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Stroke

Background

  • Preferred term: Stroke (CVA is like saying heart attack instead of STEMI)

  • Sudden onset, focal (usually one-sided) neurologic deficits: weakness, sensory loss, vision loss, ataxia/unsteadiness, vertigo, double vision, facial droop, dysarthria, aphasia

  • Differential:

    • stroke (ischemic or hemorrhagic)

    • seizure or post-ictal paralysis

    • headache phenomena (complex migraine)

    • cervical spinal cord lesions, though these more commonly cause bilateral symptoms

  • Stroke-like symptoms can also develop as recrudescence – previous stroke or brain lesion symptoms worsening with systemic toxic/metabolic/infectious processes or hypotension

Evaluation

-Critical decision-making information: last known normal (LKN), time symptoms first observed, anticoagulation status, recent surgeries, history of bleeding (severe GIB or ICH), recent medications, platelet count, and baseline neuro exam

  • If symptoms developed with LKN within 24 hours -> stroke alert! Purpose of Stroke Alert is to work pt up for acute treatment (thrombolytics and thrombectomy).

    • VUMC: call 11111 and tell the operator stroke alert and current patient location

    • NAVA: Dial 911 from a VA landline and tell them you want to call a Stroke Alert. Use Stroke Orderset and order a CTH/CTA H/N. Consult and STAT page Neurology residents at 835-5137. Call National Tele-Stroke Provider (469-627-4790), who will run the alert with Neurology residents assisting if possible.

  • If < 24 hours, can request Neuro Alert instead. Look for Neuro Alert under Orders in Epic. Neurology will determine if it should be escalated to a Stroke Alert.

  • STAT CT Head/CTA/CTP for consideration of TNK or endovascular therapy

    • If renal function is abnormal, discuss with neurology
    • MRI/MRA is an option but takes longer (MRAs are also better with Gadolinium)
    • Neurology service should be leading this portion

Management

  • Blood pressure goals

    • Ischemic stroke:

      • In general, aim for SBP 110-220, avoiding anti-hypertensives and hypotension

      • Patients with intracranial atherosclerosis may require higher BP to maintain perfusion

    • Hemorrhagic stroke:

      • In general, SBP 130-150 but no need to press if running less

      • These pts are managed in Neuro ICU

      • Reverse coagulopathies and keep platelets >100,000

    • Q1H neuro checks

    • EKG/telemetry

    • TTE with Contrast to assess for intracardiac thrombus/PFO

    • A1c with goal <7.0%

    • LDL with goal <70