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 Intracerebral Subarachnoid
Stroke Hemorrhage Hemorrhage

Clot occluding Bleeding Bleeding around

artery into brain brain
85% 10% 5%
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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

0 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 - Left gaze preference
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 MRI
Non- contrast CTH Superior for showing
remains the gold underlying structural
standard as it is superior lesions
for showing IVH and ICH
Contraindications
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
 Acute (4 hours) Subacute (4 days)
Infarction Infarction
R L R L

Subtle blurring of gray-white Obvious dark changes &

junction & sulcal effacement mass effect (e.g.,
ventricle compression)
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ters/ok/gordon.ppt
 Multimodal Imaging
Multimodal CT Multimodal MRI
Typically includes non- Standard MRI sequences
contrast CT, perfusion ( T1 weighted, T2
CT, and CTA weighted, and proton
density) are relatively
Two types of perfusion
insensitive to changes in
CT cerebral ischemia
Whole brain perfusion
Multimodal adds diffuse-
CT
weighted imaging (DWI)
Dynamic perfusion CT
and PWI (perfusion-
weighted imaging)
 tPa
Fast Facts Contraindications
Tissue plasminogen Hemorrhage
activator SBP > 185 or DBP > 110
clot buster Recent surgery, trauma
or stroke
IV tpa window 3 hours
Coagulopathy
IA tpa window 4.5
Seizure at onset of
hours symptoms
Disability risk 30% NIHSS >21
despite ~5% Age?
symptomatic ICH risk 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
Penumbra
BP increase is due to
arterial occlusion (i.e.,
an effort to perfuse Core

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
outcomes Artery

www.acponline.org/about_acp/chap
ters/ok/gordon.ppt
Save the Penumbra!!
Normal
20 function

15
Neuronal CBF
PENUMBRA dysfunctio 8-18
10 n

5 Neuronal CBF
CORE death <8

1 2 3
TIME (hours) CEREBRAL
BLOOD
FLOW
(ml/100g/min)
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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?