Stroke

Initial Assessment

  • ABC’s
  • VS (BP) and Glucose
  • Rapid exam and NIHSS
  • Initial history and time of onset
  • Access and lab draw (including troponin, coags)
  • Consider taking antihypertensives to CT
  • CT Stroke Series

Additional Workup

  • EKG
  • CXR

DDx and Mimics

  • Dissection, seizure, space occupying lesion/tumor, glucose, sodium, calcium, Bell’s Palsy, Guillain Barre, MS, Wernicke’s, spinal cord lesions, conversion DO, AMS (GOTIMES) etc.

Hemorrhagic

Types

  • Hypertensive – Deep ICH: Basal ganglia, thalamus, cerebellum, pons
  • SAH – Aneurysmal
  • Amyloid angiopathy – Lobar ICH
  • Venous infarct
  • Hemorrhagic conversion of ischemic stroke
  • Occult trauma – SDH, EDH etc.

Workup

  • Probably should just shoot CTA every time
  • Labs including Coags

Management

  • Neuro exam
  • Airway if needed
  • Elevate HOB
  • NPO
  • Reverse coagulopathy
  • BP Control
    • Goal SBP usually < 140-180 depending on center
  • Consider seizure ppx if cortical involvement (e.g. SAH)
  • Neurosurgery consultation
    • SAH – early clipping vs coiling
    • ICH – EVD if GCS < 9, herniation, intraventricular extension w/ obstructive hydrocephalus
    • Cerebellar hemorrhage – Emergent decompression

No Plt Transfusions if on ASA (maybe clopidogrel too)

Increases death and disability vs standard management alone for those on anti-platelet drugs. A weakness of study was that most pts were on ASA alone, very few on clopidogrel. (PATCH Trial, Baharoglu et al. Lancet, 2016).

Ischemic

Thrombolysis contraindications

TPA Dosing – 0.9 mg/kg to max of 90 mg. First 10% as bolus over 1 min and the remainder over 60 min

TNK Dosing – Bolus 0.25 mg/kg to max of 25 mg

Post thrombolysis bleeding: