ISCHEMIC STROKE MANAGEMENT

Question 1

MANAGEMENT OVERVIEW

Answer 1

ABCDE MOVIE
POC Glucose
ASSESS CODE STROKE
ASSESS DELAYED PRESENTATION / EVT CRITERIA
Imaging
Labs
Early stroke neurology consultation
History - LSN
R/o Mimics
NIHSS & 5 Min Neuro Exam
Antiplatelets
Thrombolysis
Blood Pressure Control
Blood Glucose Control
Temperature Management

Question 2

MANAGEMENT

Answer 2

TARGET TIMES FOR BETTER OUTCOMES AT 90 DAYS

< 90 min

AIRWAY
Rapid assessment and stabilization of ABCs:
Assess airway patency, ability to clear secretions
if ↓ LOC, may need to intubate
Avoid hypotension with induction

BREATHING
Sp02 >/ 94%

CIRCULATION
IV Access
Monitor
Blood pressure targets

DISABILITY
POC Glucose
Brief Neurological Exam
Head of Bed to 30
NPO
Strict Bedrest, aspiration and fall precautions

EARLY CONTACT WITH STROKE NEUROLOGY

ASSESS CODE STROKE CRITERIA
1. 0-6 Hours since last seen normal AND stroke - like symptoms

2. Exclude very mild deficits e.g. isolated sensory loss
3. Severe dementia / palliative care patients are not candidates
4. Order “Code Stroke CT / CTA”
5. Do NIHSS / Consult Telestroke
6. Afer hours do CT head and call tech for CTA PRN

ASSESS EVT ELIGIBILITY / DELAYED PRESENTATION

1. 6-24 hours since last seen normal
2. Deficits are NOT pre-existing (mild deficits that are now worse are acceptable as true deficits)
3. Onset of symptoms or last seen normal less than 24 hrs
4. mRS 0-2 / Living at home independently with only minor assistance - must be independent with hygiene, personal care tasks, walking (walking aids are acceptable)

Patient does not have stroke mimics: seizure preceding symptoms, hypoglycemia
= glucose < 2.8 mmol / L, active malignancy with brain mets

5. ACT-FAST Stroke Screen

ACT FAST STROKE SCREEN:

1. ARM - one sided weakness
   Position both arms at 45 degrees from horizontal with elbows straight

POSITIVE TEST: One arm falls completely within 10 seconds

For patients that are uncooperative or cannot follow commands: Witness minimal or no movement in one arm & movement in the other arm

2. IF RIGHT ARM IS WEAK: “CHAT” (severe language deficit)

Ask the patient to repeat “you can’t teach an old dog new tricks” OR perform simple tasks (“make a fist, “open and close your eyes”)

POSITIVE TEST: Mute, speaking incomprehensively, unable to follow simple commands

3. IF LEFT ARM IS WEAK: “TAP” (gaze and shoulder tap test)

Stand on patient’s weak side & call name
POSITIVE TEST: Consistent gaze to the right

OR

Tap shoulder & call name
POSTIVE TEST: does not quickly turn head and eyes to you

4. IF POSITIVE OBTAIN LATE WINDOW STROKE IMAGING “CODE STROKE RAPID PROTOCOL” (CT, CTA, and CTP RAPID)

IMAGING:

If 0-6 hours: CODE STROKE CT / CTA

If 6-24 hours: LATE WINDOW STROKE IMAGING “CODE STROKE RAPID PROTOCOL” (CT, CTA, and CTP RAPID)

IMAGES TO LOOK AT

1.thick phase 1
2. Thick phase 2
3. Perfusion scan

Assess for:
intracerebral hemorrhage, space-occupying lesions,
signs of infarction (eg, sulcal effacement, loss of gray-white differentiation, early hypodensity, and hyperdense vessel signs)

LABS:
CBC
PT/INR
Troponins
BUN / Cr
Lytes
Glucose
HbA1c
Fasting Lipid Profile
LFTs

ASSESS INCLUSION / EXCLUSION FOR THROMBOLYTICS
See Below

THROMBOLYTICS
Tenecteplase:
0.25 mg/kg intravenous push (maximum 25 mg).

SINGLE ANTIPLATELET THERAPY
Start ASAP after CT has excluded hemorrhage within 24 hr of symptom onset (ideally within 12 hrs)

NOT eligible for tPA or EVT and NOT on an antiplatelet at baseline

ASA: 160-325 mg after CT excludes hemorrhage, then 81 mg daily
OR
Clopidogrel: 300 mg loading dose then 75 mg daily

BLOOD PRESSURE MANAGEMENT
AIS / TIA: BP <220/<120 - reduced by 15% during first 24 hrs after stroke onset

AIS with tPA: <185/<110

AIS for 24 hrs after tPA: <180/105

AIS for several days: <140/90

FIRST LINE ANTIHYPERTENSIVES

Nicardipine 5 mg / hr as an IV infusion and increase by 2.5 mg/ hr every 10 minutes to a maxof 15 mg/ hr

OR

Labetalol 10-20 mg IV push given over 2 minutes followed by 20-80 mg IV push every 10 to 15 minutes to a maximum total dose of 300 mg.

This can be followed an intravenous infusion of labetalol at a rate of 0.5-2 milligram per minute

Caution with labetalol in heart block, bradycardia, asthma

GLUCOSE TARGETS
BG 7.8-10 mmol/L

PREVENTION
NPO until SLP Consult
Bladder Scan or In/out cath, avoid foley
Bowel Routine
Early mobilization, OT / PT involvement

Question 3

DOCUMENTATION

Answer 3

TIME OF ARRIVAL

HISTORY

Obtain collateral history for family, EMS, patient, witnesses

Last time seen normal (LSN) - use the exact time

Timing of onset of symptoms and signs

Main Neurological Symptoms - have they improved?

Relevant PMHx, Meds, Allergies, Social Hx (Risk Factors)

Anticoagulants

Baseline functional status and occupation

Vitals en route, EMS cardiac rhythm, blood glucose

Did they bypass a closer hospital

PHYSICAL EXAM
5 Min Neuro Exam: Focused and Screening Exam
ACT-FAST
NIHSS

TIME OF IMAGING ORDERING

TIME OF CALL TO STROKE NEUROLOGY

TIME OF CONTACT TO STROKE NEUROLOGY

TIME OF CT READ

TIME OF THROMBOCYTICS

Question 4

Stroke Mimics

Answer 4

Hypoglycemia

Migraine w/ aura OR Migraine w/ variants

Syncope / Pre-Syncope

Limb Shaking TIA

Seizures – ictal or post-ictal (Todd Paralysis)

Acute Unmasking of old stroke symptoms

Drug / Toxic encephalopathy

Meningitis / Encephalitis, Bell’s Palsy (Will have forehead involvement), Ramsay hunt (Will also have forehead involvement, ear pain, and vesicle in the auditory canal)

Peripheral Vestibulopathy

Toxic / Metabolic Encephalopathy

CNS Structural Pathology

Question 5

THROMBOLYTICS INLCUSION / EXCLUSION

Answer 5

INCLUSION

> 18 years old
AND
Clinical diagnosis of Ischemic stroke causing disabling neurological deficit
AND
Onset of symptoms <4.5 hours
OR
If the exact onset is not known, the last time the patients was known to be normal

CT HEAD EXCLUSION
Hemorrhage on brain imaging
Evidence of multilobar infarction with hypodensity involving > 33% of the cerebral hemisphere

HISTORICAL EXCLUSION
History of Intracranial Hemorrhage
Head injury, CVA or spinal injury in past 3 months
Myocardial Infarction in the previous 3 months
Gastrointestinal or Urinary Tract Bleeding in the last 21 day
Major surgery int he past 14 days
Arterial puncture at non compressible sit in past 7 days

CLINICAL EXCLUSION
Spontaneously clearing stroke symptoms
Only minor or isolated neurological signs
Active hemorrhage or acute trauma (fracture)
SBP > 185 mmHg DBP > 110 mmHg
Symptoms of stroke suggestive of subarachnoid hemorrhage
Seizure at onset of stroke if residual impairments are due to postictal phenomenon

LABORATORY EXCLUSION
BG<2.8 mmol/L
INR > 1.7 if on Warfarin
Elevated PTT on heparin
Platelets <100,000

RELATIVE EXCLUSION
Use of Dabigatran within 48 hours prior to stroke onset
Treatment between 3 and 4.5 hours and Age > 80, and / or previous stroke and diabetes
Treatment between 3 and 4.5 hours with oral anticoagulant use regardless of INR
Treatment between 3 and 4.5 hours with NIH Stroke Scale score > 25