Stroke

sx and focal neurologic deficits that occur d/t abrupt disruption of the vascular supply to an area of the brain that lasts for >24h

sx and focal neurologic deficits that occur d/t abrupt disruption of the vascular supply to an area of the brain that lasts for <24h (usually <30min)

• HTN
• DM
• smoking

• d/t clotting
• clot blocks blood supply to brain

• atherosclerotic
• penetrating artery disease (Lacunar)
• cardiogenic embolisms
• unknown (cryptogenic)
• Other (migraine, vasospasm, arteritis, etc)

• one-sided numbness, weakness, or paralysis of face, arm, or leg
• difficultyy speaking (dysarthria) or understanding simple statements (aphasia) or confusion
• sudden blurred or decreased vision
• loss of balance or coordination/vertigo, trouble walking, or dizziness
• not usually painful, but may have a HA
• visual field defects
• altered level of consciousness

• IV fluids (no D5W)
• bolus 50% dextrose if hypoglycemic
• insulin if blood sugar >300
• thiamin 100mg if malnourished or alcoholic
• APAP if febrile

• thrombolytics (tPA):
• no hemorrhage
• < 3h from onset
• after 48h, start ASA
• ASA:
• no hemorrhage
• > 3h from onset

• DVT prophylaxis
• cardioembolic stroke:
• if CT scan shows no hemorrhage
• delay 24-48h (7-10d if large stroke)
• do not give bolus doses

• ischemic stroke causing measurable neurological deficit (NIH stroke score of 4-22)
• < 3h before tx

• intracranial hemorrhage on CT scan/MRI
• sx suggest subarachnoid hemorrhage
• large stroke (>¹/₃ hemisphere)
• rapidly improving stroke sx
• arterial puncture at a noncompressible site in last 7d
• major surgery or trauma within 14d
• GI or GU bleeding within 21d
• intracranial surgery, head trauma, MI, or stroke < 3mo ago
• previous intracranial hemorrhage
• platelets < 100,000 per mm³
• blood glucose < 50 or > 400 mg/dL
• BP > 185/110 mmHg despite tx
• recent anticoagulant use and elevated aPTT or INR (> 1.7)
• witnessed seizure at stroke onset

• NO prophylactic anticonvulsants in seize-naive pts
• strongly recommend anticonvulsants to prevent recurrence once seizures have been experienced

• intubation/hyperventilation
• mannitol (osmotic diuresis)

• triple H thrapy (HTN, hemodilution, hypervolemia) - NE or DA and IV fluids: maintains perfusion
• avoids hypotension and vasospasm
• reduces blood viscosity
• HTN may be desirable for 7-14d
• antihypertensives (nicardipine, labetalol, esmolol are DOC):
• this is to provide control without cerebral vasodilation to avoid elevating ICP
• Nimodipine:
• DHP CCB
• only available orallyl
• q 4h for 21d

• stop anticoag
• give vit K
• replace clotting factors (FFP or PCCs)
• Mannitol (if high ICP)
• NO steroids
• hyperventilation (failure to respond = bad prognosis)
• BP tx (compare to pre-bleed BP)
• no antiepileptics until seizure occurs

• ASA
• clopidogrel (better than ASA if cost not a factor)
• aggrenox (ER dipyridamole + ASA)
• Warfarin (DOC for cardioembolic stroke (a-fib))
• Dabigatran

DO NOT combine ASA and clopidogrel

• < 65yo:
• ASA
• 65-75yo:
• ASA or warfarin (no risk factors)
• warfarin (at least 1 risk factors)
• > 75yo:
• warfarin

• prior TIA, embolus, or stroke
• HTN
• L ventricular dysfunction
• Diabetes
• CAD

• If warfarin CI, give ASA
• possibly add clopidogrel to ASA
• dabigatran
• rivaroxiban

• recognize and treat risk factors in pts
• appropriate selection of drug tx
• pt/caregiver education
• development of protocols for acute stroke