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
Time of onset» Consider t-PA
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
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Ischemic changes A-fib
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Normal
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Lacune
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Lacune
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Cortical - small
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Cortical - large
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Hypoperfusion
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Dense MCA sign
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Hemorrhage
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
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
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Hemorrhage causes» HTN» Amyloid angiopathy» Trauma» Bleeding predisposition
– Hereditary
– Acquired
» Vascular malformation» Aneurysm
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
HTN
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Amyloid angiopathy
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
AVM
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Cavernous malformation
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
CT Labs
Subarachnoid hemorrhage
Initial work-up
Time of onset» Consider t-PA
NIHSS (stroke scale) EKG Noncontrast head
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.
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.
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
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
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
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
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.
PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.
Medications: Lisinopril 20mg, Pravastatin 40mg, saw palmetto.
PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.
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.
PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.
Medications: Lisinopril 20mg, Pravastatin 40mg, saw palmetto.
PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.
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
END
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