Intern Morning Report July 2014 Tram Le, PGY3 Stroke

Background Annual incidence in US: 795,000 80% due to ischemia 20% due to hemorrhage Ischemic stroke: Thrombosis Embolism Systemic hypoperfusion Hemorrhagic stroke Intracerebral vs Subarachnoid

Differential Diagnoses

CASE #1 67 yo male with PMH significant for DM2, HTN, and HLD who presented with onset of left sided weakness and slurred speech approximately 2 hours ago. Pt had a recent stroke about 6 months ago and is currently on a baby aspirin. VS showed temp 98.3, HR 81, BP 182/105, RR 16, O2 98% RA. Exam was consistent with dysarthria and left hemiparesis. What is the next step in management?

Initial Assessment Rapid assessment of medical stability History Airway, breathing, circulation History F.A.S.T. - Face. Arms. Speech. Time. Focal neurologic deficit Time of stroke onset Therapeutic window for thrombolysis: 3 - 4.5 hr Any contraindications to thrombolysis?

Contraindications to Thrombolysis Historical Significant head trauma or stroke in previous 3 months Previous intracranial hemorrhage Intracranial neoplasm, AVM, or aneurysm Recent intracranial or intraspinal surgery Clinical Symptoms suggestive of subarachnoid hemorrhage BP >180/110 Glucose <50 Active internal bleeding Hematologic Plt <100,000 Current anticoagulation use with INR >1.7 or PT>15 Heparin use within 48jrs and abnormally elevated aPTT Current use of the new oral anticoagulants Head CT Evidence of hemorrhage Evidence of multilobar infarction with hypodensity >33% of cerebral hemisphere

Relative Exclusion Criteria Minor and isolated neurologic signs Rapidly improving stroke symptoms Major surgery or serious trauma in previous 14 days GI or GU bleeding in the previous 21 days MI in the previous 3 months Seizure at onset of stroke with postictal neuro impairments Pregnancy Others: Age >80 Severe stroke (NIHSS score >25)

CASE #1 67 yo male with PMH significant for DM2, HTN, and HLD who presented with onset of left sided weakness and slurred speech approximately 2 hours ago. Pt had a recent stroke about 6 months ago and is currently on a baby aspirin. VS showed temp 98.3, HR 81, BP 182/105, RR 16, O2 98% RA. Exam was consistent with dysarthria and left hemiparesis. Labs show Glucose 86, Plt of 120K, trop <0.00, and INR of 1.1. Any contraindications to tPA? Next step in management?

Immediate studies CT Head Serum glucose O2 saturation EKG CBC Cardiac enzymes and troponin Electrolytes, BUN, Creatinine PT/INR/aPTT

Other studies to Consider Pregnancy test UDS and/or blood alcohol level Lumbar puncture if subarachnoid hemorrhage suspected EEG Type and cross

Blood Pressure Goals If tPA is considered: If tPA is given: BP <180/110 If tPA is given: BP <180/105 for 24 hrs If tPA is NOT given Permissive HTN, BP <220/120 Antihypertensive can be restarted in stable patients after 24 hours. Lower BP by 5-10% daily until target BP is achieved

CASE #1 67 yo male with PMH significant for DM2, HTN, and HLD who presented with onset of left sided weakness and slurred speech approximately 2 hours ago. Pt had a recent stroke about 6 months ago and is currently on a baby aspirin. VS showed temp 98.3, HR 81, BP 182/105, RR 16, O2 98% RA. Exam was consistent with dysarthria and left hemiparesis. Labs show Glucose 86, Plt of 120K, trop <0.00, and INR of 1.1. CT Head is negative for acute processes. Next step in management?

If tPA is given… Patient should be monitored in ICU NIHSS every 4 hours BP goal <180/105 for next 24 hrs No anticoagulation or antiplatelet within 24 hours STAT CT head if new neuro changes

Other Supportive Care Cardiac monitoring for at least 24hrs Hypovolemia corrected with NS O2 supplementation to achieve O2 sat >94% No O2 if not hypoxic Blood sugar <60 should be treated Hyperglycemia target: 140-180 Sources of hyperthermia identified and treated Dysphagia screening Early PT/OT DVT ppx

CASE #2 67 yo male with PMH significant for DM2, HTN, and HLD who presented with onset of left sided weakness and slurred speech approximately 2 hours ago. Pt had a recent stroke about 6 months ago and is currently on a baby aspirin. VS showed temp 98.3, HR 81, BP 182/105, RR 16, O2 98% RA. Exam was consistent with dysarthria and left hemiparesis. Labs show Glucose 86, Plt of 120K, trop <0.00, and INR of 1.1. CT Head shows small intracranial hemorrhage in the right cerebral hemisphere. Next step in management?

Management of Intracranial Hemorrhage Admit to ICU Neurosurgery consult Fever and hyperglycemia PCD’s and TED’s Reversal of anticoagulation Target BP is 140-160 systolic or MAP 110 Below 130 may cause ischemia and worsen neurologic injury No seizure ppx Increased ICP Elevated head of bed, analgesia & sedation Mannitol (goal plasma osmo 300-310) Hyperventilation (pCO2 25-30): effect lasts mins to few hours Intraventricular cath placement

Post ICH management Repeat CT Head in 6 hours Aspirin low dose Resume after 48hrs if brain imaging stable Heparin gtt safer if anticoagulation is needed immediately after ICH Oral anticoagulation: Resume after 3-4 weeks with lower target INR Early PT/OT

S&W Protocol for Stroke If patient comes through the ED… ED evaluates patient and activates Stroke Alert Neurology evaluates patient in ED History, Physical (NIHSS), and CT head within 60 minutes If IV tPA is given in ED, patient is sent to MICU If no tPA is given, pt sent to medical floor If patient is on the floor… Physician (Daytime/Nighttime) evaluates the patient: History/Physical RAPID is called Pt transported to CT Head while physician gets more history Neurology evaluates pt over TeleHealth Screen and decides it pt qualifies for tPA

Medical Management Start baby aspirin if pt was not on aspirin MKSAP recommends at least 160mg/day CAPRIE trial Plavix > ASA MATCH trial ASA + Plavix > ASA or Plavix alone: 1% ARR SPARCL trial Atorvastatin 80mg daily – reduce incidence of strokes HOPE and PROGRESS trials ACEI reduces vascular events

Other Tests MRI brain Angiogram of head/neck Doppler carotids CTA or MRA Imaging tidbit: Imaging inside of head is without contrast Imaging of neck is with contrast Doppler carotids Greater than 70% - carotid endarterectomy TTE with bubble study Prolonged cardiac monitor

When to use Coumadin? Definite cardiac sources of embolism Atrial fibrillation LV thrombus Dilated cardiomyopathy Rheumatic valve disease Prosthetic heart valves Antiphospholipid antibody syndrome Inherited thrombophilia with hx of spontaneous cerebral venous thrombosis or recurrent thrombotic events

References AHA/ASA 2013 Stroke Guidelines CAPRIE trial CHANCE trial HOPE trial MATCH trial PROGRESS trial SPARCL trial Medscape UpToDate

Questions?