Stroke Emergency

STROKE
Introduction
second leading cause of death worldwide
world health organization Fact sheet N310 : The top 10 causes of death
Introduction
. .. 2556
Pathophysiology
any disease process that
interrupts blood flow to the brain
abrupt onset of a neurologic deficit

attributable to a focal vascular cause
Go S, Worman DJ. Chapter 161. Stroke, Transient Ischemic Attack, and Cervical Artery Dissection. In: Tintinalli JE,
Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive
Study Guide, 7e. New York, NY: McGraw-Hill; 2011
Stroke Type
87 %
Thrombotic
Ischemic
Embolic
Hypoperfusion
Stroke
13 %
Intracerebral
10 %
Nontraumatic
subarachnoid
3%
Hemorrhagic
Risk factors
Smith WS, Johnston S, Hemphill J, III. Cerebrovascular Diseases. In: Kasper D, Fauci A, Hauser S, Longo D,
Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015.
Clinical features
Sudden onset
Focal involvement of the central nervous system
Lack of rapid resolution
deficits persist for at least 24 hours to distinguish stroke from transient ischemic attack
Vascular : referable to the territory of a particular cerebral blood vessel.

Middle cerebral artery distribution :
Contralateral hemiparesis and hemisensory loss
the face and upper extremity are more affected than the lower extremity
aphasia if the infarct involves the dominant cerebral hemisphere
Anterior cerebral artery distribution:
Contralateral hemiparesis and hemisensory loss
the lower extremity is more affected than the upper extremity
Posterior cerebral artery distribution:

Contralateral hemiparesis
homonymous hemianopsia,
amnesia
Basilar artery distribution:
Quadriparesis, dysarthria, dysphagia, diplopia.
Kemp WL, Burns DK, Brown TG. Chapter 11. Neuropathology. In: Kemp WL, Burns DK, Brown TG. eds. Pathology: The Big Picture. New York, NY: McGraw-Hill; 2008.
Lacunar infarct
Lacunar infarct
Pure motor stroke/hemiparesis

Ataxic hemiparesis
Dysarthria/clumsy hand
Pure sensory stroke
Mixed sensorimotor stroke
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care Science
1. Identify signs and symptoms

of possible stroke
Activate Emergency Response
Stroke recognition and EMS care
sensitivity = 66%, specificity = 87% for acute stroke
Los Angeles Prehospital Stroke Screen

6 criteria
sensitivity = 91% , specificity = 97% for acute stroke
Age >45 y
No history of seizure disorder
New onset of neurologic symptoms in last 24 h
Patient ambulatory at baseline (prior to event)
Blood glucose level of 60400 mg%

Obvious asymmetry in any of the following examinations
facial smile/grimace
grip
arm strength
Go S, Worman DJ. Chapter 161. Stroke, Transient Ischemic Attack, and Cervical Artery Dissection. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's
Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
2. Clinical EMS
assessments and actions
2. Clinical EMS assessments and actions
Stroke.2013;44:870-947
3. Immediate general
assessment and
stabilization
Immediate general assessment and stabilization
Assess ABCs, V/S, Pulse oximetry

NPO
Strict bedrest with head of bed elevated to 30 degrees
Oxygen Hypoxia
IV isotonic crystalloids Dehydration
Lab for CBC, Coagulogram, BS, BUN, Cr, Elyte, Trop I
DTX ; treat if hypoglycemia
Perform neurological screening assessment
Activate stroke team
Emergent NC CT-scan within 25 min
12-lead EKG
Go S, Worman DJ. Chapter 161. Stroke, Transient Ischemic Attack, and Cervical Artery Dissection. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler
GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
stabilization
Hyperpyrexia
associated with increased morbidity and mortality
no conclusion of benefit of normalizing BT
probably reasonable to treat febrile stroke patients
with antipyretics
diligently search for the cause of the hyperthermia.
Hyperglycemia
less favorable outcomes with hyperglycemia
Glycemic control has been recommended
Keep 140 180 mg%
Neurological screening assessment
Go S, Worman DJ. Chapter 161. Stroke, Transient Ischemic Attack, and Cervical Artery
Dissection. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's
Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
4. Immediate neurologic assessment

by stroke team or designee
Immediate neurologic assessment by

stroke team or designee
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Review patient history
presence of associated symptoms

medical history
exclude as many stroke mimics as
possible Seizure
Syncope
Brain neoplasm or abscess
Hypoglycemia
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Stroke.2013;44:870-947
Perform neurological examination
the National Institutes of Health Stroke Scale

(NIHSS)
11-category (15-item)
score range of 0 to 42
5 to 10 minutes
yields reproducible results
high interrater reliability
correlates with infarct volume
NIHSS
1a. Level of Consciousness

1b. LOC Questions:
1c. LOC Commands:
2. Best Gaze:
3. Visual:
4. Facial Palsy:
5. Motor Arm:
6. Motor Leg:
7. Limb Ataxia:
8. Sensory:
9. Best Language:
10. Dysarthria:
11. Extinction and Inattention (formerly Neglect):
Go S, Worman DJ. Chapter 161. Stroke, Transient Ischemic Attack, and Cervical Artery Dissection. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka
RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
5. Does CT scan show

hemorrhage?
intracranial hemorrhage
Theerachai Chaitusaney . Emergency neuroradiology, Department of Radiology

King Chulalongkorn Memorial Hospital
Hyperacute infarction
Sign of early cerebral ischemia on NECT (MCA territory)
Detected in 67% of cases (imaged within 3 hours)
Stroke 2013;44(3):870-947
1. Loss of gray-white differentiation

-Insular ribbon & cortical ribbon sign
Dr Yuranga Weerakkody et al. Loss of the insular ribbon sign : http://radiopaedia.org/articles/loss-of-the-insular-ribbon-sign
2.Gyral swelling
(effacement of the cortical sulci)

3. Hyperdense MCA sign
Frank Gaillard. Hyperdense MCA : http://radiopaedia.org/images/31613
A case of sudden onset of left

hemiparesis

Does CT scan show hemorrhage
Yes consult neurosurgeon
No probable acute ischemic stroke; consider

fibrinolytic therapy
5. Use of IV rtPA for acute

ischemic stroke
Fibrinolytic therapy
The National Institutes of Health/NINDS study

IV rtPA within 3 hours of stroke onset
at 3 months OR for a favorable outcome in patients
treated with rtPA was 1.7 (p = .008)
The European Cooperative Acute Stroke Study III

(ECASS)
expansion of the rtPA treatment window to 4.5
hours
OR favored patients treated with rtPA [OR = 1.34; 95%
CI (1.02% to 1.76%)]
mortality was similar in both groups
N Engl J Med 333(24): 1581, 1995.
N Engl J Med 359(13): 1317, 2008.
IV rtPA Within 3 Hours

AHA/ASA
Guideline
2013
Inclusion criteria
Diagnosis of ischemic stroke causing measurable neurological deficit

Onset of symptoms <3 hours before beginning treatment
Aged 18 years
Exclusion criteria
Significant head trauma or prior stroke in previous 3 months
Symptoms suggest subarachnoid hemorrhage
Arterial puncture at noncompressible site in previous 7 days
History of previous intracranial hemorrhage
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
Platelet count <100 000/mm
Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the
upper limit of normal

Current use of anticoagulant with INR >1.7 or PT >15 seconds
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive
laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa
activity assays)
Blood glucose concentration <50 mg/dL (2.7 mmol/L)
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Stroke.2013;44:870-947

AHA/ASA Guideline 2013
Relative exclusion criteria

Only minor or rapidly improving stroke symptoms (clearing
spontaneously)
Pregnancy
Seizure at onset with postictal residual neurological
impairments
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract hemorrhage (within
previous 21 days)
Recent acute myocardial infarction (within previous 3
months)
Stroke.2013;44:870-947
IV rtPA Within 3 to 4.5 Hours
IV rtPA Within 3 to 4.5 Hours

AHA/ASA Guideline 2013
Additional Inclusion and Exclusion Characteristics

Inclusion criteria
Diagnosis of ischemic stroke causing measurable
neurological deficit
Onset of symptoms within 3 to 4.5 hours before
beginning treatment
Relative exclusion criteria

Aged >80 years
Severe stroke (NIHSS>25)
Taking an oral anticoagulant regardless of INR
History of both diabetes and prior ischemic stroke
Stroke.2013;44:870-947
Management of
Arterial Hypertension
Management of Arterial
Hypertension
not candidates for rtPA

no active attempts made to lower blood
pressure unless
SBP >220 mm Hg
or DBP >120 mm Hg
reduction targets 10% to 25% within the first
day
Stroke. March 2013vol. 44no. 3870-947
Management of Arterial Hypertension
candidates for rtPA
Stroke. March 2013vol. 44no. 3870-947
Give rtPA
Review risks/benefits with patient and family

Infuse 0.9 mg/kg (maximum dose 90 mg) over 60
min
with 10% of the dose given as a bolus over 1 min
If
severe headache
acute hypertension
nausea or vomiting
worsening neurological examination
discontinue the infusion (if IV rtPA is being administered)
emergent CT scan
CBC, Coagulogram, fibrinogen level, G/M PRC, FFP, PC
Go S, Worman DJ. Chapter 161. Stroke, Transient Ischemic Attack, and Cervical Artery Dissection. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD,
T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
After rtPA
Admit intensive care or stroke unit for

monitoring
if the patient can be safely managed ,
Delay placement of
nasogastric tubes
indwelling bladder catheters
intra-arterial pressure catheters
Obtain a follow-up CT or MRI scan at 24

hours after IV rtPA before starting
anticoagulants or antiplatelet agents.
hemorrhagic
transformation

Antiplatelet Agents
Aspirin within 48 hours of stroke

prevention of recurrent strokes (NNT = 100)
limited experience with the use of

clopidogrel or dipyridamole
Current AHA recommendations : Aspirin
initial dose is 325 mg
within 24 to 48 hours after stroke onset
within 24 hours of rtPA is not recommended
Lancet. 1997;349:16411649
Lancet. 1997;349:15691581
ASA vs ASA +
Dipyridamole
(A) nonfatal stroke and (B) composite outcome of nonfatal stroke, nonfatal myocardial
infarction, and vascular death.
Stroke.2008; 39: 1358-1363
ASA + clopidogrel
Stroke.2014;45:492-503
vs
ASA
5. Hemorrhagic stroke
Acute Phase of Hemorrhagic Stroke
1. Respiration
Hypoventilation, Coma, Aspiration ETT
2. Temperature
Hyperpyrexia Antipyretics, Tepid sponge
3. Blood glucose
BG > 140 mg% hyperglycemic control
4. Fluid & Electrolyte

Keep fluid balanced isotonic crystalloid
Correct electrolyte
5. Seizure
Prophylaxis not recommended
Clinical seizures should be treated with antiepileptic drugs
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Acute Phase of Hemorrhagic Stroke
6. Hypertension
If no increased ICP keep MAP < 110 or BP 160/90

If BP > 200/150
Nitroprusside 0.25-10 g/kg/min IV
Nitroglycerine 5 mg IV then 1-4 mg/hr IV
If BP > 180/105
Captopril 6.25-12.5 mg oral
Small patch of nitroglycerine
Hydralazine 5-10 mg IV
Nicardepine 5 mg/hr IV
If increased ICP keep MAP < 130 or SBP < 200

Consider IV medication while maintaining CPP > 60 mmHg
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increased intracranial
pressure
Clinical features
Severe headache
Drowsy
Vomiting
Diplopia
Mydriasis
Bradycardia
wide pulse pressure
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increased intracranial
pressure
Treatment
Clear airway, ETT, Foleys catheter
Elevated head of bed 20-30 degree
Avoid compression of jugular vein
Hyperventilation
20% mannitol : loading dose 1 gm/kg IV in
20 min then 0.25-0.5 gm/kg q6hr

Check serum osmolarity OD
keep < 320
mOsm/l
Avoid hypotonic solution
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Adapted from: http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/recs-emerg.htm#emergency; and

Jauch EC. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation. 2010;122(18 suppl 3):S818-S828.
Genentech USA, Inc. Golden Hour of Acute Ischemic Stroke

: http://www.activase.com/iscstroke/golden-hour-acute-ischemic-stroke#

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STROKE

second leading cause of death worldwide

abrupt onset of a neurologic deficit

Vascular : referable to the territory of a particular cerebral blood vessel.

Posterior cerebral artery distribution:

Pure motor stroke/hemiparesis

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and

1. Identify signs and symptoms

Stroke recognition and EMS care

sensitivity = 66%, specificity = 87% for acute stroke

Stroke recognition and EMS care

Los Angeles Prehospital Stroke Screen

Blood glucose level of 60400 mg%

Stroke recognition and EMS care

2. Clinical EMS assessments and actions

Immediate general assessment and stabilization

Assess ABCs, V/S, Pulse oximetry

Neurological screening assessment

4. Immediate neurologic assessment

Immediate neurologic assessment by

Review patient history

presence of associated symptoms

Perform neurological examination

the National Institutes of Health Stroke Scale

1a. Level of Consciousness

5. Does CT scan show

Theerachai Chaitusaney . Emergency neuroradiology, Department of Radiology

1. Loss of gray-white differentiation

Dr Yuranga Weerakkody et al. Loss of the insular ribbon sign : http://radiopaedia.org/articles/loss-of-the-insular-ribbon-sign

Theerachai Chaitusaney . Emergency neuroradiology, Department of Radiology

3. Hyperdense MCA sign

Frank Gaillard. Hyperdense MCA : http://radiopaedia.org/images/31613

A case of sudden onset of left

Theerachai Chaitusaney . Emergency neuroradiology, Department of Radiology

Does CT scan show hemorrhage

Yes consult neurosurgeon

No probable acute ischemic stroke; consider

5. Use of IV rtPA for acute

The National Institutes of Health/NINDS study

treated with rtPA was 1.7 (p = .008)

The European Cooperative Acute Stroke Study III

N Engl J Med 333(24): 1581, 1995.

N Engl J Med 359(13): 1317, 2008.

IV rtPA Within 3 Hours

IV rtPA Within 3 Hours

Diagnosis of ischemic stroke causing measurable neurological deficit

upper limit of normal

IV rtPA Within 3 Hours

Relative exclusion criteria

IV rtPA Within 3 to 4.5 Hours

IV rtPA Within 3 to 4.5 Hours

Additional Inclusion and Exclusion Characteristics

Relative exclusion criteria

not candidates for rtPA

reduction targets 10% to 25% within the first

Stroke. March 2013vol. 44no. 3870-947

Management of Arterial Hypertension

candidates for rtPA

Stroke. March 2013vol. 44no. 3870-947

Review risks/benefits with patient and family

Admit intensive care or stroke unit for

Obtain a follow-up CT or MRI scan at 24

Theerachai Chaitusaney . Emergency neuroradiology, Department of Radiology

Aspirin within 48 hours of stroke