Stroke ACNP Bootcamp 2012

1. StrokeACNP Bootcamp 2012 Briana Witherspoon, MSN, ACNP-BC, CCRN, CNRN

2. Stroke Objectives • Review Ischemic Stroke Algorithm • Identifying location of ischemic stroke • Acute management of an ischemic stroke • Acute management of hemorrhagic stroke

3. Stroke Algorithm

4. 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 • Another important use of the NIHSS is in research, where it allows for the objective comparison of efficacy across different stroke treatments and rehabilitation interventions • Scores are totaled to determine level of severity • Can also serve as a tool to determine if a change in exam has occurred

5. 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

6. NIHSS cont. • NIHSS Interpretation

7. NIHSS and Outcome Prediction • NIHSS below 12-14 will have an 80% good or excellent outcome. • NIHSS above 20-26 will have less than a 20% good or excellent outcome. • Lacunar infarct patients had the best outcomes. Adams HP Neurology 1999;53:126-131 Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)

8. 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

9. Etiology Of 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, Fat, air, or septic emboli

10. 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

11. Cortical Signs • If present, think LARGE VESSEL stroke

12. Large Vessel Stroke Syndromes • MCA: • Arm>leg weakness • LMCA cognitive: Aphasia • RMCA cognitive: Neglect, anosognosia, topographical difficulty, apraxia, constructional impairment • ACA: • Leg>arm weakness, grasp • Cognitive: muteness, perseveration, abulia, disinhibiition • PCA: • Hemianopia • Cognitive: memory loss/confusion, alexia • Cerebellum: • Ipsilateral ataxia

13. Circle of Willis

14. 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

15. Case 1 • 71 year old female with sudden onset of left-sided weakness • She was out with her sisters when she suddenly slumped her head and appeared to have a left facial droop • History of HTN and atrial fibrillation • Meds: Losartan

16. Case 1 • BP- 142/83, P– 104, T- 98.0, RR– 22, O2- 94% • General exam: Unremarkableexcept irregular rate and rhythm • NEURO EXAM: - Speech dysarthricbut language intact - Right gaze preference - Left facial droop - Left- sided hemiplegia - Neglect - DTR's are symmetric, Left toe up

17. Case 1

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22. Case 1 • Right MCA infarct, most likely cardioembolic from atrial fibrillation • Patient underwent mechanical thrombectomy with intra-arterial verapamil, clot removal successful • Excellent recovery – patient was discharged 48 hours later on Coumadin

23. 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 for watershed pattern • S/S of Hypo-perfusion

24. Etiology of Stroke SMALL VESSEL (Lacunes <1.5cm) • Risk Factors • HTN • HLD • DM • Tobacco Use • Sleep apnea

25. Case 2 • 65 year old male with acute onset of left face, arm, and leg numbness • History of HTN, DM, and tobacco use • Meds: Insulin, aspirin

26. Case 2 • BP- 168/96, P– 92 • General exam: Unremarkable, RRR • NEURO EXAM: - Decreased sensation on left face, arm, and leg

27. Case 2

28. Case 2 • Right thalamic lacunar infarct

29. 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

30. 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

31. Case 3 • 55 year old male with acute onset of right sided numbness and tingling, left sided face pain and numbness, gait imbalance, nausea/vomiting, vertigo, swallowing difficulties, and hoarse speech • History of CAD s/p CABG, DM2, HTN, HLD, OSA • Meds: Aspirin, plavix, insulin, lipitor, metoprolol, lisinopril

32. Case 3 • NEURO EXAM: BP- 194/102, P– 105 • General exam: Unremarkable, RRR • NEURO EXAM: - Decreased sensation on left face - Decreased sensation on right body - Left ataxia on FNF, and unsteady gait - Voice hoarse - Nystagmus

33. Case 3

34. Case 3

35. Case 3 • Brainstem Stroke

36. 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 for the watershed pattern • Think about reasons of hypo-perfusion • Hypotension • Stenosed vessel, etc

37. Case 4 • 56 year old female who upon waking post-op after elective surgery was found to have L sided weakness and neglect • History of HTN

38. Case 4 • BP- 132/74, P– 84 • General exam: Unremarkable, RRR • NEURO EXAM: - Left face, arm, and leg weakness - Neglect - DTR’s brisk on the left, toe up on left

39. Case 4

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45. Case 4

46. Case 4 • Right hemisphere watershed infarct secondary to hypoperfusion in the setting of Right ICA stenosis • On review of anesthesia records, blood pressure dropped to 82/54 during the procedure

47. Intracranial Hemorrhages

48. Causes of ICH • Traumatic • Spontaneous • Hypertensive • Amyloid angiopathy • Aneurysmal rupture • Arteriovenous malformation rupture • Bleeding into tumor • Cocaine and amphetamine use

49. Causes of ICH

50. 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