37 - ACUTE ISCHEMIC STROKE Flashcards
- *Ischemic Stroke**
- *S/Sx**
–SUDDEN–
Weakness / Dizziness / Difficulty Walking
CONFUSION / difficulty Speaking
changes in VISION
Facial DROOP or Numbness
Severe HA
F-A-S-T
Ask to Smile - Face Drooping
Raise Arms - Arm weakness
Talk - Speech Difficulty
Time to call 911
Acute Ischemic Stroke
VS
TIA = Transient Ischemic Attack
Ischemic Stroke
Episode of Neurological Dysfunction caused by
FOCAL CNS Infarction
TIA
brief episode of neurological dysfunctioncaused by “
clinical symptoms lasting < 1 hour** & **w/o evidence of Infarction
- -> treat similarly to stroke!
- *Major determinant of FUTURE STROKE** esp within few days
Cerebral Vasculature
Different Areas of Brain Circulation
Anterior circulation
Internal carotid arteries (ICA)
Anterior cerebral arteries (ACA)
Posterior circulation
Vertebral arteries (VA)
Basilar artery (BA)
Posterior cerebral arteries (PCA)
Hemispheric circulation
Middle cerebral artery (MCA)
Initial Management of Stroke
Assess for:
HypoGlycemia - similar sxs, just check BG
Stabilize airway / breathing / circulation
Cardiac Monitoring
Oxygen + IV Access
HISTORY
Ask about:
TIME OF ONSET of SXs = “Last known WELL”
recent: surgery or trauma / MI / stroke / bleeding
HTN or Diabetes?
meds: AC / Insulin / HTN meds
Pertinant Diagnostic Studies
STROKE
CT-HEADSCAN
Purpose is to RULE OUT HEMORRHAGE because:
no AC/Alteplase for HEMORRHAGIC STROKE
As Needed:
ECG / EEG / MRI / Chest X-ray
LABS:
BLOOD GLUCOSE - rule out hypoglycemia
Rest are AS NEEDED:
electrolytes / Renal / CBC / PT/INR/PTT / LFT etc
- *NIHSS**
- *What is this scoring system for?**
NIHSS = NIH Stroke Scale
standardized / validated assessment of:
SEVERITY OF STROKE
0 = normal
<10 = more favorable 1 year outcomes
>20 = severe stroke, less favorable 1 year outcomes
Based on a detailed neurological exam
- *ABCD2 Score**
- *What does this assess + Components?**
- *TIA SEVERITY**
- *High Risk = 6-7** / Medium = 4-5
- STAY IN ER –> HIGH RISK for ANOTHER STOKE*
- *Age > 60**
- *BP > 140/90
- *Clinical Features (max 2)
- unilateral weakness / speech difficulty
- *Duration** (max 2)
- *- >60min = 2 / 10-59min = 1**
- *Diabetes**
Outcome Measures in Stroke Care
Measures of:
Disablility / QOL / Function
mRS = Modified Rankin Scale
0->6(dead)
degree of disability or dependence
BI = Barthel Index
0-100
daily functions
GOS = Glasgow Outcomes Scale
1(dead)->5
overall functionality
ALTEPLASE DOSING
r-tPA
0.9mg/kg IV
Max Dose: 90mg, > 100kg = use 90mg
10% of Dose over 1 MIN
Remainder** infused over **1 HOUR
ALTEPLASE
Post Infusion RESTRICTIONS
- NO OTHER:*
- *Anti-Thrombotics** or Anticoagulants
- *for 24 hours**
NO:
Indwelling Bladder Catheters or NG tubes or Arterial Catheters
for 24 hours also
- *NINDS**
- *Study Results**
Alteplase improved:
30% more patients lives
with no difference in mortality
Safety:
- *ICH = Intracranial Hemorrhage @ 36 hours was >w/Alteplase**
- benefit OUTWEIGHS this risk*
Earlier Treatment = Better Results
ALTEPLASE
CONTRAINDICATIONS
Onset of Sxs > 3 hours
now OKAY to do <4.5 hours
ALTEPLASE
Monitoring Guidelines
- *Neurological Assessment**
- *q15min** during infusion
- *q30min** for 6 hours
- *q60min** until 24 hours passed
- *Blood Pressure < 180/105**
- CI is when BP > 185/110*
- *q15min** during infusion for 2 hours
- *q30**min for 6 hours
- *q60min** until 24 hours passd
- *CT after 24 hours**
- before starting antithrombotic or AC*
Monitor for:
ANGIOEDEMA** / **AIRWAY OBSTRUCTION
STROKE
BP Treatment / Management
Alteplace Contraindicated w/
BP > 185/110
- *“PERMISSIVE HYPERTENSION”**
- we want to LET the BP be HIGH for PROPER PERFUSION*
If INELIGIBLE for ALTEPLASE:
we allow for BP < 220/120
Intermittent Therapy:
- *Labetalol** 10mg IVP q10min prn (max 300mg)
- *Hydralazine** 10-20mg IVP q15min prn
Continuous Infusion:
- *NICARDIPINE** 5-15mg/hr
- *Nitroprusside** 0.25-10mcg/kg/min
INTRACRANIAL HEMORRHAGE = ICH
Symptoms / Treatment
- *SUDDEN** worsening of:
- *Neuro Exam / HA / NV / ACUTE HTN**
STOP ALTEPLASE** –> **CT SCAN STAT
LABS:
PT/INR/PTT - Platelets - Fibrinogen - CBC
Give BLOOD PRODUCTS:
6-8 units of FPP
if platelets < 100,00 –> give 6-8 units of Platelets
INTRACRANIAL HEMORRHAGE = ICH
RISK FACTORS
not following strict thrombolytic protocols
High Dose of Alteplase
↑Blood GLUCOSE
Poor HTN Control
Early Ischemic Changes on CT
Stroke Severity
Adv AGE
ALTEPLASE
Main ADR + Risk Factors
ANGIOEDEMA
acute swelling of tongue / lips –> potential airway compromise
Risk Factors:
prior ACE INHIBITOR USE
Insular** / **Frontal Cortex Stroke
- *TREATMENT**
- *Alteplase-Induced ANGIOEDEMA**
Antihistamines
Diphenhydramine 50mg IV
AND
FAMOTADINE 20mg IV OR RANITIDINE 150mg IV
Corticosteroids
MPD 80-100mg IV OR Hydrocortisone 100mg IV
MAY NEED SYMPATHOMEMETIC:
Epinephrine 0.1% 0.3mL SQ or 0.5mL by neb
VV
Consult ENT or Anesthesiology STAT
- *ECASS 3**
- *Trial Outcomes**
Outcomes at 3 Months:
- ALTEPLASE DOES NOT SAVE LIVES*
- *Alteplase = IMPROVED FAVORABLE OUTCOMES**
- death was similar*
ICH was Increased w/ Alteplase
EXCLUSION CRITERIA:
- *>80 y/o** // Diabetes // Prior Stroke
- *any form of AC** // NIHSS >25 (severe stroke)
Alternative Treatments for Acute Ischemic Stroke
IntraArterial (IA) Thrombolysis (Alteplase)
FIRST LINE >
> Stent Retriever & Cerebral Angioplasty
NOT FDA approved
Used for patients ineligeble for IV Alteplase
- *3-6 hours from onset**
- *High Grade Stroke / PREGNANCY**
Recommended for:
MCA or Vetebro-basilar Artery occlusions
Aspirin in ACUTE stroke
Aspirin 325mg
can be started within 24-48 hours of stroke onset
NOT a substitute for ALTEPLASE or Mech. Thrombectomy
HOLD ASPIRIN for 24 HOURS
AFTER
ALTEPLASE ADMIN
↓ death / ↓ recurrent stroke
No change in bleeding
