Stroke – Initial Management

Topic Progress:

Resus Priorities

Although these are listed here, you will obviously be doing much of this concurrently.

SUMMARY

> Remember TIME IS BRAIN. Refer immediately, activate local stroke protocol as soon as stroke suspected

> Aim oxygen sats > 94%.

> Get IV access, preferably with 18G IVC

> Treat hypertension if SBP > 185 or DBP > 110 mmHg to maintain thrombolysis eligibility> Get a good history, specifically thinking of time when “last known well” and of factors that rule in or out thrombolysis and ECR including medications.

> Exam centres around NIHSS

> Bloods (looking for thrombolysis exclusions) and imaging: CT, CTA, CTP

> Don’t miss treatable stroke mimics

> Get to a stroke centre ASAP if potentially suitable

> Keep nil by mouth

AIRWAY + BREATHING

WHY RARELY AN ISSUE?

Most patients who’ve had strokes do not require intubation.

Usually minimal oxygen is required for a target oxygen saturation > 94%

The location of the stroke is probably the most relevant factor related to the need for mechanical ventilation, rather than the particular type of cerebrovascular pathology.

In this context, impairment of the following brain areas increases the risk of respiratory failure:

> Level of consciousness:

Thalami, the limbic system, the reticular formation in the brainstem

> Breathing:

Respiratory centres in the cortex, pons, and medulla

> Swallowing:

Medulla and brainstem connections

REF

WHEN TO INTUBATE?

If it aligns with the patient’s known wishes and:

> Reduced level of consciousness with threatened airway (e.g. concomitant brain injury, shock, medications given etc)

> Respiratory depression causing hypercapnia or hypoxia

> Suspicion of aspiration pneumonitis causing hypoxia

TIPS FOR INTUBATION

> Maintain oxygenation, avoid hypotension and avoid further neuronal damage

> Do a neurological assessment including a NIHSS before giving sedation

> Use only short acting sedative / analgesic agents

CIRCULATION

> Haemodynamic instability is rare.

> Exisiting hypertension is common

> Initial BP targets are broad:

100-180 mmHg non-invasive systolic blood pressure

HISTORY

Age

Time last seen well (or time of onset if known)

Stroke symptoms

Baseline Modified Rankin Scale

– Scale of neurologic disability from 0 (completely normal) – 6 (dead)

– MRS </= 2 (i.e. independent with ADLs) are eligible for ECR

– Quick calculator here

Past medical history (specifically factors that would preclude TPA)

– Stroke, head trauma, neurosurgery in past 3 months

– History of intracranial haemorrhage

– Known intracranial AVM, aneurysm or neoplasm

– Active internal bleeding

– Suspected/ confirmed endocarditis

– Known bleeding diathesis

– Recent GIT or urinary tract haemorrhage last 21 days (relative contraindication)

– Major surgery or serious non-head trauma last 14 days (relative contraindication)

Medications

> Anticoagulation: NOACS, warfarin, aspirin, clopidogrel, time meds last taken

EXAMINATION

> Vital signs

Uncontrolled hypertension SBP >185 mmHg or DBP >110 mmHg is contraindication to TPA

> GCS

> NIHSS (see next topic)

EXCLUDE STROKE MIMICS

Click on the differentials below to see how to rule them out…

> ICH
Non-contrast CT brain excludes.

More on ICH


> Hypo / hyperglycaemia
Finger prick blood glucose.

If in doubt blood gas analysis is fast and more accurate


> Seizure

> Mainly ascertained by history describing a seizure preceding an acute weakness.

> Prodrome, ictal, postictal phases.

> Tongue biting and incontinence support diagnosis of seizure

> Classic presentation of Todd’s Paresis is weakness in one limb contralateral to the seizure activity after a focal seizure has occurred.

> Can range from a mild weakness of the limb to complete paralysis

> Can include confusion, amnesia, alteration of consciousness, aphasia, agitation, psychosis, gaze palsy, neglect, numbness, and visual field deficits depending on the particular anatomic epileptic focus

> It is essential to understand that pure focal seizures may cause this condition, but it may also be observed in focal-onset seizures that generalised.

> The key difference being that a focal-onset seizure begins with twitching in one limb (or other effects depending on the initial focus), then affecting one complete half of the body, and later appearing as a more generalized seizure pattern (Jacksonian march).

> A pure focal seizure persists in the affected area of the body and does not become generalized.

> Aphasia can be a manifestation of left temporal lobe epilepsy.

> Amnesia and confusion are more common after generalized seizures but can be a sequel from repetitive partial seizures.

> This post-ictal syndrome may last anywhere from minutes to days, with the vast majority of patients seeing spontaneous and complete resolution within 36 hours.

> The median time for complete resolution of symptoms is 15 hours.

> If the seizure was witnessed, it is essential to ask the observer if any focal activity was observed prior. While this history can be beneficial, it is often too subtle for the witness to recall. This is especially true in the first seizure episode.
REF


> Sepsis

Think of sepsis if presenting with new weakness plus:

> Fever or hypothermia, rigors

> Raised inflammatory markers

> Obvious source e.g cough, abdominal pain, dysuria, skin infection, line infection, meningism

> Respiratory rate > 20 / minute

> Heart rate > 90/minute

> Acute confusion or decreased level of consciousness

> Hyperglycemia (blood glucose > 7.7 mmol/L in patient without diabetes)

> Oliguria (urine output less than 0.5 mL/kg/hour)


> Intracranial Tumour

CT brain with contrast usually excludes.


> Complicated migraines

> Most migraines consist of just a headache

> The onset is typically slower than for an AIS

> 30% have an associated aura, which can be variable but is most commonly visual

Rare types of migraine are stroke mimics. These are

> Migraine with brainstem aura – before or with typical migraine symptoms

> Hemiplegic migraine – sometimes with sensory or visual symptoms; strong familial association

To diagnose migraine over stroke when there are symptoms and signs consistent with AIS, it is a diagnosis of exclusion 


> Drug Toxicity
Look for other signs of a toxidrome.

If there’s a focal neurological deficit then drug toxicity is a diagnosis of exclusion.


> Multiple Sclerosis
A acute flare in MS may mimic stroke.

Obviously patients with MS also have AIS.

The main difference is rapidity of symptom onset.

In AIS, this is sudden, in MS it is usually over a few days.

MRI is the most useful investigation to differentiate


> Wernicke's encephalopathy
WE should be suspected in nutritionally deficient patients:

  • Alcoholism
  • Bariatric surgery
  • Eating disorders
  • Malabsorption syndromes

The classic presentation of ophthalmoplegia, ataxia and confusion is only present in 10%

Other symptoms that could be stroke mimics include:

  • Altered mental state
  • Loss of vision
  • Dysphagia

If you have stroke symptoms in a patient at risk of WE, treat with thiamine while excluding stroke

Early investigations

BASELINE BLOODS

> Blood glucose

> Bloods:

Platelets (<100 a CI)

aPTT

INR (> 1.7 a CI)

Beta HCG (pregnancy a CI)

URGENT CT + CTA + CTP

CT Brain:

> Non contrast

> CT angiogram arch to COW

> CT Perfusion

12 LEAD ECG

> Look for arrhythmias especially atrial fibrillation

Also look for evidence of:

Ischaemia

Heart failure

QT prolongation

Heart block

Paced rhythm

MORE

Next steps

COMMUNICATE + REFER

Remember, time is brain.

Refer early before you have all the info.

> Airway status

> Last known well (LKW) time

> NIHSS

> Coagulation parameters—PT, PTT, INR

> CT—dense MCA sign, MCA dot sign, dense basilar sign, ASPECTS score if given, early ischemic changes

> CTA/MRA—large vessel occlusion (ICA, M1, M2, basilar, PCA)

> CTP—volume of core and penumbra, matched or mismatched perfusion

> Thrombolytic administration—yes (initiation, completion time); no (reason)

> Endovascular intervention (time to groin puncture, recanalization, TICI score)

> Target BP

OBTAIN MORE IV ACCESS

18G IVC in good vein

> Will need CTA and potentially thrombolysis via this

> New lines riskier post thrombolysis

KEEP NBM

Keep NBM until swallow formally assessed

> Follow local institutional guidelines

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