2. Stroke Objectives
Review etiology of strokes
Identify likely location/type of stroke based of
physical exam
Acute management of ischemic stroke
Acute management of hemorrhagic stroke
3. Three Stroke Types
Ischemic
Stroke
Clot occluding
artery
85%
Intracerebral
Hemorrhage
Bleeding
into brain
10%
Subarachnoid
Hemorrhage
Bleeding around
brain
5%
9. NIHSS
NIHSS (National Institute of Health Stroke Scale)
Standardized method used by health care professionals to measure the
level of impairment caused by a stroke
Purpose
Main use is as a clinical assessment tool to determine whether the
degree of disability is severe enough to warrant the use of tPA
Scores are totaled to determine level of severity
Can also serve as a tool to determine if a change in exam has occurred
10. Breaking Down the Scale
13 item scoring system, 7 minute exam
Integrates neurologic exam components
CN (visual), motor, sensory, cerebellar, inattention, language, LOC
Maximum score is 42, signifying severe stroke
Minimum score is 0, a normal exam
Scores greater than 15-20 are more severe
11. NIHSS interpretation
Stroke Scale Stroke Severity
0 No Stroke
1-4 Minor Stroke
5-15 Moderate Stroke
15-20 Moderate/Severe Stroke
21-42 Severe Stroke
12. Etiology of Ischemic Strokes
LARGE VESSEL THROMBOTIC: Virchow’s Triad….
Blood vessel injury
- HTN, Atherosclerosis, Vasculitis
Stasis/turbulent blood flow
- Atherosclerosis, A. fib., Valve disorders
Hypercoagulable state
- Increased number of platelets
- Deficiency of anti-coagulation factors
- Presence of pro-coagulation factors
- Cancer
13. Etiology Of Ischemic Stroke:
LARGE VESSEL EMBOLIC:
• The Heart
– Valve diseases, A. Fib, Dilated cardiomyopathy, Myxoma
• Arterial Circulation (artery to artery emboli)
– Atherosclerosis of carotid, Arterial dissection, Vasculitis
• The Venous Circulation
– PFO w/R to L shunt, Emboli
14. Determining the Location
• Large Vessel:
– Look for cortical signs
• Small Vessel:
– No cortical signs on exam
• Posterior Circulation:
– Crossed signs
– Cranial nerve findings
• Watershed:
– Look at watershed and borderzone areas
– Hypo-perfusion
15. Cortical Signs
RIGHT BRAIN: LEFT BRAIN:
- Right gaze preference - Left gaze preference
- Neglect - Aphasia
If present, think LARGE VESSEL stroke
17. Aphasia
Broca’s
Expressive aphasia
Left posterior inferior
frontal gyrus
Wernicke’s
Receptive aphasia
Posterior part of the superior temporal gyrus
Located on the dominant side (left) of the brain
18. Determining the Location
• Large Vessel:
– Look for cortical signs
• Small Vessel:
– No cortical signs on exam
• Posterior Circulation:
– Crossed signs
– Cranial nerve findings
• Watershed:
– Look at watershed and border zone areas
– Hypo-perfusion
19. Brainstem Stroke Syndromes
• Rarely presents with an isolated symptom
• Usually a combination of cranial nerve abnormalities, and crossed
motor/sensory findings such as:
– Double vision
– Facial numbness and/or weakness
– Slurred speech
– Difficulty swallowing
– Ataxia & Vertigo
– Nausea and vomiting
– Hoarseness
23. Hypertensive ICH
Spontaneous rupture of a small artery deep in the brain
Typical sites
Basal Ganglia
Cerebellum
Pons
Typical clinical presentation
Patient typically awake and often stressed, then abrupt onset of symptoms
with acute decompensation
24. Ganglionic Bleed
Contralateral hemiparesis
Hemisensory loss
Homonymous hemianopia
Conjugate deviation of eyes toward the side of the bleed or downward
AMS (stupor, coma)
25. Cerebellar Hemorrhage
Vomiting (more common in ICH than SAH or Ischemic CVA)
Ataxia
Eye deviation toward the opposite side of the bleed
Small sluggish pupils
AMS
26. Pontine Hemorrhage
Pin-point but reactive pupils
Abrupt onset of coma
Decerebrate posturing or flaccidity
Ataxic breathing pattern
31. Airway
Most likely related to decreased level of consciousness (LOC),
dysarthria, dysphagia
GCS < 8 - INTUBATE
Avoid Hyperventilation or Hypoventilation
NPO until swallow assessment completed- high aspiration risk
Begin mobilization as soon as clinically safe
Keep HOB greater than 30 degrees
32. After ABC
GCS
ECG and blood pressures
Blood glucose
Fluid access
Hydration
Bloods
Nil by Mouth
33. Time is brain
1.9 million neurons are lost each minute after a stroke
Protect ischaemic penumbra
34. Schedule of Neurological Assessment and
Vital Signs and Other Acute Care
Assessments in Thrombolysis-Treated
Patients
35. Schedule of Neurological Assessment and
Vital Signs and Other Acute Care
Assessments in non-thrombolysis-Treated
Patients
42. Imaging
CT scan
• Non- contrast CTH remains the gold
standard as it is superior for
showing IVH and ICH
• CT with contrast may help identify
aneurysms, AVMs, or tumors but is
not required to determine whether
or not the patient is a tPa
candidate
MRI
• Superior for showing
underlying structural lesions
• Contraindications
43. tPa
Fast Facts
Tissue plasminogen
activator
“clot buster”
IV tpa window 3 hours
IA tpa window 4.5 hours
Disability risk 30% despite
~5% symptomatic ICH risk
Contraindications
Hemorrhage
SBP > 185 or DBP > 110
Recent surgery, trauma or stroke
Coagulopathy
Seizure at onset of symptoms
NIHSS >21
Age?
Glucose < 50
44. CT
Known time of symptoms <4
hours
NIHSS score
No haemorrhage
No contraindications
Consent
Age
46. rTPA Alteplase
Do not mix t-PA with any other medications.
Do not use IV tubing with infusion filters.
All patients must be on a cardiac monitor
When infusion is complete, saline flush with Normal saline
t-PA must be used within 8 hours of mixing when stored at room
temperature or within 24 hours if refrigerated
47. Complications of Thrombolysis
Intra-cerebral haemorrhage-1.7% 0.28% fatal
Bleeding-minor bleeding is common (IV site)
Anaphylaxis- 1%
Angiodoema 1.3%
Major Hemorrhage 0.4%
48. Blood Pressure Management
BP Management
The goal is to maintain cerebral perfusion!!
CPP = MAP – ICP (needs to be at least 70)
Higher BP goals with Ischemic stroke
Lower BP goals with Hemorrhagic stroke (avoid hemorrhagic
expansion, especially in AVMs and aneurysms)
50. Supportive Therapy
Glucose Management
Infarction size and edema increase with acute and chronic
hyperglycemia
Hyperglycemia is an independent risk factor for hemorrhage when
stroke is treated with t-PA
Antiepileptic Drugs
Seizures are common after hemorrhagic CVAs
ICH related seizures are generally non-convulsive and are
associated to with higher NIHSS scores, a midline shift, and tend to
predict poorer outcomes
51.
52. Hyperthermia
Treat fevers!
Evidence shows that fevers > 37.5 C that persists for > 24 hrs correlates
with ventricular extension and is found in 83% of patients with poor
outcomes
The National Institute of Health Stroke Scale is the industry standard
It is also a research tool that allows us to quantify our clinical exam
As you can see the scale is broken down into several components that allow the clinician to complete a quick but thorough exam.
Note that the maximum score is 42
Cortical Signs
Abulia - Loss or impairment of the ability to make decisions or act independently
Anosonosia - complete unawareness or denial of a neurologic deficit.
Maintaining adequate tissue oxygenation is imperative in the setting of both types of strokes, with your overall goal being to prevent hypoxia and potential worsening of the cerebral injury.
Obviously, patients with decreased mental status and brain stem dysfunction have the greatest risk of airway compromise.
Patients who require intubation have poorer prognosis, as approximately 50% of them will be dead within 30 days after their stroke.
Included in the algorithm are critical time goals set by the National Institute of Neurological Disorders (NINDS) for in-hospital assessment and management.
These time goals are based on findings from large studies of stroke victims:
Immediate general assessment by a stoke team, emergency physician, or other expert within 10 minutes of arrival, including the order for an urgent CT scan
Neurologic assessment by stroke team and CT scan performed within 25 minutes of arrival
Interpretation of CT scan within 45 minutes of ED arrival
Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours from onset of symptoms Door-to-admission time of 3 hours
Interestingly, although the head CT is considered the standard for patients with suspected strokes, it is used to not to confirm an acute ischemic stroke but instead rule out other causes of the patient’s condition. CTs are actually relatively insensitive for in detecting acute and small corical infarctions especially in the posterior fossa region.
However, if there is evidence of early edema or mass effect noted on the intial head ct, the patients risk of hemorrhagic conversion increases by approximately 8 fold.
For the most part, ICH stroke guidelines recommend using IV medications to lower SBP < 160 while still maintaining adequate MAP and CPP
Ischemic strokes are a bit trickier to manage. One must keep in mind that the patient’s blood pressure will lower on its own by approximately 25 – 30 % within the first 24 hours.
Furthermore aggressive treatment of hypertension in ischemic strokes has been shown to worsen neurological function by reducing perfusion pressure
Castillo and collegues performed a study in 2004 that showed that a drop in either SBP or DBP > 20 points were associated with higher rates of mortality and larger volumes of infarctions. They also noted that early administration of antihypertensinve medications to patients with SBP > 180 was associated with an increased risk of death.
**** CHHIPS trial ***
According to the guidelines, sbp should be reduced by 15 – 25% within the first day as excessively high blood pressures are associated with an increased risk of hemorrhagic conversion.
Elevated glucose levels at the time of admission predicts an increased 28 day mortality rate in both diabetic and non-diabetic patients.
Study done by Vespa and collegues done in 2003 showed that 18 / 63 patients ( 28% ) of patients in a neuro ICU seized on EEG within 72 hours of admission
ICH stroke guidelines recommend IV medications to quickly stop seizures. Benzos tend to be first line choice, followed by IV phenytoin or fos-phenytoin, Brief period of prophylactic AED therapy has been shown to redice the risk of early seizures esp in patient with lobar hemorrhage.
Fevers tend to be more common in basal ganglia and lobar ICHs and patients with IVH. Scwartz and collegues published a study in 200 that stated patients who survived the first 72 hours after hospital admission, the duration of fever is realted to outcome and is a an independent prognostic factor in stroke patients.
However, although there have been several studies done, to date there is no recommended drug or dose of medication that is recommended in the treatment of fevers in stroke patients.
Guidelines currently recommend that clinicians seek out a souce (don’t just assume that the fever is neurogenic in nature) and treat accordingly.