management of acute stroke

1. Management of acute stroke Eric Kraus, MD Neurology

2. Case

3. Initial work-up Document time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

4. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs < 3 hours ..and meet inclusion and exclusion criteria Intra-venous t-PA 3-6 hours ..and have a large artery occlusion (ICA, MCA, ACA, PCA, vertebral, basilar) CT angiogram Intra-arterial t-PA > 6 hours ..and basilar occlusion which is largely fatal if not opened CT angiogram Intra-arterial t-PA

5. t-PA: Inclusion Age 18-80 Ischemic stroke NIHSS > 4 Onset < 3 hours ASA use okay

6. t-PA: Exclusion Hemorrhagic stroke NIHSS > 20 (caution) Rapidly improving symptoms Hx stroke w/in 6 weeks Possible seizure cause of paralysis Previous known intracranial hemorrhage, tumor, AVM, aneurysm Presumed septic embolus Recent MI Trauma with internal injury w/in 30d Recent head trauma w/in 90d SBP > 185, DBP > 110 Glucose < 50 or > 400 Plts < 100K Hct < 25 Hereditary or acquired (Coumadin) bleeding disorder, INR > 1.7 Recent internal bleeding Recent surgery Pregnancy or parturition w/in 30d Arterial or venous puncture at noncompressible sites w/in 1wk Other serious/terminal illness

7. NINDS t-PA trial Good outcome No or minimal disability at 3 months 29% placebo 41% t-PA Bleeding risk 0.6% placebo 6.4% t-PA

8. CT Angiogram Contraindications Contrast allergy Cr > 1.5 Alternatives MRA Limited catheter angiogram

9. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) Min score = 0 Max score = 42 Must be > 4 Caution > 20 EKG Noncontrast head CT Labs Assessment of: Level of consciousness Gaze Visual fields Facial weakness Arm and leg weakness Limb ataxia Sensation Best language Dysarthria Inattention or neglect

10. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs Ischemic changes A-fib

11. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

12. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

13. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

14. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

15. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

16. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

17. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

18. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

19. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs Hemorrhage CT angiogram ..and on antiplatelet drug Consider 6-pack plts ..and on Coumadin Vit K 10mg IV 4 units FFP repeated until INR <= 1.5 ..and on heparin Protamine 25mg IV, repeat 10mg IV prn

20. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs Hemorrhage causes HTN Amyloid angiopathy Trauma Bleeding predisposition Hereditary Acquired Vascular malformation Aneurysm

21. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

22. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

23. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

24. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

25. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs

26. Initial work-up Time of onset Consider t-PA NIHSS (stroke scale) EKG Noncontrast head CT Labs Cr Coags PTT, INR, fibrinogen Hct Plts Glucose

27. Case

28. General management Permissive HTN Glucose < 150 using insulin Temperature < 37.8 Tylenol 650mg q 6hrs x 48hrs Fluids: euvolumia, isotonic saline, no glucose SaO2 > 92% Avoid Foley DVT prophylaxis Nutrition / swallowing

29. General management Permissive HTN Glucose < 150 using insulin Temperature < 37.8 Tylenol 650mg q 6hrs x 48hrs Fluids: euvolumia, isotonic saline, no glucose SaO2 > 92% Avoid Foley DVT prophylaxis Nutrition / swallowing Stop or reduce HTN drugs Half B-blockers Consider cardiopulmonary needs Ischemic stroke BP < 210/120 BP < 180/105 if t-PA given Hemorrhagic stroke BP < 180/105 HTN treatment if needed 1st: Labetolol 10mg IV prn 2nd: Nicardipine gtt

30. General management Permissive HTN Glucose < 150 using insulin Temperature < 37.8 Tylenol 650mg q 6hrs x 48hrs Fluids: euvolumia, isotonic saline, no glucose SaO2 > 92% Avoid Foley DVT prophylaxis Nutrition / swallowing Ischemic stroke SQ heparin 5000u tid +/- SCDs Hemorrhagic stroke SCDs All patients Early mobility

31. Case

32. Acute ASA CAST, IST trials* Small reduction of death or early recurrent ischemic stroke Abs risk reduction ~0.8% over placebo NNT ~125 Good outcome No or minimal disability at 6 months 10 per 1000 over placebo Bleeding risk 0.6% placebo 1.1% ASA

33. Case

34. Don�t think heparin Multiple studies don�t support acute heparin May cause hemorrhagic conversion Larger strokes have more risk Exceptions Recurrent thrombotic emboli Risk is only 5% in first 2 weeks for A-fib Impending carotid or basilar occlusion Cerebral venous thrombosis If heparin Goal PTT 50-80 Never bolus

35. Question

36. What�s acute

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