stroke acnp bootcamp 2012
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Stroke ACNP Bootcamp 2012. Briana Witherspoon, MSN, ACNP-BC, CCRN, CNRN . Stroke Objectives. Review Ischemic Stroke Algorithm Identifying location of ischemic stroke Acute management of an ischemic stroke Acute management of hemorrhagic stroke . Stroke Algorithm . NIHSS. - PowerPoint PPT PresentationTRANSCRIPT
StrokeACNP Bootcamp 2012
Briana Witherspoon, MSN, ACNP-BC, CCRN, CNRN
Stroke Objectives
• Review Ischemic Stroke Algorithm• Identifying location of ischemic stroke• Acute management of an ischemic stroke• Acute management of hemorrhagic stroke
Stroke Algorithm
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;53:126-131Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)
Etiology of Ischemic StrokesLARGE VESSEL THROMBOTIC:Virchow’s 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 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, Fat, air, or septic 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 SignsRIGHT 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, anosognosia, topographical difficulty,
apraxia, constructional impairment
• ACA: – Leg>arm weakness, grasp– Cognitive: muteness, perseveration, abulia, disinhibiition
• PCA: – Hemianopia– Cognitive: memory loss/confusion, alexia
• Cerebellum: – Ipsilateral ataxia
Circle of Willis
Aphasia• Broca’s
– Expressive aphasia– Left posterior inferior
frontal gyrus
• Wernicke’s– Receptive aphasia– Posterior part of the superior temporal gyrus– Located on the dominant side (left) of the brain
Case 1 • 71 year old female with sudden onset of left-sided
weakness
• She was out with her sisters when she suddenly slumped her head and appeared to have a left facial droop
• History of HTN and atrial fibrillation
• Meds: Losartan
Case 1• BP- 142/83, 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- DTR's are symmetric, Left toe up
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 StrokeSMALL VESSEL (Lacunes <1.5cm)•Risk Factors
– HTN– HLD– DM– Tobacco Use– Sleep apnea
Case 2 • 65 year old male with acute onset of 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
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
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
Case 4
• BP- 132/74, P– 84
• General exam: Unremarkable, RRR
• NEURO EXAM:- Left face, arm, and leg weakness- Neglect- DTR’s 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
Intracranial Hemorrhages
Causes of ICH • Traumatic• Spontaneous
– Hypertensive– Amyloid angiopathy– Aneurysmal rupture– Arteriovenous malformation rupture– Bleeding into tumor– Cocaine and amphetamine use
Causes of ICH
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)
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
Pontine Hemorrhage• Pin-point but reactive pupils• Abrupt onset of coma• Decerebrate posturing or flaccidity • Ataxic breathing pattern
Cerebral Hemorrhage
JPG
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
ImagingCT 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
Multimodal ImagingMultimodal CT• Typically includes non-
contrast 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 diffuse-weighted imaging (DWI) and PWI (perfusion- weighted imaging)
tPaFast Facts
• Tissue plasminogen activator
• “clot buster”• IV tpa window 3 hours• IA tpa window 4.5 hours
Contraindications• Hemorrhage• SBP > 185 or DBP > 110, or
aggressive treatment (IV medication) necessary to achieve these limits
• Surgery, trauma or stroke within last 3 months
• Coagulopathy• Seizure at onset of symptoms• NIHSS <4, >21• Age?
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)
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
Hypothermia• “ Although strong experimental and clinical
evidence indicates that induced hypothermia can protect the brain in the presence of hypoxia or ischemia, including cardiac arrest, data about the utility of induced hypothermia for patients with acute stroke are not yet available”.
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
• Hesselink, J. Imaging of cerebral hemorrhages and AV malformations. http://spinwarp.ucsd.edu/neuroweb/Text/br-740.htm. accessed May 10, 2012.
Questions?