Acute Stroke

STROKE
• The sudden death of brain cells due to lack of oxygen, caused by either the blockage of blood flow or
rupture of an artery to the brain.
• According to the 2018 Acute Ischemic Stroke (AIS) Guidelines, stroke is the No. 2 cause of death worldwide
and the No. 5 cause of death in the United States.
• Each year in the United States, about 795,000 people have a new or recurrent stroke.
• The major types of stroke are:
1. Ischemic stroke: Accounts for 87% of all strokes
2. Hemorrhagic stroke: Accounts for 13% of all strokes
2

SIGNS OF POSSIBLE STROKE
The signs and symptoms of a stroke may be subtle. They include:
• Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body
• Sudden confusion
• Trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking
• Dizziness or loss of balance or coordination
• Sudden severe headache with no known cause
Early recognition of stroke and shorter time to treatment leads to better clinical outcomes.
4

THE CINCINNATI PREHOSPITAL STROKE SCALE
The American Heart Association (AHA) recommends that all EMS personnel be trained to recognize stroke by using
a validated, abbreviated out-of-hospital neurological evaluation tool.
The CPSS identifies stroke on the basis of three physical findings.
Test Findings
Facial droop: Have patient smile or try to show teeth Normal – both sides of face move equally
Abnormal – one side of face does not move as well
as the other side
Arm drift: Have patient close eyes and hold both
arms straight out, with palms up
Normal – both arms move the same or both arms do
not move at all
Abnormal – one arm does not move or one arm
drifts down compared with the other
Abnormal speech: Have patient say ”you can’t teach
an old dog new tricks”
Normal – patient uses correct words with no slurring
Abnormal – patient slurs words, uses the wrong
words, or is unable to speak
If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%
The presence of all 3 findings indicates that the probability of stroke is greater than 85%
5

THE NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS)
Diagnostic tool used to quantitatively measure
the severity and neurologic deficit of a stroke.
6

RISK FACTORS OF STROKE
9
• Overweight or obesity
• Physical inactivity
• Heavy alcohol consumption
• Illicit drug use
• Hypertension
• Smoking
• High cholesterol
• Diabetes
• Obstructive sleep apnea
• Cardiovascular disease (Heart failure, heart infections)
• Family history
• Age >55 years
• African American
• Men
• Birth control medications

EFFECTS OF STROKE
The effects of a stroke depends on several factors, including the location and how much brain tissue is affected.
Right Brain Stroke:
• Paralysis on the left side of the body
• Vision problems
• Quick, inquisitive behavioral style
• Memory loss
Left Brain Stroke:
• Paralysis on the right side of the body
• Speech/language problems
• Slow, cautious behavioral style
• Memory loss
10

IN-HOSPITAL, IMMEDIATE GENERAL ASSESSMENT AND STABILIZATION
Once the patient arrives in the ED, the goal of the stroke steam, emergency physician, or other experts should be to
assess the patient with suspected stroke within 10 minutes
Step Actions
Assess ABCs (airway, breathing, circulation) Evaluate baseline vital signs
Provide supplementary oxygen For hypoxemic (O2 sat <94% or unknown) stroke patients
Establish IV access and obtain blood samples For baseline blood count, coagulation studies, and blood glucose
Check glucose Promptly treat hypoglycemia
Perform neurologic assessment Using NUH Stroke Scale (NIHSS) or a similar tool
Activate the stroke team Arrange consultation with a stroke expert for protocols
Order CT brain scan Have it read promptly by a qualified physician
Obtain 12-lead ECG with the first 24 hours of evaluation Identify a recent or ongoing AMI or arrhythmias (eg. atrial
fibrillation) as a cause of stroke.
11

THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE (NINDS)
• Mission: To reduce the burden of neurologic disease by supporting and conducting research
• The NINDS has established critical in-hospital time goals for assessment and management of stroke patients based on
experience obtained in large studies of stroke patients.
Stroke Assessment and Care Time Goals
Immediate general assessment 10 minutes
Immediate neurologic assessment 25 minutes
Acquisition of CT of the head 25 minutes
Interpretation of the CT scan 45 minutes
Administration of fibrinolytic therapy,
timed from ED arrival
60 minutes
Administration of fibrinolytic therapy,
timed from onset of symptoms
3 hours, or 4.5 hours in selected patients
Administration of endovascular therapy,
timed from onset of symptoms
6 hours in selected patients
Admission to a monitored bed 3 hours
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CT SCAN: COMPUTERIZED TOMOGRAPHY
The initial non-contrast CT scan is the most important test for a patient with acute stroke. It should be completed
within 25 minutes of the patient’s arrival in the ED and should be read within 45 minutes from ED arrival.
A Critical Decision Point: Hemorrhage versus No Hemorrhage
The CT scan determines the next steps in treatment.
Do not give aspirin, heparin, or rtPA until the CT scan has ruled out intracranial hemorrhage.
Hemorrhage is Present
The patient is not a candidate for fibrinolytics. Consult a neurologist or neurosurgeon.
Hemorrhage is NOT Present
The patient may be a candidate for fibrinolytic therapy. If the patient is not a candidate for fibrinolytics for other
reasons, consider giving aspirin either orally or rectally if the patient is not able to swallow.
Additional imaging techniques such as CT perfusion, CT angiography, or Magnetic Resonance Imaging (MRI) scans
can be used to confirm ischemic strokes.
13

CT SCANS
Ischemic Stroke Hemorrhagic Stroke
Less dense
Highly dense
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FIBRINOLYTIC THERAPY
Inclusion Criteria
• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms <3 hours before beginning treatment
• Age ≥18 years
If the patient’s neurologic function is rapidly improving toward normal, fibrinolytics may be unnecessary.
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Exclusion Criteria (Contraindications)
• Significant head trauma or prior stroke in previous 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
➢ Intracranial neoplasm, arteriovenous malformation, or aneurysm
➢ Recent intracranial or intraspinal surgery
• Elevated blood pressure (>185/110 mm Hg)
• Active internal bleeding
• Acute bleeding diathesis, including but not limited to
➢ Platelet count >100,000/mm3
➢ Heparin received within 48 hours, resulting in aPTT greater than the upper limit of normal
➢ Current use of anticoagulant with INR >1.7 or PT >15 seconds
➢ Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory
tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays)
• Blood glucose concentration <50 mg/dL (2.7 mmol/L)
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
16

MULTILOBAR INFARCTION
Hypodensity
>1/3 cerebral hemisphere
17

POTENTIAL CANDIDATES
18
Patients otherwise eligible for fibrinolytic therapy except that blood pressure is >185/110 mmHg:
• Labetalol 10-20 mg IV over 1-2 minutes, may repeat x 1
OR
• Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes,
maximum 15 mg per hour; when desired blood pressure is reached, lower to 3 mg per hour
OR
• Hydralazine IV 10 -20 mg every 4 to 6 hour
OR
• Enalaprilat 1.25 mg IV over 5 minutes, every 6 hours

Relative Exclusion Criteria
Consider risk to benefit ratio of rTPA administration carefully if any one of these relative contraindications is present:
• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Pregnancy
• Seizure at onset with postictal residual neurological impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)
Benefit
Risk
19

Extended Window of Therapy
Treatment of carefully selected patients between 3 and 4.5 hours after onset of symptoms has also been shown to
improve clinical outcomes, although the degree of benefit is smaller than that achieved with treatment within 3 hours.
Additional Inclusion Criteria
• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms 3 to 4.5 hours before beginning treatment
Additional Exclusion Criteria
• Age >80 years
• Severe stroke (NIHSS score >25)
• Taking an oral anticoagulant regardless of INR
• History of both diabetes and prior ischemic stroke
Not yet FDA approved, but it is recommended by an AHA/American Stroke Association science advisory
Data: The ECASS-3 trial (European Cooperative Acute Stroke Study); large, randomized study
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TREATMENT FOR ISCHEMIC STROKE
Intravenous Alteplase (Recombinant Tissue Plasminogen Activator)
21

ALTEPLASE (ACTIVASE®)
Mechanism of Action
Alteplase is an enzyme that catalyzes the conversion of plasminogen to plasmin (the enzyme that breaks down clots).
22

Dosing Guidelines
Recommended Total Dose: 0.9 mg/kg (maximum total dose: 90 mg)
**Patients ≤100 kg: Load with 0.09 mg/kg (10% of 0.9 mg/kg dose) as an IV bolus over 1 minute, followed by
0.81 mg/kg (90% of 0.9 mg/kg dose) as a continuous infusion over 60 minutes.
**It is advisable to remove any excess alteplase from the bottle prior to administration, in
order to avoid overdose if the intravenous pump is inaccurately calibrated.
Patients >100 kg: Load with 9 mg (10% of 90 mg) as an IV bolus over 1 minute, followed by 81 mg (90% of
90 mg) as a continuous infusion over 60 minutes.
23

Dosing Chart
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Monitoring
All patients treated with IV alteplase should be transferred to the ICU for at least 24 hours of close monitoring.
Important Parameters to measure during the first 24 hours of alteplase treatment:
• Vital signs and neurologic status should be checked every 15 minutes for two hours, then every 30 minutes
for six hours, then every 60 minutes until 24 hours from the start of alteplase treatment.
• Blood pressure must be maintained at or below 180/105 mmHg during the first 24 hours.
• Anticoagulant and antithrombotic agents, such as heparin, warfarin, or antiplatelet drugs, should NOT be
administered for at least 24 hours after the alteplase infusion is completed and until a follow-up CT scan at
24 hours shows no intracranial hemorrhage
25

Adverse Events
>10%: Intracranial hemorrhage (15%; within 90 days, 6%; within 36 hours)
1% - 10%: New ischemic stroke (6%), Gastrointestinal hemorrhage (5%)
1%: Angioedema, Hypotension
26

INTRACEREBRAL HEMORRHAGESymptomatic intracerebral hemorrhage should be suspected in any patient who develops sudden neurologic deterioration, a
decline in level of consciousness, new headache, nausea and vomiting, or a sudden rise in blood pressure after thrombolytic
therapy is administered, especially within the first 24 hours of treatment.
Management
The alteplase infusion should be discontinued and a stat noncontrast head CT or MRI scan should be ordered.
Treatment Options: Reversal of thrombolytic therapy
1. Cryoprecipitate: 10 units immediately (infused over 10 to 30 minutes) and more as needed to achieve a serum fibrinogen level
of ≥200 mg/dL
2. Antifibrinolytic agents:
➢ Aminocaproic acid 4 to 5 g intravenously (IV) during first hour, followed by 1 g IV until bleeding is controlled,
OR
➢ Tranexamic acid 10 to 15 mg/kg IV over 20 minutes
3. Prothrombin complex concentrate: Adjunctive therapy to cryoprecipitate for patients on warfarin prior to alteplase treatment
4. Fresh frozen plasma: If prothrombin complex concentrate is not available, adjunctive therapy to cryoprecipitate for patients
on warfarin
5. Vitamin K: Adjunctive therapy for patients on warfarin
6. Six to eight units of Platelets: For patients with thrombocytopenia (platelet count <100,000/µL)
27

PATIENT CASE
Age: 50 y/o
Sex: Female
Weight: 71.1 kg
PMHx: Mitral valve prolapse (MVP), Asthma, Gastric ulcers, Heart Murmur
SH: Daily smoker
FH: No pertinent family history in first degree relatives
Allergies: NKDA Intolerances: ASA, NSAIDS (gastric ulcers)
Medication List: Ibuprofen 600 mg TAB – 1 tablet orally every 6 hours PRN pain with food
CC: Mild epigastric pain, and started not feeling well at 10:30 am 3/15/18
Her daughter dropped her off at her PCP, where she became dizzy, nauseous, had chest pain, right arm numbness, & b/l foot numbness.
Chest pain radiates up to her neck and back. She was transferred via EMS to Huntington hospital.
Upon arrival at the ED at 1:06 pm, the patient presented with a left facial droop, right arm drift, and slurred speech as per ED physicians.
Patient is currently calm, awake, alert, able to answer questioning and follow commands and denies any pain, fever, cough, chills, NVD.
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PATIENT CASE
Review of Systems @1:26pm 3-15-18 :
CONSTITUTIONAL: No weakness, fevers or chills
EYES/ENT: No visual changes; No vertigo or throat pain
NECK: No pain or stiffness
RESPIRATORY: No cough, wheezing, hemoptysis; No shortness of breath
CARDIOVASCULAR: +chest pain, + palpitations
GASTROINTESTINAL: + intermittent RUQ abdominal. + nausea, no vomiting, or hematemesis;
No diarrhea or constipation. No melena or hematochezia.
GENITOURINARY: No dysuria, frequency or hematuria
NEUROLOGICAL: + numbness and weakness
SKIN: No itching, burning, rashes, or lesions
29

PATIENT CASE
Physical Exam @1:26pm 3-15-18:
GENERAL: NAD, well-groomed, well-developed
HEAD: NC/AT
EYES: EOMI, no scleral icterus
HEENT: Moist mucous membranes
NECK: Supple, No JVD
CNS: Alert & Oriented X3, numbness bilateral upper and lower extremities. 4+ grip strength bilateral upper
extremities, 4+ strength bilateral lower extremities. Left facial droop, cranial nerves otherwise intact.
LUNG: Clear to auscultation bilaterally; No rales, rhonchi, wheezing, or rubs
HEART: RRR; S1/S2
ABDOMEN: +BS, ST/ND/NT
EXTREMITIES: 2+ Peripheral Pulses, No clubbing, cyanosis, or edema
MUSCULOSKELTAL: Joints normal ROM, no Muscle or joint tenderness
30

PATIENT CASE
Laboratory @1:26 pm 3-15-18:
Sodium, Serum: 140 [135 - 145 mmol/L]
Potassium, Serum: 3.9 [3.5 - 5.3 mmol/L]
Chloride, Serum: 109 [96 - 108 mmol/L]
Carbon Dioxide, Serum: 27 [22 - 31 mmol/L]
Anion Gap, Serum: 4 [5 - 17 mmol/L]
Blood Urea Nitrogen, Serum: 12 [7 - 23 mg/dL]
Creatinine, Serum: 0.73 [0.50 - 1.30 mg/dL]
Glucose, Serum: 87 [70 - 99 mg/dL]
Calcium, Total Serum: 9.3 [8.5 - 10.1 mg/dL]
Protein Total, Serum: 7.8 [6.0 - 8.3 gm/dL]
Albumin, Serum: 4.1 [3.3 - 5.0 g/dL]
Bilirubin Total, Serum: 0.4 [0.2 - 1.2 mg/dL]
Alkaline Phosphatase, Serum: 104 [40 - 120 U/L]
Aspartate Aminotransferase (AST/SGOT): 21 [15 - 37 U/L]
Alanine Aminotransferase (ALT/SGPT): 29 [12 - 78 U/L]
eGFR if Non African American: 96 [>=60 mL/min/1.73M2]
eGFR if African American: 111 [>=60 mL/min/1.73M2]
Creatinine Kinase, Serum: 77 [26 - 192 U/L]
Troponin I, Serum: <0.015 [0.015 - 0.045 ng/mL]
Activated Partial Thromboplastin Time: 30.6 [27.5 - 37.4 sec]
Prothrombin Time, Plasma: 11.0 [9.8 - 12.7 sec]
31

PATIENT CASE
Hematology @1:26 pm 3-15-18:
WBC Count: 4.86 [3.80 - 10.50 K/uL]
RBC Count: 5.14 [3.80 - 5.20 M/uL]
Hemoglobin: 16.0 [11.5 - 15.5 g/dL]
Hematocrit: 48.4 [34.5 - 45.0 %]
Mean Cell Volume: 94.2 [80.0 - 100.0 fl]
Mean Cell Hemoglobin: 31.1 [27.0 - 34.0 pg]
Mean Cell Hemoglobin Conc: 33.1 [32.0 - 36.0 gm/dL]
Red Cell Distrib Width: 14.3 [10.3 - 14.5 %]
Platelet Count - Automated: 233 [150 - 400 K/uL]
Auto Neutrophil #: 2.52 [1.80 - 7.40 K/uL]
Auto Lymphocyte #: 1.55 [1.00 - 3.30 K/uL]
Auto Monocyte #: 0.62 [0.00 - 0.90 K/uL]
Auto Eosinophil #: 0.10 [0.00 - 0.50 K/uL]
Auto Basophil #: 0.05 [0.00 - 0.20 K/uL]
Auto Neutrophil %: 51.8 [43.0 - 77.0 %]
Auto Lymphocyte %: 31.9 [13.0 - 44.0 %]
Auto Monocyte %: 12.8 [2.0 - 14.0 %]
Auto Eosinophil %: 2.1 [0.0 - 6.0 %]
Auto Basophil %: 1.0 [0.0 - 2.0 %]
Auto Immature Granulocyte %: 0.4 [0.0 - 1.5 %]
Nucleated RBC: 0 [0 - 0 /100 WBCs]
32

PATIENT CASE
Assessment:
NIHSS: 4/42 (Minor Stroke)
(1) Right arm drift
(1) Numbness
(2) Left facial palsy
CT Head: Negative for hemorrhage
CTA Head: Negative for acute larger vessel occlusion
34

PATIENT CASE
Plan:
Patient is eligible for rtPA therapy and given at 1:44 pm 3-15-18
TOTAL DOSE: 0.9 mg/kg x 71.1 kg = 63.99 mg ~ 64 mg
IV Bolus: 10% of 64 mg = 6.4 mg over 1 minute
IV Continuous Infusion: 90% of 64 mg = 57.6 mg ~ 58 mg over 60 minutes
Discard: 100 ml – 58 ml – 6.4 ml = 35.6 ml
35

PATIENT CASE
ICU Vital Signs Last 24 Hours :
T(C): 36.3 (16 Mar 2018 06:00), Max: 36.9 (15 Mar 2018 13:35)
T(F): 97.4 (16 Mar 2018 06:00), Max: 98.4 (15 Mar 2018 13:35)
HR: 79 (16 Mar 2018 09:00) (65 - 93)
BP(mmHg): 108/61 (16 Mar 2018 09:00) (Patient’s RANGE: 81/37 - 142/94)
BP(mean): 72 (16 Mar 2018 09:00) (Patient’s RANGE: 33 - 84)
RR: 25 (16 Mar 2018 09:00) (Patient’s RANGE: 17 - 27)
SpO2: 92% (16 Mar 2018 07:00) (Patient’s RANGE: 77% - 100%)
36

PATIENT CASE
Plan/Monitoring:
Patient is admitted to the ICU for post rtPTA protocol.
• Bedrest for 24 hours
• Continue close monitoring and neuro exams
• Follow-up MRI scan
• Echo with bubble
• ASA after 24 hours, H/o PUD in past, monitor GI upset by PCP
• Physical therapy after 24 hours
37

PATIENT CASE
Neurological exam:
HF: A x O x 3. Speech fluent, No Aphasia or paraphasic errors.
CN: facial sensation normal, no facial weakness, tongue midline, Palate moves equally
Motor: No drift or weakness
Sens: no numbness in left hand, b/l feet down going bilaterally.
MRI: Did not reveal any acute pathology
38

PATIENT CASE
Follow-up on 3-16-18:
• Patient is feeling better
• No new chief complaints.
• Left side extremities tingling and numbness resolved
• Facial weakness on left side resolved
• No headaches, dizziness.
39

PATIENT CASE
Patient Counseling on 3-16-18:
1. Risks:
• Worsening TIA/stroke
• MI
• Acute stroke
• Disability
• Arrhythmia
• Death
2. Smoking cessation and nicotine patch
3. Benefits of TEE and link recorder (LINQ placement) with cardiologist
Patient expresses understanding of these risks and requests to leave AMA
Aspirin, Atorvastatin, and Omeprazole were sent to her pharmacy
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SUMMARY
41
10:30 am
• Onset of
stroke
symptoms
1:06 pm
• ED Arrival
1:44 pm
• Alteplase
given
• Total Time: 3 hours and 14 minutes
• Patient is eligible for both 3-hour and 4-hour window of fibrinolytic therapy
• Post-care was appropriate
• Discharge medications will reduce risk of stroke in the future

REFERENCES
1. https://www-uptodate-com.jerome.stjohns.edu/contents/intravenous-thrombolytic-therapy-for-acute-ischemic-stroke-
therapeutic-use? search=Intravenous%20thrombolytic%20therapy%20for%20acute%20ischemic%20stroke:%
20Therapeutic%20use&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
2. https://www.acls.net/acls-suspected-stroke-algorithm.htm
3. http://www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects-of-
Stroke_UCM_308534_SubHomePage.jsp
4. https://www.cdc.gov/stroke/types_of_stroke.htm
5. https://healthmetrics.heart.org/wp-content/uploads/2018/02/Highlights-from-the-2018-Guidelines-for-the-Early-
Management-of-Patients-With-Acute-Ischemic-Stroke.pdf
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