Stroke class
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This document provides information on managing patients with stroke. It discusses the objectives of reviewing stroke etiology, identifying stroke type based on exam, and acute management of ischemic and hemorrhagic strokes. It then covers the three main types of strokes - ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage. Key aspects of acute stroke management are outlined, including the ABCs, use of the NIH Stroke Scale to determine severity, thrombolysis guidelines, complications to watch for, and supportive therapies. The importance of blood pressure control, glucose management, and avoiding fever are emphasized for optimizing patient outcomes.
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Stroke class
- 1. Management of patients with stroke 22/09/2015
- 2. 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
- 3. Three Stroke Types Ischemic Stroke Clot occluding artery 85% Intracerebral Hemorrhage Bleeding into brain 10% Subarachnoid Hemorrhage Bleeding around brain 5%
- 7. Prehospital Stroke assessment tools
- 9. 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 Scores are totaled to determine level of severity Can also serve as a tool to determine if a change in exam has occurred
- 10. 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
- 11. 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
- 12. Etiology of Ischemic Strokes LARGE VESSEL THROMBOTIC: Virchow’s 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
- 13. 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
- 14. 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
- 15. Cortical Signs RIGHT BRAIN: LEFT BRAIN: - Right gaze preference - Left gaze preference - Neglect - Aphasia If present, think LARGE VESSEL stroke
- 16. Large Vessel Stroke Syndromes • MCA: – Arm>leg weakness – LMCA cognitive: Aphasia – RMCA cognitive: Neglect,, topographical difficulty, apraxia, constructional impairment • ACA: – Leg>arm weakness, grasp – Cognitive: muteness, perseveration, abulia, disinhibition • PCA: – Hemianopia – Cognitive: memory loss/confusion, alexia • Cerebellum: – Ipsilateral ataxia
- 17. Aphasia Broca’s Expressive aphasia Left posterior inferior frontal gyrus Wernicke’s Receptive aphasia Posterior part of the superior temporal gyrus Located on the dominant side (left) of the brain
- 18. 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 border zone areas – Hypo-perfusion
- 19. 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
- 21. Etiology of ICH • Traumatic • Spontaneous – Hypertensive – Amyloid angiopathy – Aneurysmal rupture – Arteriovenous malformation rupture – Bleeding into tumor – Cocaine and amphetamine use
- 22. Causes of ICH
- 23. 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
- 24. Ganglionic Bleed Contralateral hemiparesis Hemisensory loss Homonymous hemianopia Conjugate deviation of eyes toward the side of the bleed or downward AMS (stupor, coma)
- 25. 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
- 26. Pontine Hemorrhage Pin-point but reactive pupils Abrupt onset of coma Decerebrate posturing or flaccidity Ataxic breathing pattern
- 27. Subarachnoid Hemorrhage “Worst headache of my life” AMS Photophobia Nuchal rigidity Seizures Nausea and vomiting
- 28. Management
- 30. A B C Airway Breathing Circulation
- 31. Airway Most likely related to decreased level of consciousness (LOC), dysarthria, dysphagia GCS < 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
- 32. After ABC GCS ECG and blood pressures Blood glucose Fluid access Hydration Bloods Nil by Mouth
- 33. Time is brain 1.9 million neurons are lost each minute after a stroke Protect ischaemic penumbra
- 34. Schedule of Neurological Assessment and Vital Signs and Other Acute Care Assessments in Thrombolysis-Treated Patients
- 35. Schedule of Neurological Assessment and Vital Signs and Other Acute Care Assessments in non-thrombolysis-Treated Patients
- 36. Ischemic stroke
- 38. Nursing Alert! Critical Actions for Suspected ICH or Systemic Bleeding After rtPA Administration
- 40. Stroke Algorithm
- 41. Nursing Alert: Recognizing Increased ICP
- 42. Imaging CT scan • 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 MRI • Superior for showing underlying structural lesions • Contraindications
- 43. tPa Fast Facts Tissue plasminogen activator “clot buster” IV tpa window 3 hours IA tpa window 4.5 hours Disability risk 30% despite ~5% symptomatic ICH risk Contraindications Hemorrhage SBP > 185 or DBP > 110 Recent surgery, trauma or stroke Coagulopathy Seizure at onset of symptoms NIHSS >21 Age? Glucose < 50
- 44. CT Known time of symptoms <4 hours NIHSS score No haemorrhage No contraindications Consent Age
- 45. Thrombolysis Alteplase rTPA 0.9mg /Kg 10% of total dose –Bolus 2-3 mins 90% of total dose –Infuse over 60 mins
- 46. rTPA Alteplase Do not mix t-PA with any other medications. Do not use IV tubing with infusion filters. All patients must be on a cardiac monitor When infusion is complete, saline flush with Normal saline t-PA must be used within 8 hours of mixing when stored at room temperature or within 24 hours if refrigerated
- 47. Complications of Thrombolysis Intra-cerebral haemorrhage-1.7% 0.28% fatal Bleeding-minor bleeding is common (IV site) Anaphylaxis- 1% Angiodoema 1.3% Major Hemorrhage 0.4%
- 48. 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)
- 49. Save the Penumbra!! CEREBRAL BLOOD FLOW (ml/100g/min) CBF < 8 CBF 8-18 TIME (hours) 1 2 3 20 15 10 5 PENUMBRA CORE Neuronal dysfunction Neuronal death Normal function
- 50. 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
- 52. 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
- 56. Effective Nursing Strategies for Successful Discharge Planning
- 57. Effective Nursing Strategies for Successful Discharge Planning
- 58. Effective Nursing Strategies for Successful Discharge Planning
- 59. Thank you !!!
Editor's Notes
- The National Institute of Health Stroke Scale is the industry standard It 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
- 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 scan Neurologic assessment by stroke team and CT scan performed within 25 minutes of arrival Interpretation of CT scan within 45 minutes of ED arrival Initiation 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 patient’s 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.
- 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 patient’s 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 pressure Castillo 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.
- 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 (don’t just assume that the fever is neurogenic in nature) and treat accordingly.