Diagnosis and Management of Acute Stroke

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Diagnosis and Management of Acute Stroke

• Briana Witherspoon DNP, ACNP-BC

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Stroke Objectives

• Review etiology of strokes
• Identify likely location/type of stroke based of
  physical exam
• Acute management of ischemic stroke
• Acute management of hemorrhagic stroke

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Stroke Fast Facts

• Affects 800, 000 people per year
• Leading cause of disability, cognitive
  impairment, and death in the United States
• Accounts for 1.7 of national health
  expenditures.
• Estimated U.S. cost for 2012 71.5 billion
• Mostly hospital (esp. LOS) post stroke costs
• Appropriate use of IV t-PA ?s long-term cost
• Appropriate billing for AIS w/ thrombolysis (?
  hospital reimbursement from 5k to 11.5k)

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Where Were Headed

• By 2030 4 of the US population over the age of
  18 is projected to have had a stroke
• Between 2012 and 2030, total direct
  stroke-related medical costs are expected to
  increase from 71.55 billion to 183.13 billion
• Total annual costs of stroke are projected to
  increase to 240.67 billion by 2030, an increase
  of 129

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Three Stroke Types
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NIHSS

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

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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

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NIHSS cont.

• NIHSS Interpretation

Stroke Scale Stroke Severity
0 No Stroke
1-4 Minor Stroke
5-15 Moderate Stroke
15-20 Moderate/Severe Stroke
21-42 Severe Stroke
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NIHSS and Outcome Prediction

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

Adams HP Neurology 199953126-131 Baseline NIH
Stroke Scale score strongly predicts outcome
after stroke (TOAST)
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Etiology of Ischemic Strokes

• LARGE VESSEL THROMBOTIC
• Virchows Triad.
• Blood vessel injury
• HTN, Atherosclerosis, Vasculitis
• Stasis/turbulent blood flow
• Atherosclerosis, A. fib., Valve disorders
• Hypercoagulable state
• Increased number of platelets
• Deficiency of anti-coagulation factors
• Presence of pro-coagulation factors
• Cancer

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Etiology Of Ischemic Stroke

• LARGE VESSEL EMBOLIC
• The Heart
• Valve 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

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Determining the Location

• Large Vessel
• Look for cortical signs
• Small Vessel
• No cortical signs on exam
• Posterior Circulation
• Crossed signs
• Cranial nerve findings
• Watershed
• Look at watershed and borderzone areas
• Hypo-perfusion

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Cortical Signs
RIGHT BRAIN LEFT BRAIN
- Right gaze preference - Left gaze preference
- Neglect - Aphasia

• If present, think LARGE VESSEL stroke

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Large Vessel Stroke Syndromes

• MCA
• Armgtleg weakness
• LMCA cognitive Aphasia
• RMCA cognitive Neglect,, topographical
  difficulty, apraxia, constructional impairment
• ACA
• Leggtarm weakness, grasp
• Cognitive muteness, perseveration, abulia,
  disinhibition
• PCA
• Hemianopia
• Cognitive memory loss/confusion, alexia
• Cerebellum
• Ipsilateral ataxia

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Aphasia

• Brocas
• Expressive aphasia
• Left posterior inferior
• frontal gyrus
• Wernickes
• Receptive aphasia
• Posterior part of the superior temporal gyrus
• Located on the dominant side (left) of the brain

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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

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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

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Case 1
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Case 1
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Case 1
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Case 1
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Case 1

• Right 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

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Determining the Location

• Large Vessel
• Look for cortical signs
• Small Vessel
• No cortical signs on exam
• Posterior Circulation
• Crossed signs
• Cranial nerve findings
• Watershed
• Look for watershed pattern
• S/S of Hypo-perfusion

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Etiology of Stroke

• SMALL VESSEL (Lacunes lt1.5cm)
• Risk Factors
• HTN
• HLD
• DM
• Tobacco Use
• Sleep apnea

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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

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Case 2

• BP- 168/96, P 92
• General exam Unremarkable, RRR
• NEURO EXAM
• - Decreased sensation on left face, arm, and leg

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Case 2
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Case 2

• Right thalamic lacunar infarct
• Not a candidate for intervention (WHY?)
• Discharged to rehab 72 hours after admission

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Determining the Location

• Large Vessel
• Look for cortical signs
• Small Vessel
• No cortical signs on exam
• Posterior Circulation
• Crossed signs
• Cranial nerve findings
• Watershed
• Look at watershed and borderzone areas
• Hypo-perfusion

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Brainstem Stroke Syndromes

• Rarely presents with an isolated symptom
• Usually a combination of cranial nerve
  abnormalities, and crossed motor/sensory findings
  such as
• Double vision
• Facial numbness and/or weakness
• Slurred speech
• Difficulty swallowing
• Ataxia
• Vertigo
• Nausea and vomiting
• Hoarseness

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Case 3

• 55 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

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Case 3

• NEURO EXAM BP- 194/102, P 105
• General exam Unremarkable, RRR
• NEURO EXAM
• - Decreased sensation on left face
• - Decreased sensation on right body
• - Left ataxia on FNF, and unsteady gait
• - Voice hoarse
• - Nystagmus

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Case 3
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Case 3
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Case 3

• Brainstem Stroke
• Received IV tPa
• Post-tPa ?symptoms greatly improved regained
  sensation, ataxia resolved
• Discharged home with out patient PT/OT

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Determining the Location

• Large Vessel
• Look for cortical signs
• Small Vessel
• No cortical signs on exam
• Posterior Circulation
• Crossed signs
• Cranial nerve findings
• Watershed
• Look for the watershed pattern
• Think about reasons of hypo-perfusion
• Hypotension
• Stenosed vessel, etc

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Case 4

• 56 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

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Case 4

• BP- 132/74, P 84
• General exam Unremarkable, RRR
• NEURO EXAM
• - Left face, arm, and leg weakness
• - Neglect
• - DTRs brisk on the left, toe up on left

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Case 4
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Case 4
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Case 4
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Case 4
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Case 4
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Case 4
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Case 4
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Case 4

• Right 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

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• Intracranial Hemorrhages

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Etiology of ICH

• Traumatic
• Spontaneous
• Hypertensive
• Amyloid angiopathy
• Aneurysmal rupture
• Arteriovenous malformation rupture
• Bleeding into tumor
• Cocaine and amphetamine use

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Causes of ICH

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Hypertensive ICH

• Spontaneous rupture of a small artery deep in the
  brain
• Typical sites
• Basal Ganglia
• Cerebellum
• Pons
• Typical clinical presentation
• Patient typically awake and often stressed, then
  abrupt onset of symptoms with acute decompensation

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Ganglionic Bleed

• Contralateral hemiparesis
• Hemisensory loss
• Homonymous hemianopia
• Conjugate deviation of eyes toward the side of
  the bleed or downward
• AMS (stupor, coma)

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Cerebral Hemorrhage
JPG
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Cerebellar Hemorrhage

• Vomiting (more common in ICH than SAH or Ischemic
  CVA)
• Ataxia
• Eye deviation toward the opposite side of the
  bleed
• Small sluggish pupils
• AMS

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Cerebellar Hemorrhage
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Pontine Hemorrhage

• Pin-point but reactive pupils
• Abrupt onset of coma
• Decerebrate posturing or flaccidity
• Ataxic breathing pattern

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Pontine Hemorrhage
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Subarachnoid Hemorrhage

• Worst headache of my life
• AMS
• Photophobia
• Nuchal rigidity
• Seizures
• Nausea and vomiting

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Subarachnoid Hemorrhage
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• Management

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Airway

• Most likely related to decreased level of
  consciousness (LOC), dysarthria, dysphagia
• GCS lt 8 - INTUBATE
• Avoid Hyperventilation or Hypoventilation
• NPO until swallow assessment completed- high
  aspiration risk
• Begin mobilization as soon as clinically safe
• Keep HOB greater than 30 degrees

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Stroke Algorithm
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Imaging

• CT scan

• MRI

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

• Superior for showing underlying structural
  lesions
• Contraindications

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Multimodal Imaging

• Multimodal CT

• Multimodal MRI

• Typically includes non-contrast CT, perfusion CT,
  and CTA
• Two types of perfusion CT
• Whole brain perfusion CT
• Dynamic perfusion CT

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

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tPa

• Fast Facts

• Contraindications

• Tissue plasminogen activator
• clot buster
• IV tpa window 3 hours
• IA tpa window 4.5 hours
• Disability risk ? 30 despite 5 symptomatic ICH
  risk

• Hemorrhage
• SBP gt 185 or DBP gt 110
• Recent surgery, trauma or stroke
• Coagulopathy
• Seizure at onset of symptoms
• NIHSS gt21
• Age?
• Glucose lt 50

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Mechanical Thrombolysis

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

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Blood Pressure Management

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

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BP-AIS Relationship

• BP 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
  outcomes
• Lowering BP starves penumbra, worsens outcomes

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Save the Penumbra!!
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Supportive Therapy

• Glucose Management
• Infarction size and edema increase with acute and
  chronic hyperglycemia
• Hyperglycemia is an independent risk factor for
  hemorrhage when stroke is treated with t-PA
• Antiepileptic Drugs
• Seizures are common after hemorrhagic CVAs
• ICH related seizures are generally non-convulsive
  and are associated to with higher NIHSS scores,
  a midline shift, and tend to predict poorer
  outcomes

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Hyperthermia

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

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References

• Adams, 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/con
  tent/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/chapt
  ers/ok/gordon.ppt?
• Hesselink, J. Imaging of cerebral hemorrhages and
  AV malformations. http//spinwarp.ucsd.edu/neurow
  eb/Text/br-740.htm. accessed May 10, 2012.

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• Questions?