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| |
| Management of acute ischemic stroke |
| History |
 | Key points in the history of present illness:
 | Last time patient known to be without symptom |
| What was the patient doing when the symptoms
began |
| Any of the following:
 | headache, seizures, vomiting, change in level of
consciousness, recent trauma |
|
|
| Key points in past medical history:
| Risk factors for stroke : Age, HTN, CVA/TIA,
Carotid stenosis, Diabetes, Smoke, Atrial Fibrillation, Obesity,
hyperlipidemia, heart
valve problem, illicit drug use. |
| Medications: on warfarin, Aspirin |
| Medication allergy |
|
|
| Evaluation |
| Send stat
| CBC, Metabolic profile, INR, PTT, Fibrinogen |
|
| CT head |
| Electrocardiogram |
| Other tests if indicated
| Chest x ray, Pulse oximetry |
| Toxicology screening, Serology |
| Cardiac enzymes |
| Lipid profile |
| Urine HCG in women of child-bearing potential |
| Erythrocyte sedimentation rate, CRP, ?Homocystiene
level |
| Blood culture if fever |
|
|
| Clues to underlying disease
causing Stroke |
| Fever
| Suspect endocarditis, meningitis, brain abscess,
other infection
|
| Suspect aspiration, dysphagia
|
|
| Recent neck injury
| Exam may show Horner’s
syndrome ipsilateral to stroke |
| Suspect carotid dissection |
|
| History of sudden onset headache recently
| Suspect subarachnoid hemorrhage |
|
| Thrombocytopenia, azotemia, purpura
| Suspect TTP |
| May need blood smear, conjuctival biopsy, plasmapheresis |
|
| Evidence of systemic emboli
| Suspect cardio/aortic source |
|
| Sickle Cell Anemia
| Large vessel thrombosis |
|
| Recent angiography
| Suspect cholesterol emboli |
|
| Drug abuse
| Suspect endocarditis, amphetamine &
cocaine related stroke |
| Need blood culture |
|
| Post partum
| Suspect hypercoagulable state |
|
| Deep Vein Thrombosis, recent immobility
| Suspect paradoxical embolus |
|
| Chest and back pain
| Suspect aortic dissection, check for asymmetric pulses. |
|
| Recent Trigeminal nerve V1 zoster ipsilateral to stroke
| Suspect granulomatous angiitis |
|
| Livedo reticularis, history of spontaneous abortions
| Suspect antiphospholipid syndrome |
| May need antiphospholipid antibody |
|
|
| Thrombolysis Therapy |
| Is patient a candidate for TPA
| Neuro deficit not improving, and is caused by stroke |
| Onset of stroke known and is < 3 hours |
| CT head no bleed |
| No contraindication: recent surgery, INR < 1.7 |
| More Inclusion, exclusion criteria |
|
| Dose
| TPA 0.9mg/kg, up to 90 mg. |
| 10% given as a bolus, and the remainder infused over
1 hour. |
| Sample orders |
|
| Symptomatic intracerebral hemorrhage in first 36 hours
| 6.4% among TPA–treated patients vs 0.6% of placebo-treated
patients. |
| Risk of hemorrhage in relation to NIH Stroke Scale score:
| Score <10: hemorrhage rate 2-3% |
| Score >20: hemorrhage rate 17% |
| Even in patients with NIH Stroke Scale score >20 the trend was for an
increased probability of good outcome in the rt-PA treated group |
| Patients treated with TPA who had evidence of edema or mass effect
on the inital CT scan, hemorrhage rate: 31% |
|
| Patients with higher risk of hemorrhage with TPA use: diabetes,
elevated blood glucose, elderly patients, changes on CT scan, atrial fibrillation, lower
platelet count, hypertension. |
| Decreased level of consciousness and increasing weakness were the most
common presentations of symptomatic intracerebral hemorrhage. Headache, increase in blood
pressure, and vomiting were other presenting signs.
|
| Risk of asymptomatic intracerebral hemorrhage: rt-PA–treated
patients (4.2%) vs. placebo-treated patients (2.6%). |
| Mortality rate in patients > 75 years old with NIH Stroke Scale score
>20:
| 48% in the rt-PA treated group vs. 45% in the placebo group.
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| Management of hemorrhage |
|
|
| Blood pressure management in acute ischemic
stroke not eligible for thrombolytic therapy (AHA guideline) |
| Systolic BP <220 or Diastolic < 120
| Observe, treat if end organ involvement |
|
| Systolic > 220 or Diastolic 121-140
| Aim for 10% reduction of BP |
| Labetolol 10-20 mg IV over 1-2 min, May repeat or
double every 10 min, maximum dose 300 mg. |
| Nicardipine 5 mg/hr IV, titrate to desired effect
by increasing 2.5 mg/hr every 5 min to max of 15 mg/hs |
|
| Diastolic > 140
| Aim for 10 - 15% reduction of BP |
| Nitroprusside 0.5 ug/kg/min IV infusion as
initial dose with continuous blood pressure monitoring. |
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| Aspirin & subcutaneous heparin |
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