4_ Stroke Final

Diagnosis and Management of Acute StrokeBriana Witherspoon DNP, ACNP-BC

Stroke Objectives

Review etiology of strokesIdentify likely location/type of stroke based of physical examAcute management of ischemic strokeAcute management of hemorrhagic stroke

Stroke Fast Facts Affects ~ 800, 000 people per yearLeading cause of disability, cognitive impairment, and death in the United StatesAccounts for 1.7% of national health expenditures.Estimated U.S. cost for 2012 = $71.5 billion Mostly hospital (esp. LOS) & post stroke costsAppropriate use of IV t-PA s long-term costAppropriate billing for AIS w/ thrombolysis ( hospital reimbursement from $5k to $11.5k)

Stroke. 2013;44:2361-2375

Stroke. 2013;44:2361-2375

Where Were HeadedBy 2030 ~ 4% of the US population over the age of 18 is projected to have had a strokeBetween 2012 and 2030, total direct stroke-related medical costs are expected to increase from $71.55 billion to $183.13 billionTotal annual costs of stroke are projected to increase to $240.67 billion by 2030, an increase of 129%Stroke. 2013;44:2361-2375

Stroke. 2013;44:2361-2375

Three Stroke Typeswww.acponline.org/about_acp/chapters/ok/gordon.ppt

www.acponline.org/about_acp/chapters/ok/gordon.ppt

http://www.phillystroke.org/content/learn_about_stroke/act_fast.asp

http://www.phillystroke.org/content/learn_about_stroke/act_fast.asp

NIHSSNIHSS (National Institute of Health Stroke Scale)Standardized method used by health care professionals to measure the level of impairment caused by a strokePurposeMain use is as a clinical assessment tool to determine whether the degree of disability is severe enough to warrant the use of tPAAnother important use of the NIHSS is in research, where it allows for the objective comparison of efficacy across different stroke treatments and rehabilitation interventionsScores are totaled to determine level of severityCan also serve as a tool to determine if a change in exam has occurred

Breaking Down the Scale 13 item scoring system, 7 minute exam Integrates neurologic exam components CN (visual), motor, sensory, cerebellar, inattention, language, LOC Maximum score is 42, signifying severe stroke Minimum score is 0, a normal exam Scores greater than 15-20 are more severe

NIHSS cont.NIHSS Interpretation

Stroke ScaleStroke Severity0No Stroke1-4Minor Stroke5-15Moderate Stroke15-20Moderate/Severe Stroke21-42Severe Stroke

NIHSS and Outcome Prediction

NIHSS below 12-14 will have an 80% good or excellent outcomeNIHSS above 20-26 will have less than a 20% good or excellent outcomeLacunar infarct patients had the best outcomes

Adams HP Neurology 1999;53:126-131Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)

Etiology of Ischemic Strokes

LARGE VESSEL THROMBOTIC:Virchows Triad.Blood vessel injuryHTN, Atherosclerosis, VasculitisStasis/turbulent blood flowAtherosclerosis, A. fib., Valve disordersHypercoagulable stateIncreased number of plateletsDeficiency of anti-coagulation factors Presence of pro-coagulation factorsCancer

Etiology Of Ischemic Stroke:

LARGE VESSEL EMBOLIC:The HeartValve diseases, A. Fib, Dilated cardiomyopathy, Myxoma

Arterial Circulation (artery to artery emboli)Atherosclerosis of carotid, Arterial dissection, Vasculitis

The Venous Circulation PFO w/R to L shunt, Emboli

Determining the Location

Large Vessel:Look for cortical signs

Small Vessel:No cortical signs on exam

Posterior Circulation:Crossed signsCranial nerve findings

Watershed:Look at watershed and borderzone areasHypo-perfusion

Cortical SignsIf present, think LARGE VESSEL stroke

RIGHT BRAIN:LEFT BRAIN:- Right gaze preference- Left gaze preference- Neglect- Aphasia

Large Vessel Stroke Syndromes

MCA: Arm>leg weaknessLMCA cognitive: AphasiaRMCA cognitive: Neglect,, topographical difficulty, apraxia, constructional impairment

ACA: Leg>arm weakness, graspCognitive: muteness, perseveration, abulia, disinhibition

PCA: HemianopiaCognitive: memory loss/confusion, alexia

Cerebellum: Ipsilateral ataxia

AphasiaBrocas Expressive aphasia Left posterior inferior frontal gyrus

WernickesReceptive aphasiaPosterior part of the superior temporal gyrusLocated on the dominant side (left) of the brain

Case 1

74 year old African American female with sudden onset of left-sided weakness

She was at church when she noted left facial droop

History of HTN and atrial fibrillation

Meds: Losartan

Case 1

BP- 172/89, P 104, T- 98.0, RR 22, O2- 94%

General exam: Unremarkable except irregular rate and rhythm

NEURO EXAM:- Speech dysarthric but language intact- Right gaze preference- Left facial droop- Left- sided hemiplegia- Neglect

Case 1

Case 1Right MCA infarct, most likely cardioembolic from atrial fibrillation

Patient underwent mechanical thrombectomy with intra-arterial verapamil, clot removal successful

Excellent recovery patient was discharged 48 hours later on Coumadin





Watershed:Look for watershed pattern S/S of Hypo-perfusion

Etiology of Stroke

SMALL VESSEL (Lacunes

Case 2 85 year old male who woke up with left face, arm, and leg numbness

History of HTN, DM, and tobacco use

Meds: Insulin, aspirin

Case 2BP- 168/96, P 92

General exam: Unremarkable, RRR

NEURO EXAM:- Decreased sensation on left face, arm, and leg

Case 2

Case 2

Right thalamic lacunar infarctNot a candidate for intervention (WHY?)Discharged to rehab 72 hours after admission





Watershed:Look at watershed and borderzone areasHypo-perfusion

Brainstem Stroke Syndromes

Rarely presents with an isolated symptom

Usually a combination of cranial nerve abnormalities, and crossed motor/sensory findings such as:

Double visionFacial numbness and/or weaknessSlurred speechDifficulty swallowingAtaxiaVertigoNausea and vomitingHoarseness

Case 355 year old male with acute onset of right sided numbness and tingling, left sided face pain and numbness, gait imbalance, nausea/vomiting, vertigo, swallowing difficulties, and hoarse speech

History of CAD s/p CABG, DM2, HTN, HLD, OSA

Meds: Aspirin, plavix, insulin, lipitor, metoprolol, lisinopril

Case 3NEURO EXAM: BP- 194/102, P 105


NEURO EXAM:- Decreased sensation on left face- Decreased sensation on right body- Left ataxia on FNF, and unsteady gait- Voice hoarse- Nystagmus

Case 3

Case 3 Brainstem StrokeReceived IV tPaPost-tPa symptoms greatly improved regained sensation, ataxia resolvedDischarged home with out patient PT/OT





Watershed:Look for the watershed patternThink about reasons of hypo-perfusionHypotensionStenosed vessel, etc

Case 456 year old female who upon waking post-op after elective surgery was found to have L sided weakness and neglect

History of HTN

Meds - Lisinopril

Case 4

BP- 132/74, P 84


NEURO EXAM:- Left face, arm, and leg weakness- Neglect- DTRs brisk on the left, toe up on left

Case 4

Case 4Right hemisphere watershed infarct secondary to hypoperfusion in the setting of Right ICA stenosis

On review of anesthesia records, blood pressure dropped to 82/54 during the procedure

Patient was discharged to in-patient rehab

Intracranial Hemorrhages

Etiology of ICH TraumaticSpontaneousHypertensiveAmyloid angiopathyAneurysmal ruptureArteriovenous malformation ruptureBleeding into tumorCocaine and amphetamine use

Causes of ICH http://spinwarp.ucsd.edu/neuroweb/Text/non-trauma-ER.htm

http://spinwarp.ucsd.edu/neuroweb/Text/non-trauma-ER.htm

Hypertensive ICH

Spontaneous rupture of a small artery deep in the brainTypical sitesBasal GangliaCerebellumPonsTypical clinical presentationPatient typically awake and often stressed, then abrupt onset of symptoms with acute decompensation

Ganglionic Bleed

Contralateral hemiparesisHemisensory lossHomonymous hemianopiaConjugate deviation of eyes toward the side of the bleed or downwardAMS (stupor, coma)

Cerebral Hemorrhage

JPG

Cerebellar Hemorrhage

Vomiting (more common in ICH than SAH or Ischemic CVA)AtaxiaEye deviation toward the opposite side of the bleed Small sluggish pupilsAMS

Cerebellar Hemorrhage

Pontine Hemorrhage

Pin-point but reactive pupilsAbrupt onset of comaDecerebrate posturing or flaccidity Ataxic breathing pattern

Pontine Hemorrhage

Subarachnoid Hemorrhage

Worst headache of my lifeAMSPhotophobiaNuchal rigidity SeizuresNausea and vomiting

Subarachnoid Hemorrhage

Management

Airway

Most likely related to decreased level of consciousness (LOC), dysarthria, dysphagiaGCS < 8 - INTUBATEAvoid Hyperventilation or HypoventilationNPO until swallow assessment completed- high aspiration risk Begin mobilization as soon as clinically safeKeep HOB greater than 30 degrees

Stroke Algorithm

ImagingCT scanNon- contrast CTH remains the gold standard as it is superior for showing IVH and ICHCT with contrast may help identify aneurysms, AVMs, or tumors but is not required to determine whether or not the patient is a tPa candidate

MRISuperior for showing underlying structural lesionsContraindications

Multimodal ImagingMultimodal CTTypically includes non-contrast CT, perfusion CT, and CTATwo types of perfusion CTWhole brain perfusion CTDynamic perfusion CT

Multimodal MRIStandard MRI sequences ( T1 weighted, T2 weighted, and proton density) are relatively insensitive to changes in cerebral ischemiaMultimodal adds diffuse-weighted imaging (DWI) and PWI (perfusion- weighted imaging)

tPaFast FactsTissue plasminogen activatorclot busterIV tpa window 3 hoursIA tpa window 4.5 hours Disability risk 30% despite ~5% symptomatic ICH risk

ContraindicationsHemorrhage SBP > 185 or DBP > 110Recent surgery, trauma or stroke CoagulopathySeizure at onset of symptomsNIHSS >21 Age?Glucose < 50

Mechanical Thrombolysis

Often used in adjunct with tPaMERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retrieval System is a corkscrew-like apparatus designed to remove clots from vesselsPENUMBRA system aspirates the clot

Blood Pressure Management

BP ManagementThe goal is to maintain cerebral perfusion!!CPP = MAP ICP (needs to be at least 70)Higher BP goals with Ischemic strokeLower BP goals with Hemorrhagic stroke (avoid hemorrhagic expansion, especially in AVMs and aneurysms)

BP-AIS RelationshipBP increase is due to arterial occlusion (i.e., an effort to perfuse penumbra)Failure to recanalize (w/ or w/o thrombolytic therapy) results in high BP and poor neuro outcomesLowering BP starves penumbra, worsens outcomes



Save the Penumbra!!www.acponline.org/about_acp/chapters/ok/gordon.ppt


Supportive Therapy

Glucose ManagementInfarction size and edema increase with acute and chronic hyperglycemiaHyperglycemia is an independent risk factor for hemorrhage when stroke is treated with t-PAAntiepileptic DrugsSeizures are common after hemorrhagic CVAsICH related seizures are generally non-convulsive and are associated to with higher NIHSS scores, a midline shift, and tend to predict poorer outcomes

Hyperthermia

Treat fevers!Evidence shows that fevers > 37.5 C that persists for > 24 hrs correlates with ventricular extension and is found in 83% of patients with poor outcomes

ReferencesAdams, H., del Zappo, G., Alberts, M., Bhatt, D., Brass, L., Furlan, A., Grubb, R., & Higashida, R. (2007). Guidelines for the early management of adults with ischemic stroke. Stroke, 38, 1655-1711. Bradley G Walter, Daroff B Robert, Fenichel M Gerald, Jancovic, Joseph; Neurology in clinical practice, principles of diagnosis and management. Philadelphia Elsevier, 2004.Castillo, J., Leira, R., Garcia, M., Serena, J., Blanco, M. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004: 35: 520-526.Goals for Management of Patients With Suspected Stroke Algorithm. http://circ.ahajournals.org/content/112/24_suppl/IV-111/F1.expansion.html. Accessed May 8, 2012 Gordon, D. L. (n.d.). Update in stroke management . Retrieved from www.acponline.org/about_acp/chapters/ok/gordon.ppt Hesselink, J. Imaging of cerebral hemorrhages and AV malformations. http://spinwarp.ucsd.edu/neuroweb/Text/br-740.htm. accessed May 10, 2012.

Questions?

***The National Institute of Health Stroke Scale is the industry standardIt is also a research tool that allows us to quantify our clinical exam

*As you can see the scale is broken down into several components that allow the clinician to complete a quick but thorough exam. Note that the maximum score is 42

**Study done by Adams and his colleagues used the Barthel Index (BI) and the Glasgow Outcome Scale (GOS) to assess over 1200 patients outcomes at 7 days and 3 months.

Between 70% and 80% of patients who have suffered a lacunar stroke are functionally independent at 1 year, compared with fewer than 50% of patients who have had a nonlacunar stroke. *Cortical Signs

*Abulia - Loss or impairment of the ability to make decisions or act independently

Anosonosia - complete unawareness or denial of a neurologic deficit.

***********Maintaining adequate tissue oxygenation is imperative in the setting of both types of strokes, with your overall goal being to prevent hypoxia and potential worsening of the cerebral injury. Obviously, patients with decreased mental status and brain stem dysfunction have the greatest risk of airway compromise. Patients who require intubation have poorer prognosis, as approximately 50% of them will be dead within 30 days after their stroke.

*Included in the algorithm are critical time goals set by the National Institute of Neurological Disorders (NINDS) for in-hospital assessment and management.

These time goals are based on findings from large studies of stroke victims:Immediate general assessment by a stoke team, emergency physician, or other expert within 10 minutes of arrival, including the order for an urgent CT scanNeurologic assessment by stroke team and CT scan performed within 25 minutes of arrivalInterpretation of CT scan within 45 minutes of ED arrivalInitiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours from onset of symptoms Door-to-admission time of 3 hours

*Interestingly, although the head CT is considered the standard for patients with suspected strokes, it is used to not to confirm an acute ischemic stroke but instead rule out other causes of the patients condition. CTs are actually relatively insensitive for in detecting acute and small corical infarctions especially in the posterior fossa region.

However, if there is evidence of early edema or mass effect noted on the intial head ct, the patients risk of hemorrhagic conversion increases by approximately 8 fold. *Both types of perfusion CT are highly sensitive and specific for detecting cerebral ischemia. There have also been studies that performed that suggest that CT perfusions may be able to differentiate between reversible and irreversible ischemia or in other words, successfully identify the pneumbra.

By adding DWI to the standard MRI sequence, clinicians are able to visualize ischemic regions of the brain within minutes of symptom onset. It actually has a high sensitivity of approximately 88-100 % and high specificity of 95-100% for detecting ischemic lesions. *MERCISymptomatic ICH occurred in 9.8% of patients overall, and a favorable outcome, (a modified Rankin score of 2 or less), was seen in 36% of patients at 90 days.

PENUMBRA- recanalization rate for patients treated with the Penumbra system, measured for the target vessel, was 81.6%. Symptomatic intracranial hemorrhages occurred in 11.2% of patients. A modified Rankin score of 2 or less at 90 days was seen in 25% of patients.*For the most part, ICH stroke guidelines recommend using IV medications to lower SBP < 160 while still maintaining adequate MAP and CPP Ischemic strokes are a bit trickier to manage. One must keep in mind that the patients blood pressure will lower on its own by approximately 25 30 % within the first 24 hours. Furthermore aggressive treatment of hypertension in ischemic strokes has been shown to worsen neurological function by reducing perfusion pressureCastillo and collegues performed a study in 2004 that showed that a drop in either SBP or DBP > 20 points were associated with higher rates of mortality and larger volumes of infarctions. They also noted that early administration of antihypertensinve medications to patients with SBP > 180 was associated with an increased risk of death. **** CHHIPS trial ***According to the guidelines, sbp should be reduced by 15 25% within the first day as excessively high blood pressures are associated with an increased risk of hemorrhagic conversion. *In AIS, high BP is a response,not a causedont lower it!

*Elevated glucose levels at the time of admission predicts an increased 28 day mortality rate in both diabetic and non-diabetic patients.

Study done by Vespa and collegues done in 2003 showed that 18 / 63 patients ( 28% ) of patients in a neuro ICU seized on EEG within 72 hours of admission ICH stroke guidelines recommend IV medications to quickly stop seizures. Benzos tend to be first line choice, followed by IV phenytoin or fos-phenytoin, Brief period of prophylactic AED therapy has been shown to redice the risk of early seizures esp in patient with lobar hemorrhage. *Fevers tend to be more common in basal ganglia and lobar ICHs and patients with IVH. Scwartz and collegues published a study in 200 that stated patients who survived the first 72 hours after hospital admission, the duration of fever is realted to outcome and is a an independent prognostic factor in stroke patients. However, although there have been several studies done, to date there is no recommended drug or dose of medication that is recommended in the treatment of fevers in stroke patients. Guidelines currently recommend that clinicians seek out a souce (dont just assume that the fever is neurogenic in nature) and treat accordingly. **

Date post:	11-Oct-2015
Category:	Documents
Upload:	yana
View:	18 times
Download:	0 times

4_ Stroke Final

Documents