Diagnosis and

Management of Acute
Stroke
Briana Witherspoon DNP,
ACNP-BC

Stroke Objectives
Review etiology of strokes
Identify likely location/type of stroke
based of physical exam
Acute management of ischemic
stroke
Acute management of hemorrhagic
stroke

Stroke Fast Facts

Affects ~ 800, 000 people per year
Leading cause of disability, cognitive
impairment, and death in the United States
Accounts for 1.7% of national health
expenditures.
Estimated U.S. cost for 2012 = $71.5 billion
Mostly hospital (esp. LOS) & post stroke costs
Appropriate use of IV t-PA s long-term cost
Appropriate billing for AIS w/ thrombolysis (
hospital reimbursement
from $5k to $11.5k)
Stroke. 2013;44:2361-2375

Where Were Headed

By 2030 ~ 4% of the US population over
the age of 18 is projected to have had a
stroke
Between 2012 and 2030, total direct
stroke-related medical costs are expected
to increase from $71.55 billion to $183.13
billion
Total annual costs of stroke are projected to
increase to $240.67 billion by 2030, an
increase of 129%
Stroke. 2013;44:2361-2375

Three Stroke Types

Ischemic
Stroke

Intracerebral
Hemorrhage

Subarachnoid
Hemorrhage

Clot occluding
artery
85%

Bleeding
into brain
10%

Bleeding around
brain
5%

www.acponline.org/about_acp/chap
ters/ok/gordon.ppt

http://www.phillystroke.org/content
/learn_about_stroke/act_fast.asp

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

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

NIHSS cont.
NIHSS Interpretation
Stroke Scale

Stroke Severity

No Stroke

1-4

Minor Stroke

5-15

Moderate Stroke

15-20

Moderate/Severe Stroke

21-42

Severe Stroke

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 1999;53:126-131
Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)

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

Etiology Of Ischemic 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, Emboli

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

Cortical Signs
RIGHT BRAIN:

LEFT BRAIN:

- Right gaze
preference

- Left gaze preference

- Neglect

- Aphasia

If present, think LARGE VESSEL stroke

Large Vessel Stroke Syndromes

MCA:
Arm>leg weakness
LMCA cognitive: Aphasia
RMCA cognitive: Neglect,, topographical difficulty,
apraxia, constructional impairment
ACA:
Leg>arm weakness, grasp
Cognitive: muteness, perseveration, abulia, disinhibition
PCA:
Hemianopia
Cognitive: memory loss/confusion, alexia
Cerebellum:
Ipsilateral ataxia

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

Case 1
74 year old African American female with
sudden onset of left-sided weakness
She was at church when she noted left
facial droop
History of HTN and atrial fibrillation
Meds: Losartan

Case 1
BP- 172/89, 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

Case 1

Case 1

Case 1

Case 1

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

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

Etiology of Stroke
SMALL VESSEL (Lacunes <1.5cm)
Risk Factors
HTN
HLD
DM
Tobacco Use
Sleep apnea

Case 2
85 year old male who woke up with left face, arm,
and leg numbness
History of HTN, DM, and tobacco use
Meds: Insulin, aspirin

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

Case 2

Case 2
Right thalamic lacunar infarct
Not a candidate for intervention (WHY?)
Discharged to rehab 72 hours after admission

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

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

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

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

Case 3

Case 3

Case 3
Brainstem Stroke
Received IV tPa
Post-tPa symptoms greatly
improved regained sensation, ataxia
resolved
Discharged home with out patient
PT/OT

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

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
Meds - Lisinopril

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

Case 4

Case 4

Case 4

Case 4

Case 4

Case 4

Case 4

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
Patient was discharged to in-patient rehab

Intracranial Hemorrhages

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

Causes of ICH

http://spinwarp.ucsd.edu/neuroweb
/Text/non-trauma-ER.htm

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

Ganglionic Bleed

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

Cerebral Hemorrhage

JPG

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

Cerebellar Hemorrhage

Pontine Hemorrhage

Pin-point but reactive pupils

Abrupt onset of coma
Decerebrate posturing or flaccidity
Ataxic breathing pattern

Pontine Hemorrhage

Subarachnoid Hemorrhage

Worst headache of my life

AMS
Photophobia
Nuchal rigidity
Seizures
Nausea and vomiting

Subarachnoid Hemorrhage

Management

Airway
Most likely related to decreased level of consciousness
(LOC), dysarthria, dysphagia
GCS < 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

Stroke Algorithm

Imaging
CT scan
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

MRI
Superior for showing
underlying structural
lesions
Contraindications

Acute (4 hours)
Infarction

Subacute (4 days)
Infarction
L
R

Subtle blurring of gray-white

junction & sulcal effacement

Obvious dark changes &

mass effect (e.g.,
ventricle compression)
www.acponline.org/about_acp/chap
ters/ok/gordon.ppt

Multimodal Imaging
Multimodal CT
Typically includes noncontrast CT, perfusion
CT, and CTA
Two types of perfusion
CT
Whole brain perfusion
CT
Dynamic perfusion CT

Multimodal MRI
Standard MRI sequences
( T1 weighted, T2
weighted, and proton
density) are relatively
insensitive to changes in
cerebral ischemia
Multimodal adds diffuseweighted imaging (DWI)
and PWI (perfusionweighted imaging)

tPa
Fast Facts
Tissue plasminogen
activator
clot buster
IV tpa window 3 hours
IA tpa window 4.5
hours
Disability risk 30%
despite ~5%
symptomatic ICH risk

Contraindications
Hemorrhage
SBP > 185 or DBP > 110
Recent surgery, trauma
or stroke
Coagulopathy
Seizure at onset of
symptoms
NIHSS >21
Age?
Glucose < 50

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

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)

BP-AIS Relationship
BP increase is due to
arterial occlusion (i.e.,
an effort to perfuse
penumbra)
Failure to recanalize (w/
or w/o thrombolytic
therapy) results in high
BP and poor neuro
outcomes
Lowering BP starves
penumbra, worsens Clot in
Artery
outcomes
www.acponline.org/about_acp/chap
ters/ok/gordon.ppt

Penumbra

Core

Save the Penumbra!!

Normal
function

20
15
10

PENUMBRA

CORE
1

Neuronal
dysfunctio
n

CBF
8-18

Neuronal
death

CBF
<8

TIME (hours)

CEREBRAL
BLOOD
FLOW
(ml/100g/min)

www.acponline.org/about_acp/chap
ters/ok/gordon.ppt

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

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

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/content/112/24_suppl/IV-111/F1.expansion.html
.
Accessed May 8, 2012
Gordon, D. L. (n.d.). Update in stroke management . Retrieved from
www.acponline.org/about_acp/chapters/ok/gordon.ppt
Hesselink, J. Imaging of cerebral hemorrhages and AV malformations.
http://spinwarp.ucsd.edu/neuroweb/Text/br-740.htm . accessed May 10,
2012.

Questions?