1. Rapid CT Protocol

2. In a typical acute ischemic stroke: With every minute of delay
1.9 million neurons
14 billion synapses
7.5 miles myelinated fibers
are DEAD
-- Saver, Stroke 2006

3. TPA Treatment Time and Benefit Magnitude 58,353 Patients from 1395 GWTG-Stroke Hospitals --Saver et al ISC 2013
Among 1000 patients, for every 15 min acceleration of tPA treatment
18 more will have improved ambulation at discharge
Including 8 more who will ambulate fully independently
13 more will be discharged to a more independent environment
Including 7 more discharged to home
4 fewer patients will die prior to discharge

4. Running a Stroke Code Obtain brief/relevant history
Determine last known normal
Identify tPA contraindications (all are relative now)
FSG, BP, draw POC INR and Cr
Hypoglycemia can cause seizures and focal deficits; hyperglycemia can increase risk of ICH post-tPA

5. Running a Stroke Code
3. Examine and determine if there is a disabling deficit present and if could be caused by a stroke 4. CTH to r/o hemorrhage 5. If disabling deficit present, BP <185/110 and normoglycemic, benefits outweigh risks, symptoms due to stroke, LKW <4.5 hrs, staff with NICU fellow and likely give tPA (10% bolus, 90% infusion over 1 hr) A. For elevated BP, use Labetalol or Cardene gtt B. For hypoglycemia, use amp of D50, for hyperglycemia, give regular insulin

6. Running a Stroke Code
6. If concern for large vessel syndrome, obtain CTA head/neck to look for thrombus 7. If large vessel occlusion present, NIHSS>6, activate INR for thrombectomy 8. After tPA, keep BP <180/105, no a/c, heparin, antiplatelets, etc.

7. Running a Stroke Code
9. VS checks q15 mins. Initially, for any exam change, stat head CT for exam change to r/o hemorrhagic transformation

8. Prehospital Notification Patient directly to ED CT scanner
Rapid CT Scan Protocol
EMS
Get a FAST exam
Connect to resident via stroke phone
18 gauge IV and draw labs
Stroke Page
ED STAFF
Triage and pre-registration
Establish IV access, order CT and labs
CT TECH
Empty out the scanner
ON-CALL RESIDENT
Take history (while pt. in ambulence) NIHSS
STROKE/ICU FELLOW
Call back in 15 minutes Decision on TPA/CTA
INR FELLOW
Review CT/CTA
PHARMACY
Pre-mix TPA
Prehospital Notification
Patient directly to ED CT scanner

9. Intracranial Hemorrhage Management
SBP <140, Cardene gtt
Reverse anticoagulants (FFP, vit K cryo, PCC, Amicar dif refractory, depending on agent)
Reverse antiplatelets (ddAVP, platelets?)
NSGY for EVD if ICP elevation, clot evac
Prophylactic AEDs if cortical or c/f seizure

10. Intracranial Pressure Crisis

11. Intracranial Pressure
Intracranial components
Total volume approx cc
75-80% Parenchyma
10 % CSF
10 % Blood

12. Monroe - Kellie Doctrine
Disturbance of volume equilibrium disrupts the pressure equilibrium
Pressure = force/ area
Pathologically elevated ICP represents the force required to displace blood and CSF from the intracranial space in order to accommodate new volume

13. Intracranial Compliance
Demonstrates that for the same increment in intracranial volume (dVe), a larger intracranial pulse pressure results when Ve is further up the volume-pressure relationship

14. ICP and CPP
Clinical management of ICP is also dependent on the relationship between blood pressure and cerebral blood flow (autoregulation)

15. Indications for ICP Monitoring
Coma (Glasgow Coma Scale score ≤8)
CT evidence of intracranial mass effect
Extra-axial mass lesion
Midline shift
Effacement of basal cisterns
Exception: severe TBI with motor posturing
Prognosis is such that aggressive ICU care is warranted

16. Clinical Signs Depressed level of consciousness Pressor response
Increased ICP
Depressed level of consciousness
Pressor response
Projectile vomiting
CN 6 palsies
Brainstem herniation
CN 3 palsy
Motor posturing
Lower extremity rigidity
Loss of lateral EOMs
Hyperventilation

17. Ventricular catheter
Epidural Monitor
Parenchymal Micosensor
Richmond Bolt

18. Universal Measures Identify cause(s) of raised ICP or reduced CPP
Head positioning
r/o seizures or start prophylaxis
Maintain Etco
Hyperventilate transient
Fever (1°C rise in core temp can inc metabolic rate by 10%)
Raised intrathoracic or intraabdominal pressures

19. Revised Columbia Stepwise ICP Protocol
PENTOBARBITAL 7
HYPOTHERMIA 6
HYPERVENTILATION 5
OSMOTHERAPY 4
CPP OPTIMIZATION 3
SEDATION 2
SURGICAL DECOMPRESSION 1

20. Bedside Shivering Assessment Scale (BSAS)
Palpate masster, pectoralis, deltoids and quadriceps muscles
0 No shivering 1 Palpable shivering localized to the neck and/or chest 2 Visible shivering involving the arms 3 Visible shivering involving all 4 extremities
Badjatia, et al: Stroke 2008;39:

21. Therapeutic Temperature Modulation
Repayment
Here is the Columbia anti-shivering protocol.
Choi et al. 2011

22. Shivering is the Enemy! Hinders the cooling process
Painful and uncomfortable
Exacerbates
Cardiovascular and sympathetic stress
Systemic metabolic stress
Cerebral metabolic stress

23. Algorithm for GCSE