update on stroke management cynthia bautista, phd, rn, cnrn nursing brains, llc
TRANSCRIPT
Update on Stroke Management
Cynthia Bautista, PhD, RN, CNRNNursing Brains, LLC
Clinical Guidelines
• Overview of the current evidence about the evaluation and treatment of adults with Ischemic Stroke, Hemorrhagic Stroke, or Aneurysmal Subarachnoid Hemorrhage.
• American Stroke Association
• Neurocritical Care Society
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Nursing and Interdisciplinary care of
the Acute Ischemic Stroke
Patient2009
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
I. Stroke Patient Triage and Care• Class I Recommendations “Should be performed”
• ED should establish procedure/protocol to expeditiously triage stroke patient
• Protocol to evaluate/treat eligible stroke patient with rtPA• Treatment with rtPA should be within 1 hour of arrival to ED• Treat eligible rtPA patients between 3 – 4.5 hour window
• NIHSS < 25, < 80 years old, no DM, no previous stroke, not on coumadin
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
II. Emergency Nursing Interventions/Hyperacute Phase• Class I Recommendations “Should be performed”
• ED personnel highly trained in stroke care• Frequent stroke assessments, more frequently with rtPA• Supplemental oxygen with oxygen saturation < 92%• Head in neutral alignment and HOB 25° – 30°• NPO until swallow assessed• At least 2 IV sites• Use nondextrose, normotonic IV fluids (normal saline) • Give IV rtPA without delay Copyright Nursing Brains, LLC
Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
II. Emergency Nursing Interventions/Hyperacute Phase• Class I Recommendations “Should be performed”• Medical Recommendations
• CT/MRI performed emergently• Rapid laboratory tests (CBC, chemistry, coagulation)• IA thrombolysis with large MCA clot presenting within 6° or
contraindications to IV thrombolysis• Interventional treatment in comprehensive stroke center• When IA rtPA is considered, give IV rtPA is eligible
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
II. Emergency Nursing Interventions/Hyperacute Phase• Class IIa Recommendations “Reasonable to perform”• Medical Recommendations
• Use of Merci Retriever and Penumbra System • Use of IA thrombolysis
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
III. Acute Phase• Class I Recommendations “Should be performed”
• Neurological assessments every 4 hours• Treat temperatures > 99.6°• Continuous cardiac monitoring for at least 24°- 48°• Monitor neurological deficits/bleeding for up to 24° after tPA• Treat hyperglycemia (>140mg/dL)
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
III. Acute Phase (con’t)• Class I Recommendations “Should be performed”
• Cautiously treat hypertension • Monitor oxygen saturation• Auscultate lungs, assess for respiratory compromise• Assess for dysphagia• Immediately treat seizure activity (no prophylactic treatment)
• Class IIa Recommendations “Reasonable to perform”• Preprinted order sets/protocols to organize stroke care
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
IV. Diagnostic Testing• Class I Recommendations “Should be performed”
• Nurses should be familiar with basic neuroimaging testing so they can educate patient/family
• CT, MRI, MRA, CTA, Angiography, Carotid Ultrasound, TTE, TEE
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
V. General Supportive Care• Class I Recommendations “Should be performed”
• Infections should be identified and treated immediately with antibiotics
• Institute early bowel/bladder care – prevent constipation, urinary retention/infection
• Early implementation of anticoagulant therapy/physical compression modalities – unable to ambulate at 2 days/risk for DVT/PE
• Early mobilizationCopyright Nursing Brains, LLC
Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
V. General Supportive Care (con’t)• Class I Recommendations “Should be performed”
• Initiate fall precautions• Prevent skin breakdown provide frequent turning if
bedridden• Use Braden Scale in prediction of pressure ulcer
development• Provide ROM in early phase of
acute stroke care
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
V. General Supportive Care (con’t)• Class I Recommendations “Should be performed”
• Keep patient NPO until swallow screen performed• Perform swallow screen in first 24 hours after stroke
preferably by speech language pathologist• Nurse to be familiar with bedside swallow assessment if
formal evaluation cannot be done within 24 hours• NG tube placed if patient cannot swallow, consider PEG if
warranted
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
V. General Supportive Care (con’t)• Class IIa Recommendations “Reasonable to perform”
• Provide excellent pericare if indwelling catheter is required (prevent infection)
• Provide feedings by IV, NG, or PEG
• Class IIb Recommendations “May be considered”• Provide ROM between PT visits
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Hypertension• Provide antihypertensive treatment• Individualize target BP level
• Average reduction of < 10/5 mmHg• Provide lifestyle modifications (diet & exercise)• Use diuretics and ACEI
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Diabetes• More rigorous control of BP and lipids• Use ACEI and ARBS• Provide near-normoglycemic levels• A1c ≤ 7%
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Cholesterol• Provide lifestyle modification, dietary guidelines and
medication• Statin agents are recommended• LDL-C of < 100 mg/dL• LDL-C of < 70mg/dL for high risk patient• Consider statin for no preexisting indications• Provide niacin or gemfibrozil(Lopid) for LOW HDL-C
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Smoking• Strongly encourage not to smoke • Avoid environmental smoke• Consider counseling, nicotine products, and oral
smoking cessation medications
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Alcohol• Eliminate or reduce consumption of alcohol• Men – light to moderate levels of ≤ 2 drinks per day • Women – light to moderate levels of 1 drink per day
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Obesity• Consider weight reduction • Goal BMI of 18.5 to 24.9 kg/m2
• Waist circumference of < 35 inches women• Waist circumference of < 40 for men• Encourage weight management
• Caloric intake, physical activity, behavioral counselingCopyright Nursing Brains, LLC
Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Secondary Stroke Prevention – Physical Activity• Most days• At least 30 minutes • Moderate-intensity physical exercise• Patient with disability, recommend supervised
therapeutic exercise regimen
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Stroke and Carotid Disease• Recommend Carotid Endarterectomy
• TIA/stroke within past 6 months• Ipsilateral severe (70-99%) stenosis• Surgeon with perioperative morbidity/mortality of < 6%
• Recent TIA/stroke• Ipsilateral moderate (50-69%) stenosis• Within 2 weeks
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Stroke and Carotid Disease• Recommend Carotid Artery Stent
• Symptomatic• Severe stenosis (>70%)• Difficult surgical candidate• Surgeon with perioperative morbidity/mortality of 4-6%
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Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)
Stroke and Atrial Fibrillation• Provide anticoagulation with adjusted-dose warfarin
• Target INR 2.5• Range 2-3
• Unable to take oral anticoagulants use aspirin 325mg/d
• May, 2009 NEJM (ACTIVE Trial)• Treatment with clopidogrel (75mg) plus aspirin(75-100mg)
reduced the rate of vascular events among patients with atrial fibrillation. There was significant increase in risk of major hemorrhage.
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Management of Spontaneous Intracerebral
Hemorrhage 2010
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
I. Emergency Diagnosis & Assessment of ICH• Class I Recommendation “Useful & Effective”
• Rapid neuroimaging with CT or MRI
• Class IIa Recommendation “In favor of”• CTA, CTV, CT with contrast, MRI, MRA, MRV
• Class IIb Recommendation “Less well established”• CT angiography & contrast-enhanced CT
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
II. Medical Treatment for ICH• Class I Recommendation “Useful & Effective”
• Provide appropriate factor replacement therapy or platelets for severe coagulation factor deficiency or severe thrombocytopenia
• Class I Recommendation “Useful & Effective”• INR elevated due to oral anticoagulants, hold warfarin,
give therapy to replace vitamin K-dependent factors, correct INR, give IV Vitamin K
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
II. Medical Treatment for ICH (con’t)• Class IIa Recommendation “In favor of”
• Consider giving Prothrombin Complex Concentrate (PCC)
• Class III Recommendation “Not Useful Effect”• rFVIIa is not routinely recommended
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
II. Medical Treatment for ICH (con’t)• Class I Recommendation “Useful & Effective
• Provide intermittent pneumatic compression prevent DVT
• Class IIb Recommendation “Less well established”• After cessation of bleeding, give low-dose sc LMWH or
UFH with lack of mobility after 1 to 4 days from onset
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
III. Blood Pressure• Class IIa Recommendation “In favor of”
• SBP 150 – 220 lower SBP to 140• Class IIb Recommendation “Less well established”
• SBP > 200 or MAP > 150 give IV infusion• SBP > 180 or MAP > 130 ↑ICP monitor ICP,
give intermittent or continuous IV medication• SBP > 180 or MAP > 130 maintain BP 160/90 or
MAP 110 with intermittent or continuous IV medicationCopyright Nursing Brains, LLC
Management of Spontaneous Intracerebral Hemorrhage (2010)
IV. Inpatient Management • Class I Recommendation “Useful & Effective”
• ICU care
• Treat fever to maintain normothermia• Monitor glucose, maintain normoglycemia
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Management of Spontaneous Intracerebral Hemorrhage (2010)
IV. Inpatient Management (con’t)• Class I Recommendation “Useful & Effective”
• Treat clinical seizures with antiepileptic drugs
• Class IIa Recommendation “In favor of”• Continuous EEG monitoring with decreased LOC
• Class III Recommendation “Not Useful”• Prophylactic anticonvulsant medication
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Management of Spontaneous Intracerebral Hemorrhage (2010)
V. Procedures• Class IIb Recommendation “Less well established”• ICP monitoring for
• GCS ≤ 8• Herniation• IVH• Hydrocephalus
• Maintain CPP 50 to 70
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Management of Spontaneous Intracerebral Hemorrhage (2010)
V. Procedures (con’t)• Class IIa Recommendation “In favor of”
• Treat hydrocephalus with ventricular drain with ↓LOC
• Class IIb Recommendation “Less well established”• Administration of intraventricular rtPA for IVH is
considered investigational
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Management of Spontaneous Intracerebral Hemorrhage (2010)
VI. Clot Removal • Class I Recommendation “Useful & Effective”
• Surgery ASAP for ….• Cerebellar hemorrhage >3cm • Deteriorating neurologically• Brain stem compression• Hydrocephalus
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Management of Spontaneous Intracerebral Hemorrhage (2010)
VI. Clot Removal (con’t)• Class IIb Recommendation “Less well established”
• Usefulness of surgery is uncertain• Lobar clot > 30mL and within 1cm of surface• Use of minimally invasive technique
• Class III Recommendation “Not Useful”• Very early craniotomy (increase risk of rebleed)
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
VII. Withdrawal of Technological Support• Class IIa Recommendations “In favor of”
• Aggressive full care until at least the second full day of hospitalization
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
VIII. Prevention of Recurrent ICH• Class I Recommendations “Should be performed”
• Treat hypertension • Discontinue
• Smoking• Heavy alcohol use• Cocaine use
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Management of Spontaneous Intracerebral Hemorrhage in
Adults (2010)
VIII. Prevention of Recurrent ICH (con’t)• Class IIa Recommendations “In favor of”• Risk factors for ICH recurrence
• Lobar location• Older age• Ongoing anticoagulation• Greater number of microbleeds on MRI
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Critical Care Management of Aneurysmal
Subarachnoid Hemorrhage2011
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2011 Neurocritical Care Society Recommendations
for aSAH
• Classification of Recommendations• High– “Further research unlikely to change effect”
• Moderate– “Further research is likely to change effect”
• Low – “Further research is very likely to change effect”
• Very Low – “Very uncertain of effect”Copyright Nursing Brains, LLC
Medical Measures to Prevent Rebleed
• Early aneurysm repair (High)
• Early short course of antifibrinolytic – Amicar prior to aneurysm repair (Low)
• Avoid antifibrinolytic therapy > 48 post ictus or > 3 days, concern with side effects (High)
• Screen for DVT while on Amicar (Moderate)• Discontinue Amicar 2 hours prior to treatment (Very
Low)Copyright Nursing Brains, LLC
Medical Measures to Prevent Rebleed
(con’t)
• Treat extreme hypertension in unsecured (Low)
• Do not treat modest hypertension (MAP <110) (Low)
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Seizures andProphylactic Anticonvulsant
Use
• Do not use phenytoin for prophylaxis(Low)• Consider other anticonvulsants for prophylaxis
(Very Low)• Short course (3-7days) AED prophylaxis (Low)• Give anticonvulsant with seizure presentation (Low)• Consider continuous EEG (Low)
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Cardiopulmonary Complications
• Obtain baseline cardiac assessment (Strong)• Monitor CO may be useful (Low)• Treat pulmonary edema by maintaining euvolemia
(Moderate)• Treat heart failure while maintaining CPP/MAP for
cerebral perfusion (Moderate)
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Monitoring Intravascular Volume
• Monitor volume status (Moderate)• No specific modality is recommended• Use clinical assessment
• Vigilant fluid balance management (Moderate)• Do not place central venous lines solely for
measurement (Moderate)• Routine use of PACs is not recommended (Moderate)
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Managing Intravascular Volume
• Target euvolemia (High)• Avoid hypervolemia (High)• Use isotonic crystalloid for replacement (Moderate)• Consider fludrocortisone or hydrocortisone for
persistent negative fluid balance (Moderate)
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Glucose Management
• Avoid hypoglycemia (<80 mg/dL) (High)• Maintain glucose <200 mg/dL (Moderate)• May adjust serum glucose with use of microdialysis
(Very Low)
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Management of Pyrexia• Frequent temperature monitoring (High)• Seek and treat infectious fever (High)• Control fever during risk for delayed cerebral ischemia
(Low)• Use acetaminophen, ibuprofen as first line agents
(Moderate)• Surface/intravascular cooling when antipyretics fail (High)• Monitor & treat shivering with cooling (High)
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Deep Vein Thrombosis Prophylaxis
• Provide DVT prophylaxis (High)• Use SCDs routinely (High)• Withhold prophylaxis LMWH or UFH in untreated
patients (Low)• Start UFH 24 hours after surgery (Moderate)• Withhold LMWH or UFH 24 hours before and after
intracranial procedures (Moderate)• Duration of DVT prophylaxis is uncertain (Low)
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Statins and Magnesium
Continue statin if previously on it (Low)Consider statin for statin-naïve patient (Moderate)
Do not induce hypermagnesemia (Moderate)Avoid hypomagnesemia (Moderate)
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Monitoring for DCI and Triggers for Interventions
Monitor for delayed cerebral ischemia (DCI) in environment with expertise in SAH (Moderate)
Give Nimodipine 60mg every 4 hours x21 days (High)Detect DCI with TCD, DSA, CTA, EEG, PbtO2
(Moderate)
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Hemodynamic Management of DCI
Maintain euvolemia (Moderate)Consider saline bolus to increase CBF (Moderate)Trial induced hypertension with DCI (Moderate)Choose vasopressor based of effects (Moderate)Augment BP based on MAP in stepwise fashion
(Poor)Change dose of nimodipine if hypotension occurs –
discontinue with persistent hypotension (Poor)Copyright Nursing Brains, LLC
Hemodynamic Management of DCI (con’t)
Consider inotropic (Dobutamine) (Low)May need to augment with vasopressor (High)
IABP maybe useful (Low)
Do not provide hemodilution (Moderate)
Caution with increasing BP in unsecured (Low)Unruptured should not influence management
(Moderate) Copyright Nursing Brains, LLC
Endovascular Management of DCI
• Consider IA vasodilators and/or angioplasty (Moderate)• Timing of endovascular treatment is unclear (Moderate)• Do not provide prophylactic angioplasty (High)
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Anemia and Transfusion
• Minimize blood loss from blood draws (Low)
• Give PRBC maintain hemoglobin 8-10g/dl (Moderate)
• Higher hemoglobin may be appropriate for patient at risk for DCI – uncertain if transfusion is useful (No Evidence)
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Management of Hyponatremia
• Do not fluid restrict (Weak) • Early treatment with hydrocortisone or fludrocortisone
(Moderate)• Mild hypertonic saline (Very Low)• Avoid hypovolemia if using vasopressin-receptor
antagonists (Weak)• Limit free water intake (Very Low)
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Endocrine Function
• Consider hypothalamic dysfunction when not responding to vasopressor (Moderate)
• Do not give high dose corticosteroids (High)• Consider mineralocorticoids (Moderate)• Consider • Stress-dose corticosteroids with vasospasm and
no response to induced hypertension (Weak)
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High Volume Centers
• Treat at high volume center (Moderate)
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Stroke Care What people are writing about..
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January, 2012
• Statin Use during Ischemic Stroke Hospitalization is Strongly Associated with Improved Poststroke Survival
• Flint, A. et al Stroke, 43(1) 147-154
• Statin use early in stroke hospitalization is strongly associated with improved poststroke survival, and statin withdrawal in the hospital is associated with worsened survival
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February, 2012
• Female Caregivers of Stroke Survivors: Coping & Adapting to a Life that Once Was
• Saban, K and Hogan, N. Journal of Neuroscience Nursing, 44(1), 1-14
• Describe experience of female caregiver (N = 46)• Losing the life that once was• Coping with daily burdens• Creating a new normal• Interacting with healthcare providers
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March, 2012• Delirium in Acute Stroke• Shi, Q. et al Stroke, 53(3), 645-649• Systematic Review and Meta-Analysis (10 studies) • Stroke patients with development of delirium have
unfavorable outcomes (high mortality, longer hospitalization, greater degree of dependence)
• Prevention and early recognition of delirium may improve stroke outcomes
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March, 2012• Lumbar Drainage of CSF after Aneurysmal
Subarachnoid Hemorrhage (LUMAS)• Al-Tamimi, Y. et al Stroke, 43(3), 677-682• N = 210• Lumbar drainage of CSF showed to
• Reduce prevalence of delayed ischemic neurological deficit• Improve early clinical outcome • Failed to improve outcome at 6 months
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March , 2012• Predicting the Lack of Development of Delayed
Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage
• Crobeddu, E. et al Stroke, 43(3), 697-701• N=307• Patients who will not develop DCI
• Age ≥ 68• WFNS I – III• Modified Fisher Grade 1 – 2
• Consider these patient for early transfer to the floor
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April, 2012• Trends in the Hospitalization of Ischemic Stroke
in the US, 2007• Lee, L. et al International Journal of Stroke, 7(4), 195-201
• Decreased rate of ischemic stroke hospitalization
• Increased rate among young adults
• Decreased mortality Copyright Nursing Brains, LLC
April, 2012• Alcohol Consumption & Risk of Stroke in Women• Jimenez, M. et al Stroke, 43(4), 939-945
• Light to moderate alcohol consumption was associated with lower risk of total stroke.
• .83 relative risk for 5 – 14g/d (1/2 to 1 glass)
• .79 relative risk for 15 – 29.9g/d (1 to 2 glasses)
• 1.06 relative risk for 30 – 45g/d (2 to 3 glasses)
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April, 2012
• Impact of Emergency Department Transitions of Care on Thrombolytic Use in Acute ischemic Stroke
• Madej-Fermo, O. et al Stroke, 43(4), 1067-1074• Stroke presentation during change of shift did NOT
delay rt-PA use • Presentation at night did result in delay of care
undergoing interventional therapy
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May, 2012• Correlation between ED Symptoms and Clinical
Outcomes in the Patient with Aneurysmal SAH• Adkins, K. et al. Journal of Emergency Nursing,
38(3), 226-33• Poor clinical grade (H&H >3) and bradycardia significant
predictor of death at 30 days
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May, 2012• Frontal Infarcts and Anxiety in Stroke• Tang, W. et al Stroke, 43(5), 1426-428
• Association between posttroke anxiety symptoms and frontal lobe infarcts
• N= 693• Poststroke anxiety patients were more likely to have
RIGHT frontal acute infarcts
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June, 2012
• Wakeup or unclear-onset strokes: are they waking up to the world of thrombolysis therapy?
• Kang, D. et al International Journal of Stroke, 7(4), 311-320
• 25% of strokes occur as wakeup or unclear onset• Many do not receive rt-PA• Actual onset time of wake-up stroke is close to the wake-
up time• Advanced imaging can identify favorable patient
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“Time is Brain”
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