1. Intern Morning Report July 2014 Tram Le, PGY3
Stroke

2. 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

3. Differential Diagnoses

4. 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?

5. 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: hr
Any contraindications to thrombolysis?

6. 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

7. 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)

8. 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?

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

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

11. 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

12. 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?

13. 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

14. 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:
Sources of hyperthermia identified and treated
Dysphagia screening
Early PT/OT
DVT ppx

15. 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?

16. Management of Intracranial Hemorrhage
Admit to ICU
Neurosurgery consult
Fever and hyperglycemia
PCD’s and TED’s
Reversal of anticoagulation
Target BP is 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 )
Hyperventilation (pCO ): effect lasts mins to few hours
Intraventricular cath placement

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. Questions?