kraus acute stroke.ppt

Management of acute stroke

Eric Kraus, MD

Neurology

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia.

PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.

Medications: ASA 81mg, Lisinopril 20mg, Pravastatin 40mg, saw palmetto.

PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.

What do you want to do first?

Initial work-up

Document time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head CT Labs

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

t-PA: Inclusion

Age 18-80 Ischemic stroke NIHSS > 4 Onset < 3 hours ASA use okay

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

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

NINDS group. NEJM 1995;333:1581

CT Angiogram

Contraindications» Contrast allergy» Cr > 1.5

Alternatives» MRA» Limited catheter

angiogram

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

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Ischemic changes A-fib

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Normal

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Lacune

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Lacune

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Cortical - small

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Cortical - large

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Hypoperfusion

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Dense MCA sign

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Hemorrhage

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

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

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

HTN

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Amyloid angiopathy

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

AVM

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Cavernous malformation

Initial work-up

Time of onset» Consider t-PA

NIHSS (stroke scale) EKG Noncontrast head

CT Labs

Subarachnoid hemorrhage

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

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia.

PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.

Medications: ASA 81mg, Lisinopril 20mg, Pravastatin 40mg, saw palmetto.

PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.

Other acute management issues to consider?

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

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

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

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia. Onset 10 hours ago.

PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.

Medications: Lisinopril 20mg, Pravastatin 40mg, saw palmetto.

PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.

What treatment should be given?

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

*Coull et al. Neurology 2002;59:13

Case

This 62 yo male presents to the ER with acute right hemiparesis and aphasia. Onset 5 hours ago.

PMH: CABG 3 years ago, HTN, hyperlipidemia, and BPH.

Medications: Lisinopril 20mg, Pravastatin 40mg, saw palmetto.

PE: 182/94, 86 regular, AF. 2/5 right hemiparesis with nonfluent aphasia.

EKG shows A-fib.

What treatment should be given?

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

Question

An 82 y.o. man presents with acute left facial weakness. A head CT scan is unremarkable so you order an MRI.

What MRI sequence is best for acute stroke?

A. DiffusionB. FlairC. T1D. T2E. Gradient echo

What’s acute

Flair

Diffusion

END