Update on Stroke Management Cynthia Bautista, PhD, RN, CNRN Nursing Brains, LLC

Copyright Nursing 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC Nursing and Interdisciplinary care of the Acute Ischemic Stroke Patient 2009 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 mobilization Copyright 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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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% Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 counseling Copyright 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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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% Copyright Nursing Brains, LLC

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. Copyright Nursing Brains, LLC

Management of Spontaneous Intracerebral Hemorrhage 2010 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

Management of Spontaneous Intracerebral Hemorrhage in Adults (2010) Copyright Nursing Brains, LLC 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 INR elevated due to oral anticoagulants, hold warfarin, give therapy to replace vitamin K-dependent factors, correct INR, give IV Vitamin K

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 Copyright Nursing Brains, LLC

Management of Spontaneous Intracerebral Hemorrhage in Adults (2010) Copyright Nursing Brains, LLC 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

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 medication Copyright 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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

Management of Spontaneous Intracerebral Hemorrhage (2010) Copyright Nursing Brains, LLC 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

Management of Spontaneous Intracerebral Hemorrhage (2010) Copyright Nursing Brains, LLC VI. Clot Removal Class I Recommendation “Useful & Effective” Surgery ASAP for …. Cerebellar hemorrhage >3cm Deteriorating neurologically Brain stem compression Hydrocephalus

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) Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

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 Copyright Nursing Brains, LLC

Critical Care Management of Aneurysmal Subarachnoid Hemorrhage 2011 Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

Seizures and Prophylactic 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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC Glucose Management Avoid hypoglycemia (<80 mg/dL) (High) Maintain glucose <200 mg/dL (Moderate) May adjust serum glucose with use of microdialysis (Very Low) Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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)

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) Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

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) Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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) Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC High Volume Centers Treat at high volume center (Moderate) Copyright Nursing Brains, LLC

Stroke Care What people are writing about.. Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC March , 2012 Copyright Nursing Brains, LLC 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

Copyright Nursing Brains, LLC 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

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) Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC 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 Copyright Nursing Brains, LLC

Copyright Nursing Brains, LLC “Time is Brain” Copyright Nursing Brains, LLC