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Stroke ACNP Bootcamp 2012

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Title: Stroke ACNP Bootcamp 2012


1
StrokeACNP Bootcamp 2012
  • Briana Witherspoon, MSN, ACNP-BC, CCRN, CNRN

2
Stroke Objectives
  • Review Ischemic Stroke Algorithm
  • Identifying location of ischemic stroke
  • Acute management of an ischemic stroke
  • Acute management of hemorrhagic stroke

3
Stroke Algorithm
4
NIHSS
  • NIHSS (National Institute of Health Stroke Scale)
  • Standardized method used by health care
    professionals to measure the level of impairment
    caused by a stroke
  • Purpose
  • Main use is as a clinical assessment tool to
    determine whether the degree of disability is
    severe enough to warrant the use of tPA
  • Another important use of the NIHSS is in
    research, where it allows for the objective
    comparison of efficacy across different stroke
    treatments and rehabilitation interventions
  • Scores are totaled to determine level of severity
  • Can also serve as a tool to determine if a change
    in exam has occurred

5
Breaking Down the Scale
  • 13 item scoring system, 7 minute exam
  • Integrates neurologic exam components
  • CN (visual), motor, sensory, cerebellar,
    inattention, language, LOC
  • Maximum score is 42, signifying severe stroke
  • Minimum score is 0, a normal exam
  • Scores greater than 15-20 are more severe

6
NIHSS cont.
  • NIHSS Interpretation

Stroke Scale Stroke Severity
0 No Stroke
1-4 Minor Stroke
5-15 Moderate Stroke
15-20 Moderate/Severe Stroke
21-42 Severe Stroke
7
NIHSS and Outcome Prediction
  • NIHSS below 12-14 will have an 80 good or
    excellent outcome.
  • NIHSS above 20-26 will have less than a 20 good
    or excellent outcome.
  • Lacunar infarct patients had the best outcomes.

Adams HP Neurology 199953126-131 Baseline NIH
Stroke Scale score strongly predicts outcome
after stroke (TOAST)
8
Etiology of Ischemic Strokes
  • LARGE VESSEL THROMBOTIC
  • Virchows Triad.
  • Blood vessel injury
  • HTN, Atherosclerosis, Vasculitis
  • Stasis/turbulent blood flow
  • Atherosclerosis, A. fib., Valve disorders
  • Hypercoagulable state
  • Increased number of platelets
  • Deficiency of anti-coagulation factors
  • Presence of pro-coagulation factors
  • Cancer

9
Etiology Of Stroke
  • LARGE VESSEL EMBOLIC
  • The Heart
  • Valve diseases, A. Fib, Dilated cardiomyopathy,
    myxoma
  • Arterial Circulation (artery to artery emboli)
  • Atherosclerosis of carotid, Arterial dissection,
    Vasculitis
  • The Venous Circulation
  • PFO w/R to L shunt, Fat, air, or septic emboli

10
Determining the Location
  • Large Vessel
  • Look for cortical signs
  • Small Vessel
  • No cortical signs on exam
  • Posterior Circulation
  • Crossed signs
  • Cranial nerve findings
  • Watershed
  • Look at watershed and borderzone areas
  • Hypo-perfusion

11
Cortical Signs
RIGHT BRAIN LEFT BRAIN
- Right gaze preference - Left gaze preference
- Neglect - Aphasia
  • If present, think LARGE VESSEL stroke

12
Large Vessel Stroke Syndromes
  • MCA
  • Armgtleg weakness
  • LMCA cognitive Aphasia
  • RMCA cognitive Neglect, anosognosia,
    topographical difficulty, apraxia, constructional
    impairment
  • ACA
  • Leggtarm weakness, grasp
  • Cognitive muteness, perseveration, abulia,
    disinhibiition
  • PCA
  • Hemianopia
  • Cognitive memory loss/confusion, alexia
  • Cerebellum
  • Ipsilateral ataxia

13
Circle of Willis
14
Aphasia
  • Brocas
  • Expressive aphasia
  • Left posterior inferior
  • frontal gyrus
  • Wernickes
  • Receptive aphasia
  • Posterior part of the superior temporal gyrus
  • Located on the dominant side (left) of the brain

15
Case 1
  • 71 year old female with sudden onset of
    left-sided weakness
  • She was out with her sisters when she suddenly
    slumped her head and appeared to have a left
    facial droop
  • History of HTN and atrial fibrillation
  • Meds Losartan

16
Case 1
  • BP- 142/83, P 104, T- 98.0, RR 22, O2- 94
  • General exam Unremarkable except irregular rate
    and rhythm
  • NEURO EXAM
  • - Speech dysarthric but language intact
  • - Right gaze preference
  • - Left facial droop
  • - Left- sided hemiplegia
  • - Neglect
  • - DTR's are symmetric, Left toe up

17
Case 1
18
Case 1
19

20
Case 1
21
Case 1
22
Case 1
  • Right MCA infarct, most likely cardioembolic from
    atrial fibrillation
  • Patient underwent mechanical thrombectomy with
    intra-arterial verapamil, clot removal successful
  • Excellent recovery patient was discharged 48
    hours later on Coumadin

23
Determining the Location
  • Large Vessel
  • Look for cortical signs
  • Small Vessel
  • No cortical signs on exam
  • Posterior Circulation
  • Crossed signs
  • Cranial nerve findings
  • Watershed
  • Look for watershed pattern
  • S/S of Hypo-perfusion

24
Etiology of Stroke
  • SMALL VESSEL (Lacunes lt1.5cm)
  • Risk Factors
  • HTN
  • HLD
  • DM
  • Tobacco Use
  • Sleep apnea

25
Case 2
  • 65 year old male with acute onset of left face,
    arm, and leg numbness
  • History of HTN, DM, and tobacco use
  • Meds Insulin, aspirin

26
Case 2
  • BP- 168/96, P 92
  • General exam Unremarkable, RRR
  • NEURO EXAM
  • - Decreased sensation on left face, arm, and leg

27
Case 2
28
Case 2
  • Right thalamic lacunar infarct

29
Determining the Location
  • Large Vessel
  • Look for cortical signs
  • Small Vessel
  • No cortical signs on exam
  • Posterior Circulation
  • Crossed signs
  • Cranial nerve findings
  • Watershed
  • Look at watershed and borderzone areas
  • Hypo-perfusion

30
Brainstem Stroke Syndromes
  • Rarely presents with an isolated symptom
  • Usually a combination of cranial nerve
    abnormalities, and crossed motor/sensory
    findings, such as
  • Double vision
  • Facial numbness and/or weakness
  • Slurred speech
  • Difficulty swallowing
  • Ataxia
  • Vertigo
  • Nausea and vomiting
  • Hoarseness

31
Case 3
  • 55 year old male with acute onset of right sided
    numbness and tingling, left sided face pain and
    numbness, gait imbalance, nausea/vomiting,
    vertigo, swallowing difficulties, and hoarse
    speech
  • History of CAD s/p CABG, DM2, HTN, HLD, OSA
  • Meds Aspirin, plavix, insulin, lipitor,
    metoprolol, lisinopril

32
Case 3
  • NEURO EXAM BP- 194/102, P 105
  • General exam Unremarkable, RRR
  • NEURO EXAM
  • - Decreased sensation on left face
  • - Decreased sensation on right body
  • - Left ataxia on FNF, and unsteady gait
  • - Voice hoarse
  • - Nystagmus

33
Case 3
34
Case 3
35
Case 3
  • Brainstem Stroke

36
Determining the Location
  • Large Vessel
  • Look for cortical signs
  • Small Vessel
  • No cortical signs on exam
  • Posterior Circulation
  • Crossed signs
  • Cranial nerve findings
  • Watershed
  • Look for the watershed pattern
  • Think about reasons of hypo-perfusion
  • Hypotension
  • Stenosed vessel, etc

37
Case 4
  • 56 year old female who upon waking post-op after
    elective surgery was found to have L sided
    weakness and neglect
  • History of HTN

38
Case 4
  • BP- 132/74, P 84
  • General exam Unremarkable, RRR
  • NEURO EXAM
  • - Left face, arm, and leg weakness
  • - Neglect
  • - DTRs brisk on the left, toe up on left

39
Case 4
40
Case 4
41
Case 4
42
Case 4
43
Case 4
44
Case 4
45
Case 4
46
Case 4
  • Right hemisphere watershed infarct secondary to
    hypoperfusion in the setting of Right ICA
    stenosis
  • On review of anesthesia records, blood pressure
    dropped to 82/54 during the procedure

47
  • Intracranial Hemorrhages

48
Causes of ICH
  • Traumatic
  • Spontaneous
  • Hypertensive
  • Amyloid angiopathy
  • Aneurysmal rupture
  • Arteriovenous malformation rupture
  • Bleeding into tumor
  • Cocaine and amphetamine use

49
Causes of ICH

50
Hypertensive ICH
  • Spontaneous rupture of a small artery deep in the
    brain
  • Typical sites
  • Basal Ganglia
  • Cerebellum
  • Pons
  • Typical clinical presentation
  • Patient typically awake and often stressed, then
    abrupt onset of symptoms with acute decompensation

51
Ganglionic Bleed
  • Contralateral hemiparesis
  • Hemisensory loss
  • Homonymous hemianopia
  • Conjugate deviation of eyes toward the side of
    the bleed or downward
  • AMS (stupor, coma)

52
Cerebellar Hemorrhage
  • Vomiting (more common in ICH than SAH or Ischemic
    CVA)
  • Ataxia
  • Eye deviation toward the opposite side of the
    bleed
  • Small sluggish pupils
  • AMS

53
Pontine Hemorrhage
  • Pin-point but reactive pupils
  • Abrupt onset of coma
  • Decerebrate posturing or flaccidity
  • Ataxic breathing pattern

54
Cerebral Hemorrhage
JPG
55
  • Management

56
Airway
  • Most likely related to decreased level of
    consciousness (LOC), dysarthria, dysphagia
  • GCS lt 8 - INTUBATE
  • Avoid Hyperventilation or Hypoventilation
  • NPO until swallow assessment completed- high
    aspiration risk
  • Begin mobilization as soon as clinically safe
  • Keep HOB greater than 30 degrees

57
Imaging
  • CT scan
  • MRI
  • Non- contrast CTH remains the gold standard as it
    is superior for showing IVH and ICH
  • CT with contrast may help identify aneurysms,
    AVMs, or tumors but is not required to determine
    whether or not the patient is a tPa candidate
  • Superior for showing underlying structural
    lesions
  • Contraindications

58
Multimodal Imaging
  • Multimodal CT
  • Multimodal MRI
  • Typically includes non-contrast CT, perfusion CT,
    and CTA
  • Two types of perfusion CT
  • Whole brain perfusion CT
  • Dynamic perfusion CT
  • Standard MRI sequences ( T1 weighted, T2
    weighted, and proton density) are relatively
    insensitive to changes in cerebral ischemia
  • Multimodal adds diffuse-weighted imaging (DWI)
    and PWI (perfusion- weighted imaging)

59
tPa
  • Fast Facts
  • Contraindications
  • Tissue plasminogen activator
  • clot buster
  • IV tpa window 3 hours
  • IA tpa window 4.5 hours
  • Hemorrhage
  • SBP gt 185 or DBP gt 110, or aggressive treatment
    (IV medication) necessary to achieve these limits
  • Surgery, trauma or stroke within last 3 months
  • Coagulopathy
  • Seizure at onset of symptoms
  • NIHSS lt4, gt21
  • Age?

60
Mechanical Thrombolysis
  • Often used in adjunct with tPa
  • MERCI (Mechanical Embolus Removal in Cerebral
    Ischemia) Retrieval System is a corkscrew-like
    apparatus designed to remove clots from vessels.
  • PENUMBRA system aspirates the clot

61
Blood Pressure Management
  • BP Management
  • The goal is to maintain cerebral perfusion!!
  • CPP MAP ICP (needs to be at least 70)
  • Higher BP goals with Ischemic stroke
  • Lower BP goals with Hemorrhagic stroke (avoid
    hemorrhagic expansion, especially in AVMs and
    aneurysms)

62
Supportive Therapy
  • Glucose Management
  • Infarction size and edema increase with acute and
    chronic hyperglycemia
  • Hyperglycemia is an independent risk factor for
    hemorrhage when stroke is treated with t-PA
  • Antiepileptic Drugs
  • Seizures are common after hemorrhagic CVAs
  • ICH related seizures are generally non-convulsive
    and are associated to with higher NIHSS scores,
    a midline shift, and tend to predict poorer
    outcomes

63
Hyperthermia
  • Treat fevers!
  • Evidence shows that fevers gt 37.5 C that persists
    for gt 24 hrs correlates with ventricular
    extension and is found in 83 of patients with
    poor outcomes

64
Hypothermia
  • Although strong experimental and clinical
    evidence indicates that induced hypothermia can
    protect the brain in the presence of hypoxia or
    ischemia, including cardiac arrest, data about
    the utility of induced hypothermia for patients
    with acute stroke are not yet available.

65
References
  • Adams, H., del Zappo, G., Alberts, M., Bhatt, D.,
    Brass, L., Furlan, A., Grubb, R.,
  • Higashida, R. (2007). Guidelines for the early
    management of adults with ischemic stroke.
    Stroke, 38, 1655-1711.
  • Bradley G Walter, Daroff B Robert, Fenichel M
    Gerald, Jancovic, Joseph Neurology in clinical
    practice, principles of diagnosis and
    management. Philadelphia Elsevier, 2004.
  • Castillo, J., Leira, R., Garcia, M., Serena, J.,
    Blanco, M. Blood pressure decrease during the
    acute phase of ischemic stroke is associated with
    brain injury and poor stroke outcome. Stroke.
    2004 35 520-526.
  • Goals for Management of Patients With Suspected
    Stroke Algorithm. http//circ.ahajournals.org/con
    tent/112/24_suppl/IV-111/F1.expansion.html.
    Accessed May 8, 2012
  • Hesselink, J. Imaging of cerebral hemorrhages and
    AV malformations. http//spinwarp.ucsd.edu/neurow
    eb/Text/br-740.htm. accessed May 10, 2012.

66
  • Questions?
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