Kraus Acute Stroke.ppt

Management of acute stroke

Eric Kraus, MD

Neurology

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia.

PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.

Medications: ASA 81mg, Lisinopril 20mg, Pravastatin 40mg, saw palmetto.

PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.

What do you want to do first?

Initial work-up

Document time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head CT Labs

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

< 3 hours» ..and meet inclusion and

exclusion criteria» Intra-venous t-PA

3-6 hours» ..and have a large artery

occlusion (ICA, MCA, ACA, PCA, vertebral, basilar)

» CT angiogram» Intra-arterial t-PA

> 6 hours» ..and basilar occlusion which is

largely fatal if not opened» CT angiogram» Intra-arterial t-PA

t-PA: Inclusion

Age 18-80 Ischemic stroke NIHSS > 4 Onset < 3 hours ASA use okay

t-PA: Exclusion

Hemorrhagic stroke NIHSS > 20 (caution) Rapidly improving symptoms Hx stroke w/in 6 weeks Possible seizure cause of

paralysis Previous known intracranial

hemorrhage, tumor, AVM, aneurysm

Presumed septic embolus Recent MI Trauma with internal injury w/in

30d Recent head trauma w/in 90d

SBP > 185, DBP > 110 Glucose < 50 or > 400 Plts < 100K Hct < 25 Hereditary or acquired

(Coumadin) bleeding disorder, INR > 1.7

Recent internal bleeding Recent surgery Pregnancy or parturition w/in

30d Arterial or venous puncture at

noncompressible sites w/in 1wk Other serious/terminal illness

NINDS t-PA trial

Good outcome» No or minimal disability at 3 months» 29% placebo» 41% t-PA

Bleeding risk» 0.6% placebo» 6.4% t-PA

NINDS group. NEJM 1995;333:1581

CT Angiogram

Contraindications» Contrast allergy» Cr > 1.5

Alternatives» MRA» Limited catheter

angiogram

Initial work-up


NIHSS (stroke scale)» Min score = 0» Max score = 42» Must be > 4» Caution > 20

EKG Noncontrast head CT Labs

Assessment of:» Level of consciousness» Gaze» Visual fields» Facial weakness» Arm and leg weakness» Limb ataxia» Sensation» Best language» Dysarthria» Inattention or neglect

Initial work-up



CT Labs

Ischemic changes A-fib

Initial work-up



CT Labs

Normal

Initial work-up



CT Labs

Lacune

Initial work-up



CT Labs

Cortical - small

Initial work-up



CT Labs

Cortical - large

Initial work-up



CT Labs

Hypoperfusion

Initial work-up



CT Labs

Dense MCA sign

Initial work-up



CT Labs

Hemorrhage

Initial work-up



CT Labs

Hemorrhage» CT angiogram» ..and on antiplatelet drug

– Consider 6-pack plts

» ..and on Coumadin– Vit K 10mg IV

– 4 units FFP repeated until INR <= 1.5

» ..and on heparin– Protamine 25mg IV,

repeat 10mg IV prn

Initial work-up



CT Labs

Hemorrhage causes» HTN» Amyloid angiopathy» Trauma» Bleeding predisposition

– Hereditary

– Acquired

» Vascular malformation» Aneurysm

Initial work-up



CT Labs

HTN

Initial work-up



CT Labs

Amyloid angiopathy

Initial work-up



CT Labs

AVM

Initial work-up



CT Labs

Cavernous malformation

Initial work-up



CT Labs

Subarachnoid hemorrhage

Initial work-up



CT Labs

Cr Coags

» PTT, INR, fibrinogen

Hct Plts Glucose

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia.


Medications: ASA 81mg, Lisinopril 20mg, Pravastatin 40mg, saw palmetto.


Other acute management issues to consider?

General management

Permissive HTN Glucose < 150 using insulin Temperature < 37.8

» Tylenol 650mg q 6hrs x 48hrs Fluids: euvolumia, isotonic saline, no glucose SaO2 > 92% Avoid Foley DVT prophylaxis Nutrition / swallowing

General management


» Tylenol 650mg q 6hrs x 48hrs

Fluids: euvolumia, isotonic saline, no glucose

SaO2 > 92% Avoid Foley DVT prophylaxis Nutrition / swallowing

Stop or reduce HTN drugs» Half B-blockers

» Consider cardiopulmonary needs

Ischemic stroke» BP < 210/120

» BP < 180/105 if t-PA given Hemorrhagic stroke

» BP < 180/105 HTN treatment if needed

» 1st: Labetolol 10mg IV prn

» 2nd: Nicardipine gtt

General management


» Tylenol 650mg q 6hrs x 48hrs

Fluids: euvolumia, isotonic saline, no glucose

SaO2 > 92% Avoid Foley DVT prophylaxis Nutrition / swallowing

Ischemic stroke» SQ heparin 5000u tid

» +/- SCDs Hemorrhagic stroke

» SCDs All patients

» Early mobility

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia. Onset 10 hours ago.


Medications: Lisinopril 20mg, Pravastatin 40mg, saw palmetto.


What treatment should be given?

Acute ASA

CAST, IST trials* Small reduction of death or early recurrent ischemic stroke

» Abs risk reduction ~0.8% over placebo

» NNT ~125 Good outcome

» No or minimal disability at 6 months

» 10 per 1000 over placebo Bleeding risk

» 0.6% placebo

» 1.1% ASA

*Coull et al. Neurology 2002;59:13

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia. Onset 5 hours ago.


Medications: Lisinopril 20mg, Pravastatin 40mg, saw palmetto.


EKG shows A-fib.

What treatment should be given?

Don’t think heparin

Multiple studies don’t support acute heparin May cause hemorrhagic conversion

» Larger strokes have more risk Exceptions

» Recurrent thrombotic emboli– Risk is only 5% in first 2 weeks for A-fib

» Impending carotid or basilar occlusion» Cerebral venous thrombosis

If heparin» Goal PTT 50-80» Never bolus

Question

An 82 y.o. man presents with acute left facial weakness. A head CT scan is unremarkable so you order an MRI.

What MRI sequence is best for acute stroke?

A. DiffusionB. FlairC. T1D. T2E. Gradient echo

What’s acute

Flair

Diffusion

Kraus Acute Stroke.ppt

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