1. Approach to Hemorrhagic and Ischemic Strokes
ACEP South Dakota
March 4, 2017
Marko Duic & Gaurav Puri

2. Objectives Classifying types of CVA Acute management
Long-term management/treatment options

3. Types of CVA
Ischemic CVA
Hemorrhagic
spontaneous
traumatic

4. Ischemic CVA Causes: Embolic Thrombosis Dissection
Vascular obstruction

5. Signs and Symptoms Transient or progressive symptoms: Visual symptoms
Speech deficits
Unilateral weakness
Coordinations issues
Vertigo
Decreased LOC
Other:

6. Deficits
Are all strokes created?
Location matters
Why?

9. So you’re having a stroke…..now what?
Acute management:
diagnosis first
ABCs
thrombolysis/stroke protocol
antiplatelet
antihypertensive
other:

10. Diagnosis Clinical diagnosis initially
If someone presents within the window for thrombolysis (3-4.5hours), and does not have contraindications for thrombolysis, they should be transferred to a stroke centre for consideration of thrombolysis
Controversial - why?
Any other options?

11. Thrombolysis
To date, roughly 12 trials examining thrombolysis with over patients
2 of 12 showed a benefit for thrombolysis
unfortunately, both use nonstandard data analysis and reporting
Several studies showed harm

13. Outside of the window for TPA - Diagnosis
CT head:
findings? early vs late findings?

15. Treatment?
Medical therapy
Antiplatelet:
ASA, Plavix

16. Antihypertensives
For candidates of thrombolysis, target BP is less than 185 systolic and 110 diastolic
For non TPA patients, blood pressure reduction is targeted at 10-15% reduction
Initial agents usually:
Labetolol 10-20mg IV initially, can repeat, consider infusion
Nitroglycerine
Enalapril 1.25mg
Nicarapine 5mg/hr (can titrate to effect)

17. What’s the point of BP control?
Need to match changes in ICP and CPP to ensure perfusion to affected area/collateral circulation
Aggressive BP management can be harmful

18. Other treatment/diagnostics
Bed position
Cholesterol/blood glucose control
Echo, holter, doppler, MRI

19. Questions?

20. Hemorrhagic CVA Bleeding secondary to: trauma aneurysm mass
hypertension
other

21. Types Subdural Epidural Subarachnoid Intraparenchymal
Are all bleeds the same?

26. Signs and Symptoms Decreased LOC Obvious Trauma Pupil abnormalities
Unilateral weakness
Headache
Elevated BP
Low heart rate
other:

27. Diagnostics CT is the initial test of choice
In sentinel bleed for aneurysmal SAH, can be negative
LP to follow if suspicion
Lab work:
INR
Troponin
ECG

28. Initial Management ABCs first
If surgical bleed, consultation with neurosurgery for transfer
Reversal of coagulation issues
Tranexamic acid?
Blood pressure management
Anticonvulsants
ICP management

29. Coagulation issues Oral anticoagulants
Warfarin - Octaplex/beriplex, Vitamin K
FFP
Pradaxa - Praxbind
Platelet dysfunction
Hepatic failure - Vitamin K, FFP
Renal failure - Platelets
Heparin - protamine sulfate

30. Traumatic ICH Tranexamic acid - 1g IV
CRASH 2 trial - Early administration of TXA safely reduced the risk of death in bleeding trauma patients
Administration beyond 3 hours of trauma is unlikely to provide benefit

31. Blood Pressure Management
No clear guidelines/studies describe optimal BP levels in hemorrhagic CVA
Significantly elevated BP may lead to rebreeding/hematoma expansion
INTERAC 1 & 2 trials showed that early intensive BP control (less than SBP < 140) led to less hematoma expansion
This was more important in patients on antithrombotic therapy
Agent of choice was either labetolol, enalapril or nicardipine (can also use hydralazine in refractory cases)
ATACH-II trial ongoing currently to assess outcomes with BP control less than 140 with nicardipine

32. Seizures in ICH
Acutely, benzodiazepines can be used to stop an active seizure
Dilantin load can be used to prevent further seizures
Patients with ICH and seizure will likely require intubation and sedation
Conflicting evidence for prophylactic anticonvulsants in ICH/SAH - more to come on this

33. Key concepts ICP - intracranial pressure
CPP - cerebral perfusion pressure
MAP - mean arterial pressure

34. ICP ICP is usually elevated in ICH
Elevation of the bed to 30 degrees improves venous outflow and decreases ICP
No evidence for use of mannitol
No evidence for use of corticosteroids - may result in complications

35. Questions?