
Conversion disorder No cranial nerve findings, nonanatomic distribution of findings (e.g., midline sensory loss), inconsistent history or examination findings.
 

Subarachnoid Hemorrhage

  • Other intracranial hemorrhage
  • Drug Toxicity
  • Ischemic Stroke
  • Meningitis
  • Encephalitis
  • Intracranial tumor
  • Intracranial hypotension
  • Metabolic derangements
  • Venous thrombosis
  • Primary headache syndrome (benign thunderclap headache, migraine, cluster headache). 

Etiology

  • Ischemic strokes account for 85% of all strokes (thrombotic 20%, lacunar 25%, cardioembolic 20%, cryptogenic 30%, or other 5%)
  • Cryptogenic is most likely embolic and often paradoxical through a PFO
  • Other causes:
    • Hypercoagulable states
    • Dissection
    • Vasculitis
    • Endocarditis
    • Complicated migraine
    • Stimulant drugs
    • Neurosyphilis
    • Paradoxical embolus through a PFO
    • Sickle cell crisis
    • Cerebral vein or cerebral sinus thrombosis
  • Embolic: patients generally experience a sudden onset of maximal deficit.
  • Thrombotic: patients generally have a stuttering or stepwise progression.
  • Paradoxical embolus presents as a sudden neurologic deficit often after a valsalva maneuver
  • Hemorrhagic strokes are managed as an acute intracranial hemorrhage
Stroke Risk Factors
Non-modifiable Modifiable Linked but not well established
Age Cigarette smoking Sleep apnea
Gender Poor diet Metabolic syndrome
Low birth weight Physical inactivity Migrane
Genetic factors Postmenopausal hormone therapy hyper-homocysteinemia
  Obesity Hypercoagulability
  Body fat distribution Inflammation
    Infection

Stroke Type/Subtypes

 
Ischemic
(80-85%)
Thrombotic
(50%)
Large Vessels
(20-25%)
Small vessels
(20-25%)
Embolic
(30%)
 
Hemorrhagic (15%-20%) Intracerebral (10%)
Subarachnoid (6%)

Risk Factor: HTN

 
Ischemic
(80-85%)
Thrombotic
(50%)
Large Vessels
(20-25%)
Small vessels
(20-25%)
Embolic
(30%)
 
Hemorrhagic (15%-20%) Intracerebral (10%)
Subarachnoid (6%)

Risk Factor: DM

 
Ischemic
(80-85%)
Thrombotic
(50%)
Large Vessels
(20-25%)
Small vessels
(20-25%)
Embolic  (30%)
- Lacunar Stroke
 
Hemorrhagic (15%-20%) Intracerebral (10%)
Subarachnoid (6%)
 

Risk Factor: A-fib

 
Ischemic
(80-85%)
Thrombotic
(50%)
Large Vessels
(20-25%)
Small vessels
(20-25%)
Embolic
(30%)
 
Hemorrhagic (15%-20%) Intracerebral (10%)
If anticoagulated
Subarachnoid (6%)

 

 

Initial Workup

Intervention/Evaluation Rationale/Discussion
All patients
Assessment of airway, breathing, circulation Immediate life threats must be addressed before other interventions are undertaken. Actively manage airway if necessary.
Establishment of IV access IV access is necessary for possible thrombolytic therapy.
Oxygen administration
(if hypoxia is present)
Routine oxygen supplementation is not indicated in mild to moderate stroke, but keep oxygen saturation 92%.
 
Cardiac monitoring Dysrhythmias, especially atrial fibrillation, are associated with acute stroke. Prophylactic administration of antiarrhythmic agents is not indicated.
Bedside glucose determination To rapidly rule out hypoglycemia mimicking stroke.
Bedside hemoglobin determination To rapidly detect polycythemia which may have caused stroke.
Pulse oximetry To detect hypoxia.
ECG and measurement of cardiac enzymes Acute coronary syndrome, dysrhythmias (atrial fibrillation, in particular), ECG changes, and elevated troponin T levels are frequently associated with acute stroke.
ECG abnormalities may also predict 3-Mo mortality. 1.5% of patients admitted for myocardial infarction (MI) experienced a stroke while still in the hospital; a subsequent analysis revealed that the presence of left ventricular dysfunction and/or heart failure with MI substantially increased the chances of early post-MI stroke.
Noncontrast brain CT or MRI To exclude intracerebral hemorrhage, abscess, and tumor. 
CBC To detect polycythemia, thrombocytosis, or thrombocytopenia.
Coagulation studies (PT/PTT, INR) To detect preexisting coagulopathy in hemorrhagic stroke or when thrombolytics are being considered.
CMP To detect electrolyte-imbalance stroke mimics (particularly Na+ and Ca2+).
 
NPO order To protect against aspiration.
Strict bedrest with head of bed elevated to 30 degrees To protect against falls and seizures (in the period immediately after stroke) and aspiration. Head of bed elevation should be avoided in the presence of low or borderline blood pressure to avoid brain hypoperfusion.
Selected patients
UA and/or CXR
(if infection suspected)
To detect infectious stroke mimics or stroke-associated infections.
Routine chest radiography is no longer recommended.
Pregnancy test (HCG)
(if female of childbearing age)
Pregnancy influences diagnosis and management considerations.
UDS and/or blood alcohol level
(if ingestion suspected)
To detect stroke mimics as well as potential causes of stroke such as ingestion of a sympathomimetic (cocaine, methamphetamine, phencyclidine).
Lumbar puncture
(if infection or subarachnoid hemorrhage suspected)
To detect stroke mimics.
Thrombolytics should probably not be given after lumbar puncture because of increased risk of post-lumbar puncture epidural hematoma.
 

rt-PA Criteria

Indications
Measurable diagnosis of acute ischemic stroke Use of NIHSS recommended. Stroke symptoms should not be clearing, minor, or isolated. Caution is advised before giving rtPA to persons with severe stroke (NIHSS score of >22), because they have increased risk of intracerebral hemorrhage; however, they are at high risk of death, regardless.
Age 18 y No clear upper age limit.
Time of symptom onset 3 h Must be well established [2009 AHA/ASA Scientific Advisory suggests time window may be extended to 3 to 4.5 h if ECASS criteria are met].
 
Exclusion Criteria
Symptoms consistent with subarachnoid hemorrhage
Prior intracranial hemorrhage at any point in life
Evidence of active bleeding or acute major fracture
Use of heparin within preceding 48 h and a prolonged activated partial thromboplastin time
Seizure with postictal residual neurologic impairments
Major surgery within preceding 14 d
Previous GI or urinary tract hemorrhage within preceding 21 d
Previous head trauma or stroke within preceding 3 mo
Previous myocardial infarction within preceding 3 mo*
Pretreatment sBP >185 mm Hg or dBP >110 mm Hg despite therapy 
Blood glucose level < 50 mg/dL (2.7 mmol/L)
INR >1.7 (oral anticoagulant use in and of itself is not a contraindication to rtPA)
Platelet count <100,000/mm3
Head CT shows multilobar infarction (hypodensity of more than one third cerebral hemisphere) or hemorrhage or tumor
Failure of the patient or responsible party to understand the risks and benefits of, and alternatives to, the proposed treatment after a full discussion
 

BP Control

Acute (ischemic) CVA

 Elevated BP is body’s desire to maintain cerebral perfusion
AHA guidelines: (2003, 2007) Treat sBP > 220
Treat dBP >120
Recommended meds: Labetalol: 10 mg IV q 10-20 min Goal: 15% decrease in BP
Nicardipine: 5 mg/hr, titrate q 5 min (NO BOLUS)


AHA Stroke Guideline, 2007, 2013

For Acute (Hemorrhagic) CVA

  • Patients with systolic BP 150-220, lowering of BP to 140 is “probably safe”

 

Class IIa, Level of Evidence B, AHA guideline, 2010

For Subarachnoid Hemorrhage

  • Decrease systolic BP < 160

 

Class IIa, Level of Evidence C, AHA guideline, 2012

BP control before rt-PA

If the patient is a candidate for rtPA therapy, the target arterial blood pressures are:
sBP
185 mm Hg and dBP 110 mm Hg
Drug Comments
Labetalol, 10–20 mg IV over 1-2 min, may repeat x1 Use with caution in patients with severe asthma, severe chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, myasthenia gravis, concurrent CCB use, hepatic insufficiency. May cause dizziness and nausea.
Pregnancy category C (D in second and third trimesters).
or
Nitroglycerin paste, 1-2 in. to skin Contraindication:
- Hypersensitivity to organic nitrates,
- Concurrent use of phosphodiesterase 5 inhibitors (sildenafil, tadalafil, or vardenafil),
- Angle-closure glaucoma.
Increases intracranial pressure. Commonly causes headache.
Pregnancy category C.
or
Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to 15-min intervals.
MAX dose: 15 mg/h.
When desired blood pressure attained, reduce to 3 mg/h
Use with caution in patients with MI, concurrent use of fentanyl (hypotension), CHF, hypertrophic cardiomyopathy, portal hypertension, renal insufficiency, hepatic insufficiency (may need to adjust starting dose).
Contraindicated in:
- Severe aortic stenosis.
Can cause headache, flushing, dizziness, nausea, reflex tachycardia.
Pregnancy category C.
If the target arterial blood pressures for rtPA administration cannot be reached with these initial measures, then the patient is no longer a candidate for rtPA therapy.
 

BP During & After rt-PA

Blood Pressure Monitoring Frequencies
Time after start of rtPA infusion Frequency of blood pressure monitoring
0-2 h Every 15 min
2-9 h Every 30 min
9-24 h Every 60 min
Drug Treatment of Hypertension during and after Administration of rtPA
Goal: sBP <185, dBP < 110
If sBP 180-230
-OR-

dBP 105-120
 
Labetalol 10 mg IV over 1-2 min. The dose may be repeated every 10-20 min up to a total dose of 300 mg.
-OR-

Labetalol
10 mg IV followed by infusion at 2-8 mg/min.
If sBP >230
-OR-
dBP 121-140
Labetalol 10 mg IV over 1-2 min. The dose may be repeated every 10-20 min up to a total dose of 300 mg.
-OR-

Labetalol
, 10 mg IV followed by infusion at 2 to 8 mg/min.
-OR-

Nicardipine
infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to 15-min intervals; maximum dose 15 mg/h.
If blood pressure is not controlled by above measures Consider Sodium Nitroprusside infusion (0.5–10 mcg/kg/min).
Continuous arterial monitoring advised; use with caution in patients with hepatic or renal insufficiency.
Increases intracranial pressure.
Pregnancy category C.
 

ED care & Disposition

  1. Rapidly assess & stabilize any airway, breathing, & circulation abnormalities. Keep O2 sat > 92%
  2. IV access, Cardiac monitor, NPO.
  3. Rapid bedside CBG & normalize any hypoglycemia.
  4. Once stabilized, immediately send the pt for a Non-contrast head CT
Hypertension management in acute ischemic stroke:
  • If a pt is NOT a candidate for thrombolysis = permissive hypertension is in order (no intervention unless sBP >220 or dBP >120).
    • If BP control is needed, use a titratable IV antihypertensive, such as
      • Labetalol (typical starting dose is 10-20 mg over 1-2 min; continuous infusion dosage generally starts at 2 mg/min, titrated to effect).
        OR
      • Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to 15-min intervals.
    • Take extreme caution to avoid overcorrection.
    • Target MAP reduction of 10% to 25%
       
  • If pt IS a candidate for thrombolysis, then the target BP = sBP <185, dBP <110.
    • For management of hypertensive pt who are potentially thrombolytic candidates, see BP Control above.
       
    • Before rTPA:
      • Target BP = sBP <185, dBP <110.
      • Labetalol, 10–20 mg IV over 1-2 min, may repeat x1
         
    • During & after rTPA:
      • BP MonitorANDNeuroAssessment:
        • q15 min for the first 2 hours, then
        • q 30 minutes for the next 6 hours, then
        • hourly until 24 hours after treatment was begun.
      • The frequency should be increased if the systolic blood pressure is ≥180 mm Hg or the diastolic blood pressure is ≥105 mm Hg
      • If the patient develops a severe headache, acute hypertension, nausea, or vomiting while the rtPA is being administered:
        • STOP rtPA and
        • Obtain Emergency REPEAT CT.
      • Follow-up CT should be performed 24 hours after the onset of symptoms, before anticoagulants or antiplatelet agents are started.
      • Placement of NG tube, indwelling bladder catheters, or intra-arterial pressure catheters should be delayed.
Thrombolytics
  1. IV recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke < 3 - 4.5 hr of symptom onset.
    • Review of rt-PA inclusion & exclusion criteria prior to administration of rt-PA.
    • Determine the precise time when pt was last known to be at their neurological baseline.
  2. Obtain informed consent from pt or their designee prior to thrombolytic therapy. Although thrombolytic tx of ischemic stroke is associated with improved outcome, the risk of symptomatic intracerebral hemorrhage (SIH) is 6.5% (45% mortality) when rt-PA is given within < 3 hr of symptom onset, & 7.9% (NINDS definition) between 3 - 4.5 hr.
  3. The total dose of rt-PA is 0.9 mg/kg IV, Max: 90 mg. 10% of the dose is given as a bolus, with the remaining amount infused over 60 min. [calculate] No Aspirin or heparin should be administered in the initial 24 hr after treatment. Intracerebral bleeding should be suspected as the cause of any neurologic worsening.
  4. Closely monitor blood pressure for pts who receive rt-PA and treat as necessary.
Antiplatelet Therapy
  • TIA pts:
    • Aspirin (325 mg PO) plus dipyridamole (400 mg PO) is recommended.
       
  • Stroke pts:
    • Aspirin (325 mg PO) is recommended within 24-48 hrs. Aspirin does not interfere with subsequent consideration for thrombolytic therapy.
    • Anti-platelet therapy is contraindicated for hemorrhagic stroke.
Anticoagulation
  1. There is currently NO role for heparin or warfarin in the acute treatment for TIA or stroke in the ED, even in the presence of A-Fib. A possible exception exists for a weight-based heparin protocol in cervical artery dissection, but this remains controversial and neurology consult is advisable for these cases.
  2. If an ischemic stroke pt presents outside the rt-PA therapeutic time window, the aggressive supportive care in the ED (aspiration prevention, normalization of glucose lever, fall precaution, treatment for comorbidities).
EVIDENCE OF INCREASED ICP :
  • Head elevation to 30 degrees, analgesia, & sedation is needed.
  • Mannitol: 25% 40g, 1.0 g/kg IV bolus over 30 min.
  • Hypertonic Saline 7.5% saline (250 cc) bolus
  • Intubation with neuromuscular blockade with mild hyperventilation (Pco2 = 28-32, Avoid < 28)
  • Invasive monitoring of ICP may be required.
Intracranial Hemorrhage:
  1. In SAH, the chances of re-bleeding can be reduced by maintaining the pts pre-bleed BP (or MAP < 130 if baseline BP is unknown). This is best done by
    • Labetalol 10-20 mg IV over 1-2 min; Continuous infusion generally starts at 2 mg/min, titrate to effect
    • Nimodipine (60 mg PO q4h) may produce modest improvements in outcome by decreasing vasospasm.
       
  2. Intracranial Hemorrhage:
    • Operative removal within 12 hours, particularly when performed by less-invasive methods, is supported by most of the available evidence.
      • Very early craniotomy may be associated with an increased risk of recurrent bleeding.
    • Infusion of urokinase
      • Decreases clot burden and risk of death, but
      • Increases the risk of rebleeding and does not improve functional outcome.
      • SO! its usefulness is unknown
    • Current guidelines support surgical removal of the hemorrhage as quickly as possible in patients with:
      • Cerebellar hemorrhage >3 cm who are deteriorating neurologically or
      • Have brain stem compression and/or
      • Hydrocephalus from ventricular obstruction
    • They also support consideration of standard craniotomy to evacuate a supratentorial intracranial hemorrhage in patients with a lobar clot within 1 cm of the surface
       
  3. Blood Pressure management:
    • In patients with a hemorrhagic stroke and a sBP >200 mm Hg or a mean arterial pressure (MAP) >150 mm Hg, the guidelines recommend consideration of aggressive reduction of blood pressure with a continuous intravenous infusion of an appropriate antihypertensive agent, with blood pressure monitoring every 5 minutes.
    • For those with an SBP <200 mm Hg, less aggressive measures are recommended for lowering blood pressure.
      • If the SBP is >180 mm Hg or the MAP is >130 mm Hg, management depends on whether elevation of intracranial pressure (ICP) is suspected.
      • If elevated ICP is suspected, monitoring of ICP should be considered and blood pressure reduced to maintain a cerebral perfusion pressure >60–80 mm Hg.
      • If elevated ICP is not suspected, blood pressure can be reduced by a moderate amount (e.g., to a target of 160/90 mm Hg, or to a target MAP of 110 mm Hg).
      • The patient should be monitored every 15 minutes.
    • Medications that can be considered for intravenous administration to lower blood pressure in patients with hemorrhagic stroke include labetalol, nicardipine, esmolol, enalapril, hydralazine, nipride, and nitroglycerin. Some of these may be started with a bolus:
      • Labetalol 10-20 mg IV over 1-2 min; Continuous infusion generally starts at 2 mg/min, titrate to effect
      • Nimodipine (60 mg PO q4h) may produce modest improvements in outcome by decreasing vasospasm.
sBP > 200
or

MAP > 150
Aggressive reduction of blood pressure with a continuous intravenous infusion of an antihypertensive agent, with BP monitoring every 5 minutes.
  • Labetalol 10-20 mg IV over 1-2 min; Continuous infusion generally starts at 2 mg/min, titrate to effect
  • Nicardipine infusion 5 mg/h, titrate by 2.5 mg/h @ 5-15 min intervals, MAX 15 mg/hr; when desired BP is attained, reduce to 3 mg/hr
  • Nimodipine (60 mg PO q4h) may produce modest improvements in outcome by decreasing vasospasm.
sBP <200 what is ICP? High
(e.g; Blown pupil)
Monitoring of ICP should be considered and blood pressure reduced to maintain a cerebral perfusion pressure >60–80 mm Hg
The patient should be monitored every 15 minutes.
Normal BP can be reduced by a moderate amount (e.g., to a target of 160/90 mm Hg, or to a target MAP of 110 mm Hg)
The patient should be monitored every 15 minutes.
Glucose control
  • NO evidence that tight control of glucose in acute setting is of any benefit.
  • LOW Glucose in acute CVA has poor prognosis.
  • HIGH Glucose = Worse prognosis
    • Associated with expansion of stroke size.
Further Management
  1. Emergent Neurosurgical consult is indicated. Administer medications and antiemetics as needed, Seizure prophylaxis is controversial and should be discussed with the specialist who will manage the pt after the leave ED
  2. Management of BP for spontaneous intracerebral hemorrhage remains controversial
  3. Emergent Neuro consult may be helpful in difficult stroke cases where thrombolytics are contraindicated, however therapy should not be delayed while waiting for a response. Early Neurosurgical consult is indicated for pt with intracerebral hemorrhage with evidence of increased ICP or in other conditions where surgical intervention may be indicated.
    • For example, cerebellar stroke mandated a neurosurgical consult because swelling with compression of the brainstem may lead to rapid deterioration; posterior fossa decompression may be life saving.
  4. Admit all pts with acute ischemic stroke or intracerebral hemorrhage, even if they are not candidate for interventional therapy. Admission to specialized stroke units is associated with improved outcomes from stroke pts; therefore, transfer to a designated stroke center may be indicated if the pt presents to a non-stroke center.
Seizure
  • Seizure prophylaxis is controversial.
  • Early-Onset
  • Late-Onset (> 2wk)
    • Likely secondary to gliosis (Scaring)
    • Treat with Lamictal (Has neuro-protective effects)
The ABCD² scoring system
  1. The ABCD² scoring system may be used to predict stroke risk in TIA pt. Using this system, the 2-day risk of subsequent stroke are:
    • 1% for score 0-3
    • 4.1% for score 4-5
    • 8.1% for score 6-7
Criteria Points
Age 60 y 0 = Absent
1= Present
Blood pressure 140/90 mm Hg 0 = Absent
1= Present
Clinical features 0 = Absent
1 = Speech impairment without unilateral weakness
2 = Unilateral weakness (with or without speech impairment)
Duration 0 = Absent
1 = 10–59 min
2 = 60 min
Diabetes 0 = Absent
1 = Present
  • Because of the proven efficacy of early carotid endarterectomy, many stroke experts recommend admission for most TIA pts for inpatient evaluation and observation. In Select low-risk, asymptomatic pts, next day follow-up and evaluation with a specialist may be appropriate, but responsible adults to observe the pt in a favorable social situation must be available and very strong return precautions give.


 

Stroke Preventionn

Primary Prevention

Stroke Risk Factors
Non-modifiable Modifiable Linked but not well established
Age Cigarette smoking Sleep apnea
Gender Poor diet Metabolic syndrome
Low birth weight Physical inactivity Migrane
Genetic factors Postmenopausal hormone therapy hyper-homocysteinemia
  Obesity Hypercoagulability
  Body fat distribution Inflammation
    Infection
 

 
Primary Prevention:
  • Physical Activity (at least 30 min/day) = Risk of CVA
  • Aspirin:
    • Men:
      • NOT recommended for first CVA prevention
      • Recommended to prevent CAD, CVA in the presenve of Risk factors.
    • Women:
      • Useful if pt has significant risk factors
  • Alcohol consumption:
    • Men = 2 drinks/day
    • Women = 1 drink/day
       
  • Sickle Cell Disease:
    • Screening: transcranial Doppler for blood flow.
    • Prim. Prevention: Prophylactic transfusion therapy.
      • Complication = Iron Overload = NOT a reason to stop transfusion
    • About 20% of children with sickle cell disease are found to have “silent infarcts” on MRI, and these are associated with deterioration of cognitive function, affecting learning and behavior
       
  • Diet:
    • Increase Risk of CVA:
      • Excessive Vit E intake
         
    • Decrease Risk of CVA:
      • Moderate alcohol cosumption
      • Diet high in fruits & vegetables
      • High K+ intake (May have some BP loweing effects)
         
  • NO evidence that CRP adds any benefit
Cardiac Risk
Aspirin Women 55-79 when net benefit present (low risk of GI Bleed)
NO aspirin for primary prevention in men <45, women < 55.
NO recommendation for or against pt >80
 

Secondary Prevention

Modifiable risk factor Therapeutic goals/recommendations
Hypertension BP < 140/90 mmHg (<130/80 for DM or CKD)
HTN + DM:
- Lifestyle modificaiton, ACEI, Diuretics
(Q) Diabetes mellitus (DM) - Risk factore for initial and recurrent CVA
- A1c ≤ 7%, Too aggressive control can be harmful
- Control BP in DM = Profound in CVA risk
- LDL goal < 70
 
Sympathomimetic abuse Abstinence
Smoking Smoking cessation
Daily alcohol use Men < 2 drinks; nonpregnant women ≤1 drink
Obesity Weight loss until waist circumference <35 inches for women and <40 inches for men
Physical inactivity ≥30 min moderate exercise most days
Symptomatic severe CAS CEA recommended for stenosis 70–99%
Symptomatic moderate CAS Consider CEA for stenosis 50–69%
Left ventricular thrombuss Warfarin anticoagulation to INR 2.5 (2–3) for 3–12 months
Afib/Aflut Warfarin anticoagulation to INR 2.5 (range 2–3)
Rheumatic MV disease Warfarin anticoagulation to INR 2.5 (range 2–3)
Dilated cardiomyopathy Warfarin anticoagulation or antiplatelet therapy
HMG-CoA Reductase Inhibitors (statins) -Statins beneficial even with normal cholesterol levels and no CAD
  • Desire LDL <100 mg/dL or <70 mg/dL for very high risk patients* with multiple risk factors
(Q) Antiplatelet therapy (ASA, clopidogrel, or ASA-extended-release dipyridamole) All patients after a noncardioembolic stroke:
- Aspirin monotherapy (50–325 mg/day)
- combination therapy with aspirin and extended-release dipyridamole, and
- clopidogrel monotherapy are all acceptable initial options for secondary prevention of ischemic stroke in a patient without known heart disease

NOTE:
- DO NOT USE combination ASA + Plavix increases risk of bleed in stroke pt. unless they have a specific indication such as a coronary stent or acute coronary .
Prosthetic heart valves Chronic anticoagulation to INR 2.5 (range 2–3)
Mitral valve prolapse/aortic stenosis Antiplatelet therapy
Sickle cell disease Exchange transfusion until Hgb S <30%
Cerebral vein thrombosis Anticoagulation to INR 2.5 (range 2–3) for 6 mo
Antiphospholipid syndrome Antiplatelet therapy or chronic anticoagulation to INR 2.5 (range 2–3) if multiple organs involved
 

Post Stroke Management

Rehab

  • Rehabilitation therapy should be provided for stroke patients as soon as medically tolerated, including:
    • Range-of-motion exercises
    • Physiologically sound changes of bed position on the day of admission, followed by a progressive increase in the level of activity
    • Early mobilization should also include encouraging the patient to resume self-care activities and socialization.
      • Early mobilization of the patient with an acute stroke is recommended to prevent deep-vein thrombosis ((DVT), skin breakdown, contracture formation, constipation, and pneumonia
         
    • Scores on the National Institutes of Health Stroke Scale strongly predict the likelihood of a patient’s recovery after stroke.
      • A score >16 indicates a high probability of death or severe disability,
      • A score <6 indicates that a good recovery is more likely.
      • Assessment of stroke recovery should be performed at the time of presentation/admission if possible, and definitely within the first 24 hours of presentation.
         
  • Functional Rehab
    • Botulinum toxin injections improve spasm and pain but do not improve functional outcomes.
    • Constraint-induced movement therapy
      • Involves constraining the unaffected upper extremity while using the affected upper extremity for repetitive movement exercises and tasks.
      • This therapy requires certain minimal functional abilities in the affected limb, and is recommended only for patients with 20° of wrist extension and 10° of finger extension.
      • Benefit has been demonstrated only with 6–8 hours of training daily for 2 weeks.
    • Repetitive task-oriented practice strategies show more improvement than general rehabilitation spread across multiple activities.
    • If no hand dexterity is apparent at 6 weeks there is very little likelihood of further recovery, and attempts should be made to maintain a comfortably mobile arm.
    • Benzodiazepines are not recommended for muscle spasm in post-stroke rehabilitation because of potential deleterious effects on recovery
       
  • Spasticity Treatment
    • Spasticity can lead to contractures, which render the limb functionally useless.
    • It is usually treated using a stepwise approach, starting with positioning, passive stretching, and range-of-motion exercises several times a day.
    • Contractures:
      • may be treated with splinting, serial casting, or surgery.
         
    • Medications:
      • FDA-approved medications for spasticity include oral forms of tizanidine, baclofen, dantrolene, and diazepam.
      • Tizanidine
        • Shown to improve spasticity and pain in chronic stroke patients.
      • Dantrolene:
        • Trial data is limited for dantrolene, although a lack of cognitive side effects appears to be a benefit.
      • Baclofen:
        • There is some data to support the use of baclofen in stroke victims, but it may cause significant sedation and have less effect on spasticity due to stroke than spasticity caused by other conditions.
        • Intrathecal baclofen has been shown to reduce spasticity in a small trial of chronic stroke patients whose stroke occurred more than 6 months in the past.
      • Diazepam
        • Relatively contraindicated in stroke patients, at least in the stroke recovery period, due to the possibility of deleterious effects on recovery
           
  • Testing before Rehab:
    • Stress Testing
      • Up to 75% of stroke victims have coexisting cardiac disease and 20%–40% of asymptomatic stroke patients have abnormal tests for silent cardiac ischemia.
      • It is recommended that stroke patients undergo graded exercise testing with EKG monitoring before beginning an exercise program.
      • If possible, the test should involve exercise in order to show how the patient tolerates physical activity.
      • This will allow evaluation for exercise capability, cardiac arrhythmias, and possible coronary disease.
      • Pharmacologic stress testing does not provide information about exercise capacity
         
  • Rehab Education:
    • Research has not consistently demonstrated better overall health or well-being in patients and families with better knowledge about stroke.
    • Patient education should be documented in the patient’s medical record to prevent duplication or contradiction by other health care providers
    • Multiple formats are preferable to single formats for successful education retention
    • Active interventions are more likely to be effective than passive ones
       
  • Pressure Ulcer:
    • Due to decreased mobility and the altered level of consciousness in many patients with stroke, the risk for pressure ulceration is increased.
    • Initial documentation of a skin condition is required to guide further intervention, if needed
    • Protective dressings, padding, special mattresses, positioning, turning at least every 2 hours, and transferring techniques are generally considered to be effective if used correctly
    • Despite the use of all these measures, some pressure ulcers may develop.
    • Early recognition of a break in skin integrity is central to successful therapy, making daily skin checks imperative

 

Post-Stroke Depression

  • All pts should be screened routinely post-stroke
  • Universal screening of all stroke pts
  • Multi-modal therapy (Rx + counseling)
  • Cognitive impairment post-stroke can complicate Dx of depression

Prophylaxis:

  • Not recommended

Treatment:

  • SSRI


Admit Orders: Ischemic Stroke

1. Admit to:

2. Diagnosis: Ischemic stroke

3. Condition:

4. Vital Signs: q1h and neurochecks q8h. Call physician if BP >185/105, <110/60; P >120, <50; R>24, <10; T >38.5°C; or change in neurologic status.

5. Activity: Bedrest.

6. Nursing: Head-of-bed at 30 degrees, turn q2h, range of motion exercises tid. Foley catheter, eggcrate mattress. Inputs and outputs.

7. Diet: NPO except medications for 24 hours or or dysphagia ground with thickened liquids.

8. IV Fluids and Oxygen: 0.45% normal saline at 100 mL/h. Oxygen at 2 L per minute by nasal cannula.

9. Special Medications:

Ischemic Stroke <3 hours:

a. Tissue plasminogen activator (t-PA,Alteplase) is indicated if the patient presents within 3 hours of onset of symptoms and the stroke is non-hemorrhagic; 0.9 mg/kg (max 90 mg) over 60 min. Give 10% of the total dose as an initial bolus over 1 minute.

b. Repeat CT scan 24 hours after completion of tPA. Begin heparin if scan results are negative for hemorrhage.

c. 12 U/kg/h continuous IV infusion, without a bolus. Check aPTT q6h to maintain 1.2-1.5 x control.

Completed Ischemic Stroke >3 hours:

-Aspirin enteric coated 325 mg PO qdOR

-Clopidogrel (Plavix) 75 mg PO qd ORR

-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab PO bid 
OR

-Aspirin 325 mg PO qd PLUS Clopidogrel (Plavix) 75 mg PO qd

10. Symptomatic Medications:s:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Omeprazole (Prilosec) 20 mg PO bid or qhs.

-Docusate sodium (Colace) 100 mg PO qhs

-Bisacodyl (Dulcolax) 10-15 mg PO qhs or 10 mg PR prn.

-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn temp >38°C or headache.

11. Extras: CXR, ECG, CT without contrast or MRI with gadolinium contrast; echocardiogram, 24-hour Holter monitor; swallowing studies. Physical therapy consult for range of motion exercises; neurology and rehabilitation medicine consults.

12. Labs: CBC, glucose, CMP, fasting lipid profile, VDRL, ESR, INR/PTT, UA. Lupus anticoagulant, anticardiolipin antibody, high sesitivity CRP

 

Admit Orders: TIA

1. Admit to:

2. Diagnosis: Transient ischemic attack

3. Condition:

4. Vital Signs:

5. Activity: Up as tolerated.

6. Nursing: Guaiac stools.

7. Diet: Dysphagia ground with thickened liquids or regular diet.

8. IV Fluids:: Heparin lock with flush q shift.

9. Special Medications:

-Aspirin 325 mg PO qd OR

-Clopidogrel (Plavix) 75 mg PO qd OROR

-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab PO bid.

-Heparin (if recurrent TIAs or cardiogenic or vertebrobasilar source for emboli) 700-800 U/h (12 U/kg/h) IV infusion without a bolus (25, 000 U in 500 mL D5W); adjust q6-12h until PTT 1.2-1.5 x control.

-Warfarin (Coumadin) 5.0-7.5 mg PO qd for 3d, then 2-4 mg PO qd. Titrate to INR of 2.0-2.5.

10. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Docusate sodium (Colace) 100 mg PO qhs.

-Milk of magnesia 30 mL PO qd prn constipation.

11. Extras: CXR, ECG, CT without contrast; carotid duplex scan, echocardiogram w/ bubble study, 24-hour Holter monitor. Physical therapy, neurology consults.

12. Labs: CBC, glucose, CMP, fasting lipid profile, VDRL, INR/PTT, UA. drug screen, blood cultures, lupus anticoagulant, anticardiolipin antibody, lipoprotein(a) level, homocysteine level, ANA, ESR, and sickle cell prep (if patient is African American or of Mediterranean or Southeast Asian descent).

 

Admit Orders: Subarachnoid Hemorrhage

1. Admit to:

2. Diagnosis: Subarachnoid hemorrhage

3. Condition:

4. Vital Signs: Vital signs and neurochecks q1-4h. Call physician if BP >185/105, <110/60; P >120, <50; R>24, <10; T >38.5°C; or change in neurologic status.

5. Activity: Bedrest.

6. Nursing: Head-of-bed at 30 degrees, turn q2h. Foley catheter to closed drainage, eggcrate mattress. Inputs and outputs.

-Keep room dark and quiet..

7. Diet: NPO except medications.

8. IV Fluids and Oxygen: 0.45% normal saline at 100 mL/h. Oxygen at 2 L/min by nasal cannula.

-Restrict total fluids to 1000 mL/day; diet as tolerated.

9. Special Medications:

-Nimodipine (Nimotop) 60 mg PO or via NG tube q4h for 21d; start within 96 hours of stroke.

-Phenytoin (seizures) load 15 mg/kg IV in NS (infuse at max 50 mg/min), then 300 mg PO/IV qAM (4-6 mg/kg/d) OR

-Valproic acid (Depakene) 500-1000 mg IV q6h.

Hypertension:

-Labetalol (Trandate) 10-20 mg IV q15min prn or 1-2 mg/min IV infusion.

10. Extras: CXR, ECG, CT without contrast; MRI angiogram; cerebral angiogram. Neurology, neurosurgery consults.

11. Labs: CBC, CMP, VDRL, UA.

 
Source: Tarascon Hospital Medicine. Tintinalle ED 7th