Performance Improvement: Emergency Management in Acute Cerebrovascular Patients Current US Guidelines Lisa A. Shultz, MD Medical Director, Lourdes Stroke Center Chief, Division of Neurology

tPA Contra-indications ABSOLUTE Concurrent acute MI or current Platelets < 100,000 or INR ≥ 1.4 Major surgery within past 14 days Co-morbidity that predisposes to hemorrhage ICH on Head CT or clinical suspicion of SAH Pregnant or lactating Stroke within past 3 months Lifetime history of intracranial hemorrhage Serious head trauma within past 3 months • Known AVM or Aneurysm HTN >185/110 despite 2 PRN Rx doses RELATIVE FS glucose <50 or > 400 Seizure at onset of stroke Post-MI pericarditis GI or GU hemorrhage in past 21 days Lumbar puncture in past 7 days Arterial puncture at non-compressible site in past 7 days

HTN Rx in Ischemic CVA In setting of CVA, cerebrovascular autoregulation impaired and penumbra at highest risk for ischemia due to hypoperfusion with BP changes Non-tPA candidates: No prn Rx unless systolic>220, diastolic>120 Pre-tPA candidates: If BP>185/110, prn Hydralazine 10-20mg IV q15min or Labetalol 10mg IV q10min -Aggressive measure, ie Rx gtt, is absolute contra-indication to tPA per Brain Attack Coalition (AAN, AANS, ACEP, ASA, NINDs) Post-tPA patients: If BP>180/105, prn Hydralazine or Labetalol as above with initiation of Nicardipine gtt 5mg/h if BP remains elevated s/p 2 prn dosages or as first line Rx -American Stroke Association, 2003

HTN Rx in Hemorrhagic CVA HTN may be present as etiology of ICH, brain’s attempt to maintain cerebral perfusion pressure, sympathetic activation but can lead to hematoma expansion Immediate reduction of BP by 20% does not lead to neuro deterioration Current standard is systolic<180 within 1 hour Current trial for aggressive management of systolic<140 is ongoing but initial data indicates hematoma growth is decreased by 60% First-line Rx options: Nicardipine or Labetalol Nitroprusside leads to arterial and venous dilatation, which leads to elevated ICP - Considered last choice and should be accompanied by documentation why agent being used and acknowledgement of risks - American Stroke Association, 2007

Reversing Coagulopathy in ICH Fresh Frozen Plasma: Immediate reversal - May require repeat of 30ML/Kg at least once in 24 hour period Vitamin K - Sub-cutaneous is inferior to oral or IV and is not recommended - Oral: 24-48 hours for reversal - IV: 2-24 hours for reversal diluted 5-10 mg administered as slow infusion (no IV push) Recombinant Activated Factor VII did not reduce mortality or improve functional outcome in ICH

Posterior Fossa ICH Risks for rapid deterioration Admit sys BP > 200 Pinpoint pupils Hematoma > 30mm Extension into vermis Brainstem distortion Intraventricular blood Upward herniation Hydrocephalus GCS and NIH may not reflect early signs of deterioration – Drowsiness, slowed response time & intractable vomiting are more specific