Content Archana Hinduja MD M Sohel Ahmed MD Slides Archana Hinduja MD M Sohel Ahmed MD Editors Note Global Considerations The intent of the editors authors and reviewers of this ENLS topic was not to address all the variations in international practice for the different ID: 934749
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Slide1
Slide2ENLS Version 5.0Acute Ischemic Stroke
Content
: Archana Hinduja, MD; M
Sohel
Ahmed, MD
Slides
: Archana Hinduja, MD; M
Sohel
Ahmed, MD
Slide3Editors’ Note: Global Considerations
The intent of the editors, authors, and reviewers of this ENLS topic was not to address all the variations in international practice for the different diseases. We have discussed major practice variances (e.g., the availability of diagnostic testing, or the type of medications used) and encourage learners to use the ENLS algorithms as a framework on which any relevant local practice guidelines can be incorporated.
Slide4Slide5Stroke
Clinical diagnosis
Sudden onset of neurological deficit that can be explained by vascular cause
Unable to distinguish between a hemorrhagic and ischemic stroke until imaging obtained
Slide6Initial Prehospital Evaluation by EMS:
History & physical
Determine LKW
ABCs
Glucose check
Stroke screen exam
Obtain IV access
Obtain blood vials for eval at ED
Call and transport to closest certified Stroke Center
Activate prehospital notification
Consider taking patient directly to imaging on EMS gurney (brief doorway assessment)
Slide7ED Evaluation
Checklist for the first hour
☐ Activate stroke code system (if available)
☐ Vital signs
☐ M
aintain oxygen saturation >94%
☐ Determine time of onset
/ LKW
☐ Determine NIHSS score
☐ CT, CTA
☐ Medication list (e.g. anticoagulants)
☐ IV access – 18g peripheral IV
☐ Labs: capillary glucose, CBC with platelets, PT/INR, PTT, and beta-HCG
☐ EKG
Slide8Slide9Transient Ischemic Attack
Slide10ABCD
2
Criteria
Points
A
ge ≥ 60 years
1
B
P ≥ 140/90 mmHg at initial evaluation
1
C
linical features of the TIA:
Speech disturbance without weakness, or
Unilateral weakness
1
2
D
uration of symptoms:
10-59 minutes, or
≥ 60 minutes
1
2
D
iabetes mellitus in patient’s history
1
Slide11Transient Ischemic Attack
Start antithrombotic agent – ASA,
clopidogrel
, ASA/dipyridamole
Start high-intensity statin (consider moderate intensity in age >75
yrs)
Carotid imaging (ultrasound, CTA, MRA)
Consider transthoracic echocardiogram
Consider 30-day ambulatory cardiac monitor
Encourage smoking cessation
Slide12Test Question #1
A 62-year-old man presents to the hospital after a TIA.
He has a history of hypertension and tobacco use but is not taking any medications.
He is at neurological baseline; head CT was unremarkable; the ABCD2 score is 2; there is no evidence of atrial fibrillation.
What would constitute an appropriate management plan?
Obtain a STAT MRI and administer tPA if there is demonstrable injury.
Discharge home on antiplatelet therapy and a statin with follow-up in 90 days.
Admit to the ICU for q1h neuro checks and administer tPA if symptoms return.
Discharge home on antiplatelet therapy and a statin with outpatient follow-
up in 1-2 days.
Slide13Test Question #1
A 62-year-old man presents to the hospital after a TIA.
He has a history of hypertension and tobacco use but is not taking any medications.
He is at neurological baseline; head CT was unremarkable; the ABCD2 score is 2; there is no evidence of atrial fibrillation.
What would constitute an appropriate management plan?
Obtain a STAT MRI and administer tPA if there is demonstrable injury.
Discharge home on antiplatelet therapy and a statin with follow-up in 90 days.
Admit to the ICU for q1h neuro checks and administer tPA if symptoms return.
Discharge home on antiplatelet therapy and a statin with outpatient follow-up in 1-2 days.
Slide14Slide15A 79-year-old female goes to bed at 10 p.m., awakens at 6 a.m., and notices her left arm is floppy and her left face droops.
The patient's daughter calls her mom at 6:30 a.m. and notices slurring speech. When the daughter arrives at her mother's house at 7 a.m., she notices that her mom looks only to the right side.
The daughter calls 911 at 7:15 a.m., and the patient arrives in the ED at 7:45 a.m.
Based on her case presentation, what is the time used to determine eligibility for possible tPA treatment? A. 6 a.m. B. 6:30 a.m. C. 7 a.m. D. 7:45 a.m. E. 10 p.m. the night prior
Test Question #2
Slide16A 79-year-old female goes to bed at 10 p.m., awakens at 6 a.m., and notices her left arm is floppy and her left face droops.
The patient's daughter calls her mom at 6:30 a.m. and notices slurring speech. When the daughter arrives at her mother's house at 7 a.m., she notices that her mom looks only to the right side.
The daughter calls 911 at 7:15 a.m., and the patient arrives in the ED at 7:45 a.m.
Based on her case presentation, what is the time used to determine eligibility for possible tPA treatment? A. 6 a.m. B. 6:30 a.m. C. 7 a.m. D. 7:45 a.m.
E. 10 p.m. the night prior
Test Question #2
Slide17Case
65-year-old woman presents to ED with:
Left face and arm weakness
Inattention and visual field deficit
Onset 30 mins prior (witnessed) PMH: hypertension and hyperlipidemia
Meds: simvastatin, lisinopril and baby aspirinVitals: afebrile; BP 160/90 mmHg; P 95/min; RR 18/min; O
2sat 98%
NIHSS 14
General exam unremarkable
Bedside blood sugar check normal
Slide18Case: Imaging
Slide19Case: Imaging
Volume of ischemic core = 25 mL
Volume of perfusion lesion = 96 mL
Mismatch volume = 71 mL
Mismatch ratio = 3.8
Slide20Absolute Contraindications for IV tPA - Abbreviated
Major head trauma, ischemic stroke, intracranial/spinal surgery in previous 3 months
History of intracerebral hemorrhage or intracranial neoplasm
Signs and symptoms of subarachnoid hemorrhage, infective endocarditis, or aortic arch dissection
GI malignancy or recent bleeding within 21 days
Taking direct thrombin inhibitors or direct factor
Xa
inhibitors or warfarin (INR > 1.7)
CT shows severe hypoattenuation, hypodensity > 1/3 of cerebral hemisphere or intracerebral hemorrhage
Slide21Case
< 3 hours from onset
NIHSS 14
Bedside blood sugar check normal
Head CT without hemorrhageNo contraindications
BP < 185/110 mmHg
Slide22IV tPA Delivery
Two peripheral IV lines
Calculate actual body weight
Can be estimated by two experienced providers
0.9 mg/kg (MAX 90 mg)10% given in bolus over 1
st minuteThe rest given over a 1-hour infusion
Stop immediately if neurological deteriorationThink hemorrhagic conversion
Slide23Special Considerations
In patients with wakeup symptoms and unclear LKW time >4.5 hours and ineligible for thrombectomy consider IV
tPA
if “DWI-FLAIR-mismatch” on MRI study present that is DWI positive and FLAIR negative.
Slide24Risk of Intracranial Hemorrhage after IV-tPA
NIHSS
Risk of ICH
0-10
2-3%
11-20
4-5%
> 20
17%
Slide25STOP tPA infusion
Vital signs every 15 mins (including GCS/pupils)
Non-invasive interventions to lower ICP
Obtain non-contrast CT scan
Notify the neurosurgeon on call
If not available, begin the process of transfer
Stat labs: PT, PTT, platelets, fibrinogen, type and cross
Give cryoprecipitate if confirmed hemorrhage
Consider platelet transfusion
Consider antifibrinolytics
Deterioration During
or After IV tPA
Slide26Large vessel occlusion
Allows later time window of therapy up to
24
hours
Continually defining best patient inclusion and exclusion
Continually developing newer devices
Yes
Intra-arterial Thrombectomy
Slide27Intra-Arterial Embolectomy Devices
Slide28Recommendations for Endovascular
Therapy
Give IV
tPA if eligible
Endovascular
therapy indicated if the following criteria are met:
Prestroke
mRS
score 0 to 1
LVO
of the ICA or proximal MCA (M1). May be reasonable for posterior circ or M2/M3 but
uncertain benefit
.
Age ≥
18. May be reasonable for < 18 years but uncertain benefit.
NIHSS
≥ 6
ASPECTS score ≥ 6
Groin puncture within 6 hours
of LKW
6-24 h window based on target mismatch profile on CTP/MR perfusion imaging
Reduced time from symptom onset to reperfusion is highly associated with better outcomes
Slide29Case
s/p IV tPA
CTA confirms a proximal MCA occlusion
She is taken for endovascular therapy
Yes
Slide30Case
Pre-
Post stent retriever
Slide31Case of Reperfusion Therapy
Patient NIHSS went from 14 to 3
Admitted to the NCCU for post IV tPA and endovascular care protocols
Slide32Communication
☐ Age
☐ Airway status
☐ Last known well time
☐ NIHSS
☐ Coagulation parameters
☐ CT – dense MCA sign, ASPECT score, etc.
☐ CTA/MRA – LVO status
☐ CTP / MRP – volume of core and penumbra, matched or mismatched perfusion
☐ MRI DWI/FLAIR mismatch if ineligible for thrombectomy
☐ Thrombolytic administration – initiation, completion time, reason if not administered
☐ Thrombolytic administration –Time based(within 4.5 hours), Imaging based (4.5-9 hours)
☐ Endovascular intervention – time to groin puncture, recanalization, TICI score
☐ Target BP
Slide33Admission/Transfer
Neuro and BP checks 15 min x 2h, then q30 min x 6h, then hourly x 16h
Supplemental O2 to keep O2 sat
> 94%Keep BP < 180/105 mmHg post tPA and likely lower post successful thrombectomy
Slide34Admission/Transfer
Continuous telemetry
IV normal saline –
euvolemiaKeep glucose 140-180 mg/dl (7.8-10 mmol/L)Aggressive fever controlIf tPA administered,
no anticoagulation or antiplatelets for 24 hoursavoid indwelling urinary catheters, nasogastric tubes and intra-arterial catheters for 4 hours
Swallow assessment before feeding
Slide35Pediatric Considerations
Not as common
as adults (1.6-13/100K children per year)
More often presents with seizure
Tends to occur in select populationSickle cell disease
Cardiac abnormalitiesPediatric NIHSS
is validated tool Many stroke mimics (seizure, migraine) in children
MRI
is generally the preferred imaging modality
IV tPA not approved for < 18 years
Only case reports of its use in children
One clinical trial in children age 2-18 was closed due to insufficient enrollment
Approach on case by case basis
Case reports only for endovascular therapy
Slide36Nursing Pearls
If acute neurological deficit, check fingerstick glucose and activate stroke team.
CT should not be delayed for lab work.
Obtain actual weight of patient.Obtain 18g IV access for perfusion imaging and 2nd IV if patient will be receiving thrombolytics or going for thrombectomy.
tPA is mixed with swirling, not shaking.tPA dose should be double-checked with 2nd clinician and BP and neuro status checked within 15 min prior to administration.Bolus dose, infusion dose, wasted tPA, and follow-up flush post-tPA should be documented.
Patients not receiving tPA may be allowed to have permissively higher blood pressure.Notify the provider immediately for decline in neuro status, acute hypertension, angioedema.
Slide37Clinical Pearls
LKW in wake-up stroke is time patient went to bed.
In cases of stuttering symptoms, the clock is reset only if patient is 100% back to baseline.
With patients on direct oral anticoagulation, determine the last time the patient took their medication.Low NIHSS is not a contraindication to thrombolysis.Observing patients after thrombolysis for response is not required prior to mechanical thrombectomy.
Consider short-term dual antiplatelet therapy in patients with TIA and ischemic stroke.
Slide38Slide39Slide40