1. Diagnosis and Management of Acute Stroke
Briana Witherspoon DNP, ACNP-BC

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. Stroke Fast Facts Affects ~ 800, 000 people per year
Leading cause of disability, cognitive impairment, and death in the United States
Accounts for 1.7% of national health expenditures.
Estimated U.S. cost for 2012 = $71.5 billion
Mostly hospital (esp. LOS) & post stroke costs
Appropriate use of IV t-PA s long-term cost
Appropriate billing for AIS w/ thrombolysis ( hospital reimbursement from $5k to $11.5k)
Stroke. 2013;44:

4. Where We’re Headed
By 2030 ~ 4% of the US population over the age of 18 is projected to have had a stroke
Between 2012 and 2030, total direct stroke-related medical costs are expected to increase from $71.55 billion to $ billion
Total annual costs of stroke are projected to increase to $ billion by 2030, an increase of 129%
Stroke. 2013;44:

5. Intracerebral Hemorrhage Subarachnoid Hemorrhage
Three Stroke Types
Ischemic
Stroke
Clot occluding
artery
85%
Intracerebral Hemorrhage
Bleeding
into brain
10%
Subarachnoid Hemorrhage
Bleeding around brain 5%

7. 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
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

8. 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 are more severe
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

9. NIHSS cont. NIHSS Interpretation Stroke Scale Stroke Severity
No Stroke
1-4
Minor Stroke
5-15
Moderate Stroke
15-20
Moderate/Severe Stroke
21-42
Severe Stroke

10. NIHSS and Outcome Prediction
NIHSS below will have an 80% good or excellent outcome
NIHSS above will have less than a 20% good or excellent outcome
Lacunar infarct patients had the best outcomes
Study done by Adams and his colleagues used the Barthel Index (BI) and the Glasgow Outcome Scale (GOS) to assess over 1200 patients’ outcomes at 7 days and 3 months.
Between 70% and 80% of patients who have suffered a lacunar stroke are functionally independent at 1 year, compared with fewer than 50% of patients who have had a nonlacunar stroke.
Adams HP Neurology 1999;53:
Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)

11. 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

12. 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

13. 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

14. Cortical Signs RIGHT BRAIN: LEFT BRAIN: - Right gaze preference
- Left gaze preference
- Neglect
- Aphasia
Cortical Signs
If present, think LARGE VESSEL stroke

15. 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
Abulia - Loss or impairment of the ability to make decisions or act independently
Anosonosia - complete unawareness or denial of a neurologic deficit.

16. 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

17. Case 1
74 year old African American female with sudden onset of left-sided weakness
She was at church when she noted left facial droop
History of HTN and atrial fibrillation
Meds: Losartan

18. Case 1
BP- 172/89, P– 104, T- 98.0, RR– 22, O2- 94%
General exam: Unremarkable except irregular rate and rhythm
NEURO EXAM:
- Speech dysarthric but language intact
- Right gaze preference
- Left facial droop
- Left- sided hemiplegia
- Neglect

19. Case 1

20. Case 1

21. Case 1

22. Case 1

23. 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

24. 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

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

26. Case 2
85 year old male who woke up with left face, arm, and leg numbness
History of HTN, DM, and tobacco use
Meds: Insulin, aspirin

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

28. Case 2

29. Case 2 Right thalamic lacunar infarct
Not a candidate for intervention (WHY?)
Discharged to rehab 72 hours after admission

30. 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

31. 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

32. 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

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

34. Case 3

35. Case 3

36. Case 3 Brainstem Stroke Received IV tPa
Post-tPa symptoms greatly improved regained sensation, ataxia resolved
Discharged home with out patient PT/OT

37. 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

38. 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
Meds - Lisinopril

39. 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

40. Case 4

41. Case 4

42. Case 4

43. Case 4

44. Case 4

45. Case 4

46. Case 4

47. 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
Patient was discharged to in-patient rehab

48. Intracranial Hemorrhages

49. Etiology of ICH Traumatic Spontaneous Hypertensive Amyloid angiopathy
Aneurysmal rupture
Arteriovenous malformation rupture
Bleeding into tumor
Cocaine and amphetamine use

50. Causes of ICH

51. 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

52. Ganglionic Bleed Contralateral hemiparesis Hemisensory loss
Homonymous hemianopia
Conjugate deviation of eyes toward the side of the bleed or downward
AMS (stupor, coma)

53. Cerebral Hemorrhage
JPG

54. 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

55. Cerebellar Hemorrhage

56. Pontine Hemorrhage Pin-point but reactive pupils Abrupt onset of coma
Decerebrate posturing or flaccidity
Ataxic breathing pattern

57. Pontine Hemorrhage

58. Subarachnoid Hemorrhage
“Worst headache of my life”
AMS
Photophobia
Nuchal rigidity
Seizures
Nausea and vomiting

59. Subarachnoid Hemorrhage

60. Management

61. 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
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.

62. Stroke Algorithm
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

63. Imaging
CT scan
MRI
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
Superior for showing underlying structural lesions
Contraindications
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.

64. Subacute (4 days) Infarction
Acute (4 hours)
Infarction
Subtle blurring of gray-white junction & sulcal effacement
Subacute (4 days) Infarction
Obvious dark changes & “mass effect” (e.g., ventricle compression) R L

65. Multimodal Imaging Multimodal CT Multimodal MRI
Typically includes non-contrast CT, perfusion CT, and CTA
Two types of perfusion CT
Whole brain perfusion CT
Dynamic perfusion CT
Standard MRI sequences ( T1 weighted, T2 weighted, and proton density) are relatively insensitive to changes in cerebral ischemia
Multimodal adds diffuse-weighted imaging (DWI) and PWI (perfusion- weighted imaging)
Both types of perfusion CT are highly sensitive and specific for detecting cerebral ischemia. There have also been studies that performed that suggest that CT perfusions may be able to differentiate between reversible and irreversible ischemia or in other words, successfully identify the pneumbra.
By adding DWI to the standard MRI sequence, clinicians are able to visualize ischemic regions of the brain within minutes of symptom onset. It actually has a high sensitivity of approximately % and high specificity of % for detecting ischemic lesions.

66. tPa Fast Facts Contraindications Tissue plasminogen activator
“clot buster”
IV tpa window 3 hours
IA tpa window 4.5 hours
Disability risk  30% despite ~5% symptomatic ICH risk
Hemorrhage
SBP > 185 or DBP > 110
Recent surgery, trauma or stroke
Coagulopathy
Seizure at onset of symptoms
NIHSS >21
Age?
Glucose < 50

67. Mechanical Thrombolysis
Often used in adjunct with tPa
MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retrieval System is a corkscrew-like apparatus designed to remove clots from vessels
PENUMBRA system aspirates the clot
MERCI
Symptomatic ICH occurred in 9.8% of patients overall, and a favorable outcome, (a modified Rankin score of 2 or less), was seen in 36% of patients at 90 days.
PENUMBRA- recanalization rate for patients treated with the Penumbra system, measured for the target vessel, was 81.6%. Symptomatic intracranial hemorrhages occurred in 11.2% of patients. A modified Rankin score of 2 or less at 90 days was seen in 25% of patients.

68. 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)
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 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.

69. In AIS, high BP is a response,
BP-AIS Relationship
Penumbra
Core
Clot in Artery
BP increase is due to arterial occlusion (i.e., an effort to perfuse penumbra)
Failure to recanalize (w/ or w/o thrombolytic therapy) results in high BP and poor neuro outcomes
Lowering BP starves penumbra, worsens outcomes
In AIS, high BP is a response,
not a cause—don’t lower it!

70. Save the Penumbra!! PENUMBRA CORE TIME (hours) CEREBRAL BLOOD FLOW CBF
(ml/100g/min)
CBF
< 8
8-18
TIME (hours) 1 2 3 20 15 10 5
PENUMBRA
CORE
Neuronal dysfunction
Neuronal death
Normal function

71. 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
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.

72. 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
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.

73. References
Adams, H., del Zappo, G., Alberts, M., Bhatt, D., Brass, L., Furlan, A., Grubb, R., &
Higashida, R. (2007). Guidelines for the early management of adults with ischemic stroke. Stroke, 38,
Bradley G Walter, Daroff B Robert, Fenichel M Gerald, Jancovic, Joseph; Neurology in clinical practice, principles of diagnosis and management. Philadelphia Elsevier, 2004.
Castillo, J., Leira, R., Garcia, M., Serena, J., Blanco, M. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004: 35:
Goals for Management of Patients With Suspected Stroke Algorithm. Accessed May 8, 2012
Gordon, D. L. (n.d.). Update in stroke management . Retrieved from
Hesselink, J. Imaging of cerebral hemorrhages and AV malformations. accessed May 10, 2012.

74. Questions?