Critical Care Management

> Control blood pressure

> Closely monitor neuro neurology, act on deterioration fast

> Ensure correct anti-coagulation given

> Obtain appropriate imaging

> Assess swallow

> Supportive ICU care

Neurological observations must be recorded every 30 minutes for the first 6 hours post-procedure, then hourly until 24 hours post-procedure.
Neurological observations should include:

• GCS assessment and motor strength.
• NIHSS every 4 hours

Changes in neurological observations must be escalated promptly as it may represent a time-dependent emergency e.g.

In-stent thrombosis
New clot formation and vessel occlusion
Hemorrhagic transformation
Significant cerebral oedema

Signs of deterioration requiring escalation might include the following

• Reduced level of consciousness, fluctuations or a change in Glasgow Coma Score
• Pupillary changes – unequal, dilated, pinpoint or non-reactive to light
• New onset or worsening of a neurological deficit such as weakness in the face, arm or leg down one side of the body, as well as problems with swallow, speech, sensation or vision.
• A change in the NIHSS score
• Severe headache
• Nausea and vomiting
• Blood pressure out of target range

> Continuous pulse oximetry to ensure hypoxia is prevented

> Cardiac telemetry, in particular to detect thrombogenic arrhythmia such as atrial fibrillation

> Non-invasive blood pressure monitoring

THROMBOLYSIS ONLY

Non-invasive SBP 100 – 180 mmHg

Unless specific alterations e.g. BP known to be chronically low, may accept SBP 90-150 mmHg

ECR

Most patients will return to the ICU with a specific BP target (e.g. systolic NIBP 120-180 mmHg) as determined by the Interventional Neuroradiologist (refer to operation note).

This may be influenced by the following:

Core infarct size
Degree of recanalisation achieved following ECR
Whether an intra-arterial stent has been placed and flow within this
Whether symptoms have been altered by blood pressure targets
Anticoagulation/antiplatelet medication
Concurrent other cardiovascular disease
Baseline BP
Other procedural/clinical factors

In select cases, patients may require therapeutic hypertension – refer to the operation report for target thresholds.
REF

If ECR performed, arterial access is usually via femoral artery or occasionally radial.

As with any arterial access there’s the potential for bleeding, which may manifest as:

> Superficial or retroperitoneal haematoma, potentially high volume causing hypovolaemic shock

> Limb ischaemia (from emboli, dissection or excessive pressure)

AN APPROACH

> Check and record dorsalis pedis and posterior tibial pulses should be palpated, and limb assessed for capillary return every 15 minutes for the first 2 hours

> Femoral puncture site should be assessed for any haematoma or bleeding.

> Follow local protocol for femoral compression system being used.

> Immediately escalate concerns about bleeding or ischaemia

BLOOD GLUCOSE MONITORING & CONTROL

> BGL should checked on admission to ICU and every 6 hours thereafter

> BGL should be maintained 6-10 mmol/L

> Patients on metformin should have this medication withheld for 48 hours following ECR and an eGFR measured prior to recommencement

> Fever is associated with poorer outcomes after stroke.

> All stroke patients should have their temperature monitored at least four times a day for 72 hours

> Antipyretic therapy, comprising regular paracetamol or physical cooling measures should be used routinely where fever i.e. temperature > 37.5 degrees occurs

> There is no evidence for routine hypothermia in the context of acute stroke

> IV cannulation and urinary catheterization should be avoided for 24 hours; careful preservation of in-situ devices is therefore essential.

> Tooth–brushing and shaving should be avoided for the first 24 hours

> Avoid NGT insertion until 8 hours post thrombolysis

> Glucose monitoring is ideally performed from a central sample, e.g. from central line or arterial line, but these lines should not be placed after thrombolysis.

> Finger prick testing is an alternative for BGL monitoring, but extra pressure should be applied to the puncture site.

> All patients should have intermittent pneumatic compression stockings in addition to routine care (aspirin and hydration) is recommended.

> Elastic compression stockings should NOT be used in AIS.

> The benefit of prophylactic-dose subcutaneous heparin (unfractionated heparin [UFH] or LMWH) in immobile patients with AIS is not well established.

> The benefit of prophylactic-dose LMWH over prophylactic-dose UFH is uncertain
REFERENCE

> All patients should have a neuro imaging approximately 24 hours following ECR and/or rtPA.

> This is usually a CT to exclude hemorrhage but occasionally a CTA or MRI are indicated.

> Due to the significant contrast load given during the procedure, ideally patients should have a Spectral CT to allow an iodine subtraction CTB.

> The advantage of the spectral CT is the ability to differentiate iodine from haemorrhage with the spectral dual energy detector.

> Some patients may require a CT Angiogram (CTA) after discussion with the INR or Neurology teams or if specified in the operation report.

Routine stroke workup generally includes the following investigations:

> Carotid duplex ultrasound

> Echocardiography +/- bubble study

> Venous duplex

> Fasting blood glucose

> HbA1c and lipid profile

> Usually commencement or recommencement of antiplatelets/anticoagulation only occurs after review of the 24 hr CT.

> The size of the infarct and evidence of haemorrhage on neuroimaging may delay timing of anticoagulation.

> If the patient has had an intra/extracranial stent placed or has undergone angioplasty, earlier antiplatelet/anticoagulation therapy may be required; refer to operation report for specific instructions.

> Heparin infusions are used infrequently following ECR for acute stroke, especially if intra-arterial stents have been used.

DYSPHAGIA & NUTRITION ASSESSMENT

> All stroke patients are to be kept ‘Nil By Mouth’ (NBM) until swallow assessment performed

> If patient fails the assessment, they should be kept NBM until Speech Pathology review

> An NGT may be inserted 8 hours following administration of rt-PA, although it may be more appropriate to wait until 24 hours in the absence of significant underlying nutritional risk or essential oral medications (e.g. Parkinson’s disease medications), particularly where NGT insertion is anticipated to be difficult

NEUROLOGICAL DETERIORATION

> Any deterioration in neurological function should be urgently discussed with the treating team (process outlined below).

Urgent priorities may include:

> Protecting the patient’s airway with consideration of the need to intubate the patient, while supporting BP and oxygenation
> Urgent neuro-imaging
> Management of specific causes of deterioration as outlined below

INTRACRANIAL HAEMORRHAGE MANAGEMENT

> Patients who show evidence of haemorrhage following rtPA warrant consideration of rtPA reversal in select cases.

Thrombolysis is not easily reversed but guidelines suggest:

> Cryoprecipitate as soon as possible after detection of sICH with empirically transfusing with 10 U cryoprecipitate and anticipate giving more cryoprecipitate as needed to achieve a fibrinogen level of ≥ 150 mg/dL

> Platelet transfusion is NOT routinely recommended except in those with thrombocytopenia (platelet count < 100 000/μL)

> Use of 4-factor PCC/ prothrombin complex concentrate is recommended in patients on warfarin treatment before getting tPA (those with a sub therapeutic INR who qualified for IV thrombolysis). PCC is the preferred modality, but if unavailable, fresh frozen plasma may be used.

> Adjunctive therapy with vitamin K should also only be reserved for this subgroup that was on warfarin before receiving alteplase.

> Antifibrinolytics have limited data but should be considered in patients with sICH, particularly in patients who decline blood products.

> Use of activated factor VIIa is not recommended (lack of safety data)

Patients should have BP parameters reviewed and discussion with the neurosurgical team if appropriate.

CEREBRAL OEDEMA

> Monitor for signs of elevated ICP

> Consider osmotherapy or hyperventilation as a temporizing measure in cerebral oedema

> Patients may be considered for decompressive craniectomy if eligible

> Steroids and barbiturates are not indicated in context of cerebral oedema in acute stroke

SEIZURE MANAGEMENT

> Seizure prophylaxis is not indicated for primary prevention of seizures following acute stroke.

> Patient should be considered for anti-epileptic treatment if evidence of seizures.

> If seizures occur, consider Levetiracetam 500 mg BD in patients with no evidence of renal dysfunction.

FEMORAL ACCESS COMPLICATION MANAGEMENT

> Patients should be monitored for evidence of femoral artery injury.

> Decrease in pulses or perfusion should prompt further investigation for femoral dissection, thrombosis or peripheral emboli.

> Any evidence of hypovolemia, anaemia, back pain or enlarging haematoma should prompt investigation for retroperitoneal haemorrhage, femoral pseudoaneurysm or ongoing bleeding from puncture site.

> Complications related to femoral artery access should be escalated to the INR team.

> Urgent manual haemostasis may be required while awaiting surgical review. Digital compression of artery is preferred over use of a femoral compression device.

> Further investigation may include a triple phase CT of abdomen if retroperitoneal haematoma is suspected or US duplex of the femoral artery if dissection or pseudoaneurysm is suspected

> Retroperitoneal bleeding may require angio-embolisation in a minority of cases, especially if there is active bleeding seen on a CT angiogram.