Stroke resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Definitions

The term 'stroke' is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013), the updated definitions are:

Ischemic Stroke

This is defined as an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction.

CNS Infarction

CNS infarction is brain, spinal cord, or retinal cell death attributable to ischemia, based on:

1. Pathological, imaging, or other objective evidence of cerebral, spinal cord, or retinal focal ischemic injury in a defined vascular distribution; or

2. Clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting ≥24 hours or until death, and other etiologies excluded.

Hemorrhagic Stroke

This is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma.

Time of Onset

This is defined as when the patient was last awake and symptom-free or known to be “normal".

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• All the causes of stroke are life-threatening.

Common Causes

Ischemic Stroke

• Embolic causes - Cardiac arrhythmias, infective endocarditis, left atrial myxoma, cardiomyopathy, atrial or ventricular thrombus

• Thrombotic causes - Atherosclerosis of large vessels, arteritis/vasculitis, dissection, Takayasu arteritis

• Systemic hypoperfusion (Watershed stroke) - Myocardial infarction, cardiac arrhythmias, pericardial effusion, pulmonary embolism

Hemorrhagic Stroke

• Hypertension
• Bleeding disorders
• Illicit drug use (e.g., amphetamines or cocaine)
• Trauma
• Vascular malformations
• Rupture of arterial aneurysms

Management

Evaluation Goal: Evaluation done within 60 mins of patient's arrival Check vitals ABCs Rapid Hx - time of onset, time of arrival at the ED, medications (especially anticoagulants) Rapid physical exam - neuro exam, NIHSS Activate stroke team Stat fingerstick Labs EKG, troponin, CXR NPO Obtain stroke protocol

Rule out DD Seizure, syncope, migraine, hypoglycemia

Non-contrast enhanced CT (or MRI) to r/o hemorrhage

Bleed positive

Hemorrhagic stroke

Bleed negative

Hemorrhagic stroke algorithm

Acute ischemic stroke

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Time of onset

<3 hours

3 -4.5 hours

>4.5 hours

Eligibility criteria for IV rTPA

Consider rTPA after excluding patients >80 years old, those taking anticoagulants regardless of INR, baseline NIHSS >25, those with imaging evidence of ischemic injury involving >1/3 of the MCA territory, or those with a history of both stroke and diabetes mellitus

Eligible

Not eligible

Blood pressure control algorithm Treat fever with IV antipyretics

BP≤180/110

BP≥180/110

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IV rTPA 0.9 mg/kg (maximum of 90 mg) with 10% given as intravenous bolus over 1 minute and the rest as IV infusion over 1 hour

Commence IV antihypertensives

Admit ICU for BP monitoring + bleeding complications Vitals Neurocheck hourly Aspiration precautions

After 24 hours post rTPA or no rTPA

Follow-up head CT/MRI before commencing antiplatelets

ASA 325 mg (if no contraindication) Statins DVT prophylaxis

PTOT evaluation Speech and swallow evaluation

Investigate the cause MRA/CTA/carotid duplex Venous doppler USS Echocardiography