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C3 - Stroke - Introduction

Jessica Mason, MD, Mel Herbert, MD MBBS FAAEM, and Stuart Swadron, MD, FRCPC
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C3 2018 01 January Stroke Written Summary 365 KB - PDF

C3 - Stroke

 Jessica Mason MD, Stuart Swadron MD, Mel Herbert MD

 * Drug doses are a guide only, always check a second source and follow local practice guidelines

 

Take Home Points

  • Stroke care is systems-based; it cannot be done well without a well functioning team within an organized system
  • Although an immediate priority is to get the patient with acute stroke to the CT scanner, it is critical not to overlook the basics: airway, breathing and circulation
  • If the initial CT reveals intracranial hemorrhage, treatment focuses on prevention of further bleeding, control of BP and possible neurosurgical intervention
  • If the initial CT does not reveal hemorrhage, focus turns to the timely administration of tPA in eligible patients within a 3 hour (in some cases 4.5) window following the onset of symptoms
  • Attention to good basic medical and nursing care, as well as a multidisciplinary team of providers, is essential for good patient outcomes 

INTRODUCTION

In this episode of C3, we review the management of the patient with acute stroke.  Although cerebrovascular disease is a leading cause of death worldwide, advances in acute stroke care have been overshadowed to some degree by advances in cardiovascular care.   After years of slow and difficult progress, the battle against stroke is picking up steam.  Advances in imaging allow us to more precisely define the various stroke syndromes and new interventional techniques now the hold promise of more effective targeted treatments.

When most providers refer to stroke they are referring to an ischemic stroke - an infarction of brain tissue caused by an arterial occlusion in the brain.  But stroke is actually a broader term encompassing any injury to central nervous system (CNS) tissue caused by vascular pathology.  This includes hemorrhagic strokes of different types, subarachnoid hemorrhage (SAH) and also venous occlusions (central venous thrombosis).

In many respects, there are common principles that unify the management of these various stroke syndromes.  Attention to airway management and prevention of secondary brain injury due to fever or hypoglycemia, for example, are important objectives in the treatment of all strokes.  In other respects, however, current treatment recommendations differ depending on the syndrome.  Blood pressure management is one of the most obvious examples of this, with very different goals in patients with ischemic versus hemorrhagic stroke.

IMMEDIATE CONSIDERATIONS

  • Primary Survey
    • It is important not to let the excitement of a “Code Stroke” (as it is called in many institutions) interfere with the primary survey
      • Airway, breathing, and circulation come first!
    • After the primary survey and brief initial assessment, the priority is to obtain imaging - this should be within 25 minutes of arrival or less
    • Elevate the head of the bed 30 degrees
      • Apart from as necessary during the initial imaging, elevation of the head of bed decreases passive regurgitation and aspiration
      • It also decreases intracranial pressure and improved venous drainage of the injured brain
    • Maintain O2 sat >94%
      • There is a trend in critical care to avoid excessive oxygenation due to the poorer clinical outcomes seen in brain injured patients
      • However, in patients with acute CNS injury the need to avoid secondary hypoxic injury leads to a higher O2 sat goal
    • Avoid hypotension
      • Similar to hypoxia, even transient decreases in blood pressure have been associated with poor outcomes in CNS injury
      • Hypotension should be scrupulously avoided, utilizing vasopressors if necessary 
  • Critical Initial Assessment
    • Time of onset
      • It is critical to establish the time on onset of symptoms to guide management
      • The clock is ticking once the patient arrives and therapy is time dependent - each minute counts
      • What to do with a wake up stroke?
        • Imaging may allow you to bend the rules with time if edema is minimal and there is a favorable perfusion/diffusion ratio on advanced imaging
    • Cursory physical examination
      • The National Institutes of Health Stroke Scale (NIHSS) serves as a standard in the evaluation of stroke severity and is used to measure the patient’s degree of deficit
        • The NIHSS can be performed by any trained provider
        • Measurement of the NIHSS can be performed as the patient is being prepared for CT or even on the CT table
        • The NIHSS score ranges from 0-42, with higher numbers indicating more severe stroke
        • The NIHSS is not perfect, for example, it underestimates strokes in the posterior circulation (brainstem and cerebellum)
    • Blood pressure
      • Blood pressure can be very labile in the setting of acute stroke and high blood pressures are very common in the initial presentation
      • Unless pressure is extremely elevated (>220/120) it is appropriate to obtain the initial CT and recheck BP
        • The presence or absence of bleeding will guide the subsequent BP management
        • If the pressure is >220/120, an initial dose of IV antihypertensive such as labetalol (10-20 mg) on the way to CT is appropriate
  • Labs and tests
    • Blood glucoseis the most important initial lab test
      • Both hypo- and hyperglycemia are stroke mimics
      • Blood glucose control is important to clinical outcomes
    • Other important and routine blood tests include complete blood count (CBC), electrolytes and coagulation studies
    • Troponin testing is appropriate
      • Acute coronary or aortic disease can lead to stroke
      • Cardiac ischemia may complicate stroke, which generally results in a hyperadrenergic state
  • ECG
    • Electrocardiography (ECG) or the cardiac monitor may detect arrhythmias
    • Atrial fibrillation (AF) suggests a possible embolus from the heart as a cause for the stroke
  • CXR
    • Chest x-ray is appropriate when there is suspicion of concurrent cardiopulmonary and is generally obtained
  • Imaging
    • The immediate priority is to obtain a non-contrast CT Head
      • The first important “branch” in the management is to determine the presence or absence of bleeding in the brain
    • In cases where stroke appears clinically obvious, CT angiography while the patient is still on the CT table can be extremely helpful
      • If hemorrhage is seen, angiography can identify a source of the bleeding (e.g. an aneurysm or arteriovenous malformation)
      • If no hemorrhage is seen, the patient may be a candidate for fibrinolytic treatment
    • Some specialized centers have imaging protocols that involve magnetic resonance (MR) imaging and MR angiography
      • MR gives more precise detail but:
        • is more time consuming
        • is actually less sensitive for the presence of acute bleeding
        • may be contraindicated in patients who are critically ill if it compromises the ability to resuscitate and safely monitor the patient
        • MR angiography, unlike CT angiography, does not necessarily require contrast dye

 

Tim V. -

Thanks for the great review.

Does anyone fight the tPA fight anymore? One weak RCT to support its use.

Here’s a good summary of the literature:
https://emergencymedicinecases.com/thrombolysis-endovascular-therapy-for-stroke/

J. Thompson D.O. -

Any comments on Hypertensive Encephalopathy? This was not mentioned as a stroke mimic. Given the tremendous pressure now a days to meet metrics and do things as fast as possible, is it reasonable or unreasonable to watch and wait for your Labetalol or Cardene to resolve symptoms, and if so, what is that time frame.
At my facility, we are pushed for a door to needle time of <60min.
Just in the past 2 weeks I have had 2 different patients present with neurologic deficits consistent with having a stroke, but ended up with diagnosis of Hypertensive Encephalopathy.
There was talk of "not lowering the blood pressure" in certain cases. I disagree leaving BP high in the face of neurologic defecits if TPA is not going to be given.
TPA is not a benign drug and it seems that the stroke neurologists will give TPA on a whim if non-contrast head CT is negative and absence of contraindications, solely to meet the metric.

Jess Mason -

We get to this in a later chapter.

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C3 - Stroke Full episode audio for MD edition 79:24 min - 110 MB - M4AC3 2018 01 January Stroke Board Review Answers 85 KB - PDFC3 2018 01 January Stroke Board Review Questions 90 KB - PDFC3 2018 01 January Stroke Individual MP3 Files 102 MB - ZIPC3 2018 01 January Stroke Written Summary 365 KB - PDF