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Acute Management of Stroke

Initial Treatment
The goal for the acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival.[1] (See Table 1, below.) Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention. Table 1. NINDS* and ACLS** Recommended Stroke Evaluation Time Benchmarks for Potential Thrombolysis Candidate (Open Table in a new window) Time Interval Time Target Door to doctor 10 min Access to neurologic expertise 15 min Door to CT scan completion 25 min Door to CT scan interpretation 45 min Door to treatment 60 min Admission to stroke unit or ICU 3h *National Institute of Neurologic Disorders and Stroke **Advanced Cardiac Life Support guidelines

Hypoglycemia and hyperglycemia need to be identified and treated early in the evaluation. Not only can both produce symptoms that mimic ischemic stroke, but they can also aggravate ongoing neuronal ischemia. Administration of glucose in hypoglycemia produces profound and prompt improvement, while insulin should be started for patients with stroke and hyperglycemia. Ongoing studies will help to determine the optimal level of glycemic control.[2] Hyperthermia is infrequently associated with stroke but can increase morbidity. Administration of acetaminophen, by mouth or per rectum, is indicated in the presence of fever (temperature >100.4° F [38° C]). Supplemental oxygen is recommended when the patient has a documented oxygen requirement. To date, there is conflicting evidence whether supernormal oxygenation improves outcome. Optimal blood pressure targets remain to be determined. Many patients are hypertensive on arrival. American Stroke Association guidelines have reinforced the need for caution in lowering blood pressures acutely.

and failure to initiate primary and secondary stroke prevention exposes the patient to undue risk of stroke and exposes clinicians to potential litigation.) In patients with transient ischemic attacks (TIAs). and one half of the strokes occurring after a TIA.[3] Table 2.[5] Surgical management with hemispheric decompression in patients with middle cerebral artery territory infarction and associated life-threatening parenchymal edema has also been supported. 7] Newer stroke trials have shown the benefit of using neuroimaging to select patients who are most likely to benefit from thrombolytic therapy and the potential benefits of extending the window for thrombolytic therapy beyond the guideline of 3 hours with t -PA and newer agents. failure to perform a timely assessment for stroke risk factors. pharmacologically increasing blood pressure may improve flow through critical stenoses.In the small proportion of patients with stroke who are relatively hypotensive. failure to recognize the potential for nearterm stroke. below. 4] (Open Table in a new window) Treat hypoglycemia with D50 Blood glucose Blood pressure Treat hyperglycemia with insulin if serum glucose >200 mg/dL See recommendations for thrombolysis candidates and noncandidates (Table 3) Cardiac monitor Continuous monitoring for ischemic changes or atrial fibrillation Intravenous Avoid D5W and excessive fluid administration fluids IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated Oral intake Oxygen Temperature NPO initially. Serial monitoring and interventions when necessary early in the clinical course and eventual stroke rehabilitation and physical and occupational therapy are the ideals of management. (See Table 2. CT angiography may demonstrate the location of vascular occlusion. General Management of Patients With Acute Stroke[1.[8] . aspiration risk is great. use oral or rectal acetaminophen and cooling blankets as needed Thrombolytic Therapy Current treatments for acute ischemic stroke include IV thrombolytic therapy with tissue-type plasminogen activator (t-PA) and endovascular therapies. avoid oral intake until swallowing assessed Supplement if indicated (Sa02 < 94%) Avoid hyperthermia. CT perfusion studies are capable of producing perfusion images and together with CT angiography are becoming more available and utilized in the acute evaluation of stroke patients. occurred within 48 hours. TIAs confer a 10% risk of stroke within 30 days. including intra-arterial thrombolytic therapy and the use of clot retrieval devices.[6.

19] Additionally. normoglycemic patients should not be given excessive glucose-containing IV fluids. 12. 14] Stabilization of Airway and Breathing Patients presenting with Glasgow Coma Scale scores of 8 or less. rapidly decreasing Glasgow Coma Scale scores.[10] Advanced neuroimaging with diffusion and perfusion imaging may then serve an important role in identifying potentially salvageable tissue at risk and guiding clinical decision making regarding therapy. atrial fibrillation may be associated with acute stroke as either the cause (embolic disease) or as a complication. or inadequate airway protection or ventilation require emergent airway control via rapid sequence intubation. as this may lead to hyperglycemia and may exacerbate ischemic cerebral injury. . The most common causes of hypoxia in the patient with acute stroke are partial airway obstruction. 16] Intravenous Access and Cardiac Monitoring Patients with acute stroke require IV access and cardiac monitoring in the emergency department (ED). as well as extension of the infarcted territory. IV mannitol can be considered as well. 18.The Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) trial demonstrated the benefit of administering IV t-PA within 3-6 hours of stroke onset in patients with small ischemic cores on diffusion-weighted magnetic resonance imaging (MRI) and larger perfusion abnormalities (large ischemic penumbras). or aspiration of stomach or oropharyngeal contents. rapid sequence induction should be directed at minimizing the potentially adverse effects of intubation. 13.[17. [10. Patients should receive supplemental oxygen if their pulse oximetry reading or arterial blood gas measurement reveals that they are hypoxic (SaO 2 < 94%). Patients with acute stroke are at risk for cardiac arrhythmias. When increased intracranial pressure (ICP) is suspected. hypoventilation. In addition. where the goal of mechanical ventilation is hyperventilation to decrease ICP by decreasing cerebral blood flow. Blood Glucose Control Severe hyperglycemia appears to be independently associated with poor outcome and reduced reperfusion in thrombolysis.[15. In unusual cases of potential imminent brain herniation.[9] The Desmoteplase In Acute Ischemic Stroke (DIAS) trial similarly demonstrated the benefit of administering desmoteplase in patients within 3-9 hours of onset of acute stroke in patients with a significant mismatch (>20%) between perfusion abnormalities and ischemic core on diffusion-weighted MRI. Supplemental oxygen use should be guided by pulse oximetry. atelectasis. the recommended endpoint is an arterial pCO2 of 32-36 mm Hg. 11.

with the goal of establishing normoglycemia (90-140 mg/dL). including deep venous thrombosis. with these outcomes correlating with the degree of pressure decline. below. Hypertension control in non±rt-PA candidates For patients who are not candidates for thrombolysis with recombinant t-PA (rt-PA) and who have a systolic blood pressure of less than 220 mm Hg and a diastolic blood pressure of less than 120 mm Hg in the absence of evidence of end-organ involvement (ie. patients should not be kept flat for longer than 24 hours. Rapid reduction of blood pressure. Therefore. no matter the degree of hypertension.Blood sugar control should be tightly maintained with insulin therapy.[20] Blood Pressure Control In poor flow states which occur with thrombotic and embolic ischemic stroke. pressure ulcer aspiration. may in fact be harmful.[16] However. . Therefore. 22] The consensus recommendation is to lower blood pressure only if systolic pressure is in excess of 220 mm Hg or if diastolic pressure is greater than 120 mm Hg. aortic dissection. aggressive efforts to lower blood pressure may decrease perfusion pressure and may prolong or worsen ischemia. Dosing may be repeated or doubled every 10 minutes to a maximum dose of 300 mg. Furthermore. For patients with a systolic blood pressure above 220 mm Hg or a diastolic blood pressure greater than 120 mm Hg.) Studies have demonstrated that blood pressure typically drops in the first 24 hours after acute stroke. a systolic blood pressure greater than 185 mm Hg or a diastolic pressure greater than 110 mm Hg is a contraindication to the use of thrombolytics. blood pressure should be monitored (without acute intervention) and stroke symptoms and complications (eg. studies have revealed poorer outcomes in patients with lower blood pressures. Both elevated and low blood pressures are associated with poor outcomes in patients with acute stroke. and pneumonia. hypertensive encephalopathy). seizures) should be treated. Because prolonged immobilization may lead to its own complications. as well as with increased ICP due to cerebral edema the cerebral vasculature loses vasoregulatory capability and thus relies directly on mean arterial pressure (MAP) and cardiac output for maintenance of cerebral blood flow. depending on whether the patient is a candidate for thrombolytic therapy.[21. lying flat may serve to increase ICP and thus is not recommended in cases of subarachnoid or other intracranial hemorrhage. the management of elevated blood pressure in acute ischemic stroke may vary. increased ICP. Additionally.[1] Patient Positioning Studies have shown that cerebral perfusion pressure is maximized when patients are maintained in a supine position. whether or not antihypertensives are administered. labetalol (10-20 mg IV for 1-2 min) should be the initial drug of choice. pulmonary edema. However. unless a contraindication to its use exists.[21] (See Table 3. close monitoring of blood sugar level should continue throughout hospitalization to avoid hypoglycemia.

Nicardipine is given intravenously at an initial rate of 5 mg/h and titrated to effect by increasing the infusion rate 2. Hypertension control in rt-PA candidates For patients who will be receiving rt-PA. For patients with systolic blood pressure of 185-230 mm Hg or diastolic blood pressure of 110-120 mm Hg. then every 30 minutes for 6 hours. up to 300 mg total. may be repeated (maximum dose 300 mg). One to 2 inches of transdermal nitropaste may also be used. labetalol (10-20 mg IV for 1-2 min). labetalol at the above doses can be considered. for the first 2 hours. to a maximum of 15 mg/h. have failed to demonstrate any beneficial outcome in comparison with placebo. titrated up to a maximum dose of 15 mg/h. blood pressure should be checked every 15 minutes.[1] The use of sublingual nifedipine to lower blood pressure in the ED is discouraged.[1] Table 3. because uncontrolled hypertension is associated with hemorrhagic complication. The goal of intervention is a reduction in blood pressure of 10-15%.[1] For systolic blood pressure of greater than 230 mm Hg or diastolic blood pressure of 121-140 mm Hg. Lastly. However. initially thought to be beneficial given its vasodilatory effect as a calcium-channel blocker.5 mg/h every 5 minutes. and finally.[23] The initial drug of choice. every hour for 16 hours.5 mcg/kg/min IV infusion may be used in the setting of continuous blood pressure monitoring. labetalol is given at a dose of 10-20 mg IV over 1-2 minutes. nitroprusside at 0. sodium nitroprusside can be considered. nicardipine infusion at 5 mg/h. to a maximum of 15 mg/h. can be used.[15] Consensus agreement is that these blood pressure guidelines should be maintained in the face of other interventions to restore perfusion.Alternatively. since extreme hypotension may result. Trials of nimodipine. systolic blood pressure greater than 185 mm Hg and diastolic blood pressure greater than 110 mm Hg require intervention. As an alternative to these choices. might be a better first choice. with continued blood pressure control during hospitalization. or an infusion rate of up to 2-8 mg/min may be used.[16] Monitoring of blood pressure is crucial. For difficult-to-control blood pressure. nicardipine infusion administered at a rate of 5 mg/h. Blood Pressure Management in Patients With Stroke* (Open Table in a new window) Blood Pressure Pretreatment: SBP >185 or DBP or Treatment Labetalol 10-20 mg IVP repeated every 10-20 minutes Candidates for fibrinolysis . the dose may be repeated every 10-20 minutes. nicardipine may be used for blood pressure control. such as intra-arterial thrombolysis. The goal of therapy should be to reduce blood pressure by 15-25% in the first day. Monitoring and control of blood pressure during and after thrombolytic administration are vital.

MAP .25 mg IVP Posttreatment: DBP >140 mm Hg Sodium nitroprusside (0. severe CHF.5 mg/h every 5DBP 105-120 mm Hg 15 min. when desired blood pressure reached. may repeat DBP 121-140 mm Hg and double every 10 min up to maximum dose of or 150 mg or nicardipine 5 mg/h IV infusion and titrate MAP >130 mm Hg or SBP < 220 mm Hg or Nicardipine 5 mg/h.IV push.5 mcg/kg/min. may repeat and double every 10 min up to maximum dose of 300 mg Noncandidates for DBP >140 mm Hg fibrinolysis SBP >220 or Sodium nitroprusside 0. may reduce approximately 10-20% Labetalol 10-20 mg IVP over 1-2 min. or hypertensive encephalopathy present *Adapted from 2005 Advanced Cardiac Life Support (ACLS) guidelines and 2007 American Stroke Association Scientific Statement Abbreviations: SBP .5 mg/h every 515 min.5 mcg/kg/min) Labetalol 10-20 mg IVP and consider labetalol infusion at 1-2 mg/min or nicardipine 5 mg/h IV SBP >230 mm Hg or infusion and titrate DBP 121-140 mm Hg or SBP 180-230 mm Hg Nicardipine 5 mg/h. aortic dissection. when desired blood or pressure reached. maximum 15 mg/h. titrate by 2. maximum 15 mg/h. titrate by 2.diastolic blood pressure. lower to 3 mg/h MAP < 130 mm Hg Antihypertensive therapy indicated only if acute myocardial infarction. titrate by 2. lower to 3 mg/h or Enalapril 1.mean arterial pressure Control of hypotension .systolic blood pressure. IVP . maximum 15 mg/h. lower to 3 mg/h or Labetalol 10 mg IVP.>110 mm Hg Nicardipine 5 mg/h. when desired blood Hg pressure reached.5 mg/h every 5or DBP 105-120 mm 15 min. DBP .

if necessary. a search for the etiology of hypotension. and failure to initiate primary and secondary stroke prevention exposes the patient to undue risk of stroke and exposes clinicians to potential litigation. Recent research has demonstrated the benefits of early and aggressive mobilization.[24] Additional Care Referral to a physician with a special interest in stroke is ideal.[1] Patients should receive deep venous thrombosis prophylaxis. although the timing of institution of this therapy is unknown.Given the need to maintain adequate cerebral blood flow. Evidence suggests that baseline systolic blood pressure below 100 mg Hg and diastolic blood pressure below 70 mm Hg correlate with a worse outcome.[21] Further Outpatient Care Poststroke outpatient care largely focuses on rehabilitation and prevention of recurrent stroke. and. Rehabilitation planning and initiation begins within the first day of the acute stroke. Stroke care units with specially trained personnel exist and are said to show improved outcomes Comorbid medical problems need to be addressed. severe hypotension should be managed in standard fashion with aggressive fluid resuscitation. vasopressor support. Medical/Legal Pitfalls In patients with transient ischemic attacks. Assessments of swallow function prior to the reinstitution of oral feeding is recommended. failure to perform a timely assessment for stroke risk factors. failure to recognize the potential for near term stroke.[3] .