ISCHEMIC STROKE

INTERNAL MEDICINE HOSPITAL ROTATION

WEEK-1
CASE SUMMARY

• M. T., 68-year-old woman, married, from Buhangin, Davao City, was brought to the Brokenshire
Hospital emergency room after suddenly developing speech difficulty and weakness of the right
arm and leg. She was in her usual state of health when she was observed by her children to
become mute and slump in her chair. Her past medical history is significant for hypertension and
angina. The patient’s temperature is 36.6°C; heart rate, 84 beats/min; and blood pressure, 172/86
mmHg. Her physical examination reveals no carotid bruit and an irregularly irregular cardiac
rhythm. Neurologic examination shows an alert, attentive patient who is able to follow some
simple commands but has severe impairment of word fluency, naming, and repetition. There is a
left gaze deviation and right lower facial droop. There is severe weakness of the right upper
extremity and, to a lesser degree, weakness of the right lower extremity. The left limbs display full
antigravity power without drift for 5 seconds. Cardiac monitor showed an irregular rate. (Height 5'
2", Weight 56 kgs).
PRIMARY IMPRESSION

• Cardiogenic ischemic stroke probably

secondary to arrhythmia
STROKE

Stroke or cerebrovascular accident is

defined as an abrupt onset of
neurologic deficit that attribute a focal
vascular cause
Stroke will occur in those whose
neurologic sign and symptoms last for
more than 24 hours or brain infraction
occur
Two main types of stroke:

Ischemic stroke : Vessel obstruction limits

the blood flow to part of the brain and
cause infarction
• Global
• Focal
• Lacunar
• Thrombotic
• Cardioembolic stroke
Hemorrhagic stroke
• Intracerebral
• Subarachnoid
ETIOLOGY

Ischemic stroke result from an event that limit or stop the blood flow
such as extracranial or intracranial thrombotic embolism, thrombosis
in situ, as blood flow decreases neuron stop functioning
Although a range of threshold has been described that irreversible
neuronal ischemia and injury thought to begin at blood flow rate less
than 18 ml per 100g of tissue per min
With cell death occurs rapidly at rate below 10ml per 100g of tissue
per min
EPIDEMIOLOGY

Stroke is the leading cause of disability and 5th leading cause of death
in the united state
Each year approximately 795,000 people in US experience
new(610,000) or recurrent (185,000) suffer from stroke
Epidemiologic studies indicate that 82-92% of stroke in the united
states are ischemic stroke
According to world health organization (WHO), 15 million people
suffer stroke worldwide each year; of these 5 million die and another 5
million are left permanently disabled
NON-MODIFIABLE RISK FACTORS

• Age
• Race
• Sex
• Ethnicity
• Heredity: family history of Stroke or Transient Ischemic Attack(TIA)
MODIFIABLE FACTORS

• Hypertension
• Atrial fibrillation
• Diabetes
• Hyperlipidemia
• Asymptomatic carotid stenosis
• Symptomatic carotid stenosis
PATHOPHYSIOLOGY
CLINICAL PRESENTATION WITH CASE CORRELATION

Signs and Symptoms Patient

Paralysis/weakness of contralateral arm and leg Weakness of the left arm and leg

Paralysis/ weakness of contralateral face Right lower facial droop

Sensory loss over the contralateral arm, leg and face Absent in the patient

Motor aphasia- anomia, jargon speech Difficulty of speech, word fluency

Central aphasia Difficulty in recalling name

Conduction aphasia Difficulty in repetition

Apractognosia of the non-dominant hemisphere Absent in patient

Homonymous hemianopia Left gaze deviation

Noncontrast CT of the patient
shows hypodense lesion involving
the left inferior motor cortex which
control the execution of movement
of contralateral, i.e right side (arm,
leg), as well as affecting Broca’s
area, which controls vocalization
required for normal speech.
The sign and symptoms in the
patient, i.e. right-sided weakness
and speech difficulty are in
conjugation with the lesion seen
here in the CT.
The findings in the patient’s ECG are-
Tachycardia with irregularly irregular
rhythm, Bisfascicular block (Right bundle
branch block with left axis deviation), Atrial
fibrillation pattern.

Atrial fibrillation is a modifiable risk factor

of ischemic stroke and its presence leads to
poor outcome of the stroke.
LAB RESULTS
Analyte Results Interpretation
S. Na 145 mEq/L Normal
S. K 4.3 mEq/L Hyperkalemia
S. Cl 100 mEq/L Decreased
S. Ca 8.7 mg/dl Normal
S. Mg 1.7 mg/dl Normal
S. Crea 1.2 mg/dl Increased
Random Blood Glucose 115 mg/dl Normal
Hgb 11.6 g/dl Anemia
Hct 35.2% Normal
WBC 5.6 x 10 3 mm3 Normal
Platelets 264 x 10 3/mm3 Normal
APTT 24.6 sec Decreased
Total Cholesterol 223 mg/dl Borderline high
LDL cholesterol 121 mg/dl Near optimal/above optimal
ECG

EVALUATE FINDINGS

Rate 150 bpm(tachycardia)

Rhythm Irregular

PR P wave not discernable

QRS 0.12s(narrow QRS complex)

Axis (give exact numerical value) - 90 degrees(left axis deviation)

QT Normal (360 ms)

QTc Prolonged QTc (538 ms)

RBBB present/absent RBBB present

Final ECG Diagnosis Bifascicular block with atrial

fibrillation
FINAL DIAGNOSIS

• Cardiogenic ischemic stroke secondary to atrial fibrillation

NIH STROKE SCALE (NIHSS)

• WHAT?- It is a 15-item neurologic examination stroke scale used to

evaluate the effect of acute cerebral infarction on the levels of
consciousness, language, neglect, visual-field loss, extraocular
movement, motor strength, ataxia, dysarthria, and sensory loss.
• WHEN?- This is used in patients presenting with stroke in the acute
setting.
• WHY?- This score can be used to help clinicians determine the
severity of a stroke and predict clinical outcomes
HOW?

SCALE CATEGORY AND DESCRIPTION SCORING

1a Level of consciousness 0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor
stimulation to obey,
answer, or respond.
2 = Not alert; requires repeated stimulation
to attend, or is
obtunded and requires strong or painful
stimulation to
make movements (not stereotyped).
3 = Responds only with reflex motor or
autonomic effects or
totally unresponsive, flaccid, and areflexic.

1b Level of consciousness questions 0 = Answers both questions correctly.

• Month 1 = Answers one question correctly.
• Age 2 = Answers neither question correctly.
1c Level of consciousness commands 0 = Performs both tasks correctly.
• Open/close eyes 1 = Performs one task correctly.
• Grip/release non-paretic hand 2 = Performs neither task correctly.
2 Best Gaze 0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze paresis not overcome by the
oculocephalic maneuver.

3 Visual Field Testing 0 = No visual loss.

1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).

4 Facial Paresis 0 = Normal symmetrical movements.

1 = Minor paralysis (flattened nasolabial fold, asymmetry on
smiling).
2 = Partial paralysis (total or near-total paralysis of lower
face).
3 = Complete paralysis of one or both sides (absence of
facial movement in the upper and lower face)
5a Motor Function (Left arm) 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion

5b Motor Function (right arm) 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion
6a Motor function(left leg) 0 = No drift; leg holds 30-degree position for full 5 seconds.
1 = Drift; leg falls by the end of the 5-second period but does
not hit bed.
2 = Some effort against gravity; leg falls to bed by 5
seconds, but has some effort against gravity.
3 = No effort against gravity; leg falls to bed immediately.
4 = No movement.
UN = Amputation or joint fusion,

6b Motor function(right leg) 0 = No drift; leg holds 30-degree position for full 5 seconds.
1 = Drift; leg falls by the end of the 5-second period but does
not hit bed.
2 = Some effort against gravity; leg falls to bed by 5
seconds, but has some effort against gravity.
3 = No effort against gravity; leg falls to bed immediately.
4 = No movement.
UN = Amputation or joint fusion,

7 Limb Ataxia 0 = Absent.

1 = Present in one limb.
2 = Present in two limbs.
UN = Amputation or joint fusion
8 Sensory 0 = Normal; no sensory loss.
1 = Mild-to-moderate sensory loss; patient feels pinprick is
less sharp or is dull on the affected side; or there is a
loss of superficial pain with pinprick, but patient is aware
of being touched.
2 = Severe to total sensory loss; patient is not aware of
being touched in the face, arm, and leg.

9 Best language 0 = No aphasia; normal.

1 = Mild-to-moderate aphasia; some obvious loss of fluency
or facility of comprehension, without significant
limitation on ideas expressed or form of expression.
Reduction of speech and/or comprehension, however,
makes conversation about provided materials difficult
or impossible. For example, in conversation about
provided materials, examiner can identify picture or
naming card content from patient’s response.
2 = Severe aphasia; all communication is through fragmentary
expression; great need for inference, questioning, and guessing
by the listener. Range of information that can be exchanged is
limited; listener carries burden of communication. Examiner
cannot identify materials provided from patient response.
3 = Mute, global aphasia; no usable speech or auditory
comprehension.
10 Dysarthria 0 = Normal.
1 = Mild-to-moderate dysarthria; patient slurs at least some
MAMA words and, at worst, can be understood with some
TIP – TOP difficulty.
FIFTY – FIFTY 2 = Severe dysarthria; patient's speech is so slurred as to be
THANKS unintelligible in the absence of or out of proportion to
HUCKLEBERRY any dysphasia, or is mute/anarthric.
BASEBALL PLAYER UN = Intubated or other physical barrier

11 Extinction and inattention(neglect) 0 = No abnormality.

1 = Visual, tactile, auditory, spatial, or personal inattention
or extinction to bilateral simultaneous stimulation in one
of the sensory modalities.
2 = Profound hemi-inattention or extinction to more than
one modality; does not recognize own hand or orients
to only one side of space.
INTERPRETATION
 MANAGEMENT OF ACUTE ISCHEMIC STROKE
• Basic emergent supportive care (ABC of resuscitation)
• Hypoglycemia (<60 mg/dL) and Hypertension (SBP >180 mmHg and DBP >110 mmHg) should
be treated before initiation of rt-PA
• Normoglycemia should be achieved in all patients of stroke.
• Antihypertensive:
• Labetalol: 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
• Nicardipine: 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 min, maximum 15
mg/h; or
• Clevidipine: 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached;
maximum 21 mg/h
• If BP not controlled or diastolic BP >140 mmHg, consider IV sodium nitroprusside
• The goal is to complete an evaluation and to begin fibrinolytic treatment within 60
minutes of the patient’s arrival in an ED.
• rt-PA (0.9 mg given in first 60 mins; 10% given as bolus in first min; max: 90mg)
given in carefully selected patients within 3 to 4.5 hours of onset of symptoms unless
contraindicated.
The following are the indications and contraindications of rtPA (alteplase)
Indication Contraindication
Clinical diagnosis of stroke Sustained BP >185/110 mmHg despite treatment

Onset of symptoms to time of drug administration Bleeding diathesis

< or equal to 4.5 hours
CT scan showing no hemorrhage or edema of >1/3
of the MCA territory
Age more than or equal to 18 years.
Recent head injury or intracerebral hemorrhage
Major surgery in preceding 14 days
Gastrointestinal bleeding in preceding 21 days

Recent MI
• Monitor BP every 15 min for 2 h from the start of Alteplase therapy, then every 30
min for 6h, and then every hour for 16 h
• Mechanical thrombectomy for recanalization in patients with large artery occlusion is
indicated within 24 hours of onset of symptoms.
NEUROPROTECTIVE INTERVENTION: 5 ‘H’ PRINCIPLE
Avoid Hypotension Hypotension is detrimental in stroke. Permissive
hypertension is maintained to restore the blood
circulation. INTERVENTION:The cause of arterial
hypotension in acute stroke should be determined and
addressed: e.g., aortic dissection, volume depletion,
blood loss, and decreased cardiac output secondary to
MI or cardiac arrhythmias. Correct hypovolemia with
plain NSS, and treat arrhythmias to optimize cardiac
output.Available vasopressors agents include
dopamine, dobutamine, and phenylephrine.

Avoid Hypoxemia Hypoxemia is avoided to maintain adequate tissue

oxygenation INTERVENTION:supplemental oxygen
is given when O2sat is <94%
Avoid Hypoglycemia Hypoglycemia can mimic the stroke symptoms

INTERVENTION:Prompt determination of blood

glucose should be done in all stroke patients
Avoid Hyperglycemia Hyperglycemia can increase the severity of stroke

INTERVENTION:For patients who are feeding,

add prandial insulin ( fast acting insulin)Avoid
glucose containing D5 IV fluids. Give isotonic
(0.9% NaCl) solution for 24 hours
Avoid Hypothermia Hyperthermia increases the relative risk (RR) of 1-
year mortality by 3.4 times. For every 1°C increase
in the body temperature, the RR of death or
disability increases by 2. On the other hand,
hypothermia can reduce the infarct size by 44% in
animal studies.

INTERVENTION:Maintain normothermia for all

stroke patients.Treat fever with antipyretics and
cooling blankets. Investigate for the source of fever
(e.g. infection).
• IV isotonic solution (0.9% NaCl) is mandatory for hydration
• Bed is elevated to 30 degrees to help handle patient’s oral secretions, especially if
dysphagia is present.
• Early rehabilitation once the patient is stable
• Any age diagnosed to have first or recurrent stroke admitted within 24 hours
• Systolic BP between 120 220 mm Hg
• Oxygen saturation of 92% (with or without supplementation)
• Heart rate between 40-100 beats per minute
• Temperature < 38.5 degrees Celsius
• Oral anticoagulants or warfarin should be administered after 24 hours of rt-PA
administration
• Swallow and speech evaluation is done before the diet is started.
• Stroke neurological assessment should be performed every 4 hours
• Continuous cardiac monitoring of stroke patient should be provided for atleast 24 to 48
hours.
 MANAGEMENT FOR THIS PATIENT
• Admit the patient in Intensive Care Unit
• Diet: NPO until Speech and swallowing evaluation is done screen for dysphagia
• IV Fluids: PNSS 1 litre at 70cc/hr
• Vital signs: Monitor vitals BP every 15 min for 2 h from the start of Alteplase therapy, then
every 30 min for 6h, and then every hour for 16 h; Monitor neuro vital signs every 4 hrs
• Meds:
 Alteplase 50mg (10% -IV bolus,90%- over 1 hr)IV within 3-4.5 hrs of stroke symptom onset
 Aspirin 300mg/d PO within 48 hrs of stroke symptom onset but after 24 hrs of alteplase
treatment
• Monitor I and O q shift
• Complete bed rest without bathroom privilege
• Provide bedside commode
• Monitor for any other unusualities
• Refer to neurologists