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

2. 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

3. 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

4. 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

5. 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: 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

6. 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