Ischemic Stroke

LITERATURE

  • Score with NIH Stroke Scale
  • Image with CT Head (non-contrast), unless there is indication for MRI
  • Labs, glucose before lytic, otherwise:
    • CBC, CMP, Coags, Troponin, EKG, CXR
  • TNK?!? 0.25 mg/kg
  • tPA!?! 0.9mg/kg IV, first 10% bolus in 1 minute and remaining dose over 60 mins.

General Management Considerations:

  • Intubate based on clinical status with consideration of various scales (GCS, HH, ICH, etc)
  • q1h neuro checks
  • keep head of bed 30°
  • Goal euglycemia (140-180)
  • Goal normothermia
  • Goal Na 135-145 and higher if cerebral edema is a concern.

Indications for Lytics (Inclusion Criteria)

  • Clinical Diagnosis of Ischemic stroke causing a measurable neurological deficit.
  • Typically viewed to be a National Institute of Health Stroke Scale (NIHSS) ≥4 although any disabling deficit should be considered
  • Within 4.5 hours from symptom onset.

Contraindications to Alteplase (Exclusion Criteria)

Absolute contraindications:

  • Evidence of intracranial hemorrhage on CT scan
  • Suspicion of subarachnoid hemorrhage based on clinical presentation
  • History of intracranial hemorrhage
  • Uncontrolled hypertension at the time of treatment (SBP>185, DPB>110) Note; IV antihypertensives agents may be used to lower blood pressure to an acceptable level prior to lytic infusion.
  • Blood glucose concentration < 50 mg/dL and >400 mg/dL. Note an attempt should be made to correct the blood glucose and the patient should be reassessed for ongoing neurological deficits. If the glucose is corrected and the disabling neurological symptoms persist, lytic should be considered.
  • Any active bleeding
  • Any intracranial/intraspinal surgery, serious head trauma or previous stroke with in the past 3 months.
  • History of intracranial neoplasm, arteriovenous malformation or aneurysm
  • Acute bleeding diathesis, including but not limited to:
  • Current use of oral anticoagulants with PT.> 15 sec or INR >1.7
  • Patients taking direct thrombin inhibitors and direct Factor Xa inhibitors.
  • Administration of heparin within 48 hours and an elevated PTT at presentation greater than upper limits of normal.
  • Platelet count <100,000/mm3 (Patients transfused platelets can be reconsidered)
  • Arterial puncture at a noncompressible site in previous 7 days
  • CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
  • Use of low molecular weight heparin within the past 12 hours
  • Infective endocarditis

Relative Contraindications: risk of intracranial (Use caution) hemorrhage may be increased in the conditions listed below: In these situations, anticipated benefits should be weighed against the potential risk.

  • Patients with minor (non-disabling) or rapidly improving stroke symptoms,
  • Pregnancy,
  • Seizure at symptom onset,
  • Lumbar puncture within 48 hours,
  • Patients with a INR between 1.4.- 1.7
  • Patients with recent myocardial infarction within 3 months,
  • Major surgery or serious trauma within 14 days
  • Recent gastrointestinal or urinary tract hemorrhage within 21 days
  • Arterial puncture at a noncompressible site in previous 7 days
  • Age > 80
  • NIHSS greater than 25

Endovascular treatment of Ischemic Stroke!?! Consider if NIHSS and ASCPECTS are > 6.

  • All patients eligible for lytics should receive lytics, even if being considered for endovascular treatment
  • Endovascular treatments (esp. with stent retriever) may be effective in patients presenting within 6-24 hours of symptoms.
  • ICA or proximal M1 occulsions

Blood Pressure in Ischemic Stroke

  • Hypertension common in ischemic stroke – attempted mechanism to perfuse ischemic areas
  • BP goals dependent of whether tPA is administered or not, and co-morbid conditions present
  • if lytics are contraindicated
    • permissive HTN < 220/120 for initial 24 hours unless evidence of other hypertensive emergency
    • if elevated above 220/120 – lower BP by 15% during 1st 24 hours
  • if administering lytics
    • BP must be < 185/110  before administration and must be maintained < 180/105 for initial 24 hours POST administration to decrease risk of ICH BP q15min x 2hrs; then q30min x 6hrs; then q1hr x 16hrs
  • Choice of Anti-HTN for lytic candidates
    • Labetolol 10-20mg IV over 1-2 min or Nicardipine 5mg/h IV (titrate up 2.5mg/h every 5-15 min to max of 16mg/h)
    • Others may include hydralazine, enalaprilat, esmolol, nitroprusside etc
  • Other Management
    • Antiplatelet ► Aspirin within 48 hours of stroke + Statin (after assurance of no hemorrhagic conversion)
    • Further imaging considerations: CT/MRI/MRA with contrast, TTE, Carotid Dopplers, EEG
    • Patients are at risk for cerebral edema (see treatment of cerebral edema and increased ICP)

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