update on stroke management cynthia bautista, phd, rn, cnrn nursing brains, llc

Update on Stroke Management

Cynthia Bautista, PhD, RN, CNRNNursing Brains, LLC

Clinical Guidelines

• Overview of the current evidence about the evaluation and treatment of adults with Ischemic Stroke, Hemorrhagic Stroke, or Aneurysmal Subarachnoid Hemorrhage.

• American Stroke Association

• Neurocritical Care Society

Copyright Nursing Brains, LLC

Nursing and Interdisciplinary care of

the Acute Ischemic Stroke

Patient2009


Nursing & Interdisciplinary Care of Acute Ischemic Stroke (2009)

I. Stroke Patient Triage and Care• Class I Recommendations “Should be performed”

• ED should establish procedure/protocol to expeditiously triage stroke patient

• Protocol to evaluate/treat eligible stroke patient with rtPA• Treatment with rtPA should be within 1 hour of arrival to ED• Treat eligible rtPA patients between 3 – 4.5 hour window

• NIHSS < 25, < 80 years old, no DM, no previous stroke, not on coumadin



II. Emergency Nursing Interventions/Hyperacute Phase• Class I Recommendations “Should be performed”

• ED personnel highly trained in stroke care• Frequent stroke assessments, more frequently with rtPA• Supplemental oxygen with oxygen saturation < 92%• Head in neutral alignment and HOB 25° – 30°• NPO until swallow assessed• At least 2 IV sites• Use nondextrose, normotonic IV fluids (normal saline) • Give IV rtPA without delay Copyright Nursing Brains, LLC


II. Emergency Nursing Interventions/Hyperacute Phase• Class I Recommendations “Should be performed”• Medical Recommendations

• CT/MRI performed emergently• Rapid laboratory tests (CBC, chemistry, coagulation)• IA thrombolysis with large MCA clot presenting within 6° or

contraindications to IV thrombolysis• Interventional treatment in comprehensive stroke center• When IA rtPA is considered, give IV rtPA is eligible



II. Emergency Nursing Interventions/Hyperacute Phase• Class IIa Recommendations “Reasonable to perform”• Medical Recommendations

• Use of Merci Retriever and Penumbra System • Use of IA thrombolysis



III. Acute Phase• Class I Recommendations “Should be performed”

• Neurological assessments every 4 hours• Treat temperatures > 99.6°• Continuous cardiac monitoring for at least 24°- 48°• Monitor neurological deficits/bleeding for up to 24° after tPA• Treat hyperglycemia (>140mg/dL)



III. Acute Phase (con’t)• Class I Recommendations “Should be performed”

• Cautiously treat hypertension • Monitor oxygen saturation• Auscultate lungs, assess for respiratory compromise• Assess for dysphagia• Immediately treat seizure activity (no prophylactic treatment)

• Class IIa Recommendations “Reasonable to perform”• Preprinted order sets/protocols to organize stroke care



IV. Diagnostic Testing• Class I Recommendations “Should be performed”

• Nurses should be familiar with basic neuroimaging testing so they can educate patient/family

• CT, MRI, MRA, CTA, Angiography, Carotid Ultrasound, TTE, TEE



V. General Supportive Care• Class I Recommendations “Should be performed”

• Infections should be identified and treated immediately with antibiotics

• Institute early bowel/bladder care – prevent constipation, urinary retention/infection

• Early implementation of anticoagulant therapy/physical compression modalities – unable to ambulate at 2 days/risk for DVT/PE

• Early mobilizationCopyright Nursing Brains, LLC


V. General Supportive Care (con’t)• Class I Recommendations “Should be performed”

• Initiate fall precautions• Prevent skin breakdown provide frequent turning if

bedridden• Use Braden Scale in prediction of pressure ulcer

development• Provide ROM in early phase of

acute stroke care



V. General Supportive Care (con’t)• Class I Recommendations “Should be performed”

• Keep patient NPO until swallow screen performed• Perform swallow screen in first 24 hours after stroke

preferably by speech language pathologist• Nurse to be familiar with bedside swallow assessment if

formal evaluation cannot be done within 24 hours• NG tube placed if patient cannot swallow, consider PEG if

warranted



V. General Supportive Care (con’t)• Class IIa Recommendations “Reasonable to perform”

• Provide excellent pericare if indwelling catheter is required (prevent infection)

• Provide feedings by IV, NG, or PEG

• Class IIb Recommendations “May be considered”• Provide ROM between PT visits



Secondary Stroke Prevention - Hypertension• Provide antihypertensive treatment• Individualize target BP level

• Average reduction of < 10/5 mmHg• Provide lifestyle modifications (diet & exercise)• Use diuretics and ACEI



Secondary Stroke Prevention - Diabetes• More rigorous control of BP and lipids• Use ACEI and ARBS• Provide near-normoglycemic levels• A1c ≤ 7%



Secondary Stroke Prevention - Cholesterol• Provide lifestyle modification, dietary guidelines and

medication• Statin agents are recommended• LDL-C of < 100 mg/dL• LDL-C of < 70mg/dL for high risk patient• Consider statin for no preexisting indications• Provide niacin or gemfibrozil(Lopid) for LOW HDL-C



Secondary Stroke Prevention - Smoking• Strongly encourage not to smoke • Avoid environmental smoke• Consider counseling, nicotine products, and oral

smoking cessation medications



Secondary Stroke Prevention - Alcohol• Eliminate or reduce consumption of alcohol• Men – light to moderate levels of ≤ 2 drinks per day • Women – light to moderate levels of 1 drink per day



Secondary Stroke Prevention - Obesity• Consider weight reduction • Goal BMI of 18.5 to 24.9 kg/m2

• Waist circumference of < 35 inches women• Waist circumference of < 40 for men• Encourage weight management

• Caloric intake, physical activity, behavioral counselingCopyright Nursing Brains, LLC


Secondary Stroke Prevention – Physical Activity• Most days• At least 30 minutes • Moderate-intensity physical exercise• Patient with disability, recommend supervised

therapeutic exercise regimen



Stroke and Carotid Disease• Recommend Carotid Endarterectomy

• TIA/stroke within past 6 months• Ipsilateral severe (70-99%) stenosis• Surgeon with perioperative morbidity/mortality of < 6%

• Recent TIA/stroke• Ipsilateral moderate (50-69%) stenosis• Within 2 weeks



Stroke and Carotid Disease• Recommend Carotid Artery Stent

• Symptomatic• Severe stenosis (>70%)• Difficult surgical candidate• Surgeon with perioperative morbidity/mortality of 4-6%



Stroke and Atrial Fibrillation• Provide anticoagulation with adjusted-dose warfarin

• Target INR 2.5• Range 2-3

• Unable to take oral anticoagulants use aspirin 325mg/d

• May, 2009 NEJM (ACTIVE Trial)• Treatment with clopidogrel (75mg) plus aspirin(75-100mg)

reduced the rate of vascular events among patients with atrial fibrillation. There was significant increase in risk of major hemorrhage.


Management of Spontaneous Intracerebral

Hemorrhage 2010


Management of Spontaneous Intracerebral Hemorrhage in

Adults (2010)

I. Emergency Diagnosis & Assessment of ICH• Class I Recommendation “Useful & Effective”

• Rapid neuroimaging with CT or MRI

• Class IIa Recommendation “In favor of”• CTA, CTV, CT with contrast, MRI, MRA, MRV

• Class IIb Recommendation “Less well established”• CT angiography & contrast-enhanced CT



Adults (2010)

II. Medical Treatment for ICH• Class I Recommendation “Useful & Effective”

• Provide appropriate factor replacement therapy or platelets for severe coagulation factor deficiency or severe thrombocytopenia

• Class I Recommendation “Useful & Effective”• INR elevated due to oral anticoagulants, hold warfarin,

give therapy to replace vitamin K-dependent factors, correct INR, give IV Vitamin K



Adults (2010)

II. Medical Treatment for ICH (con’t)• Class IIa Recommendation “In favor of”

• Consider giving Prothrombin Complex Concentrate (PCC)

• Class III Recommendation “Not Useful Effect”• rFVIIa is not routinely recommended



Adults (2010)

II. Medical Treatment for ICH (con’t)• Class I Recommendation “Useful & Effective

• Provide intermittent pneumatic compression prevent DVT

• Class IIb Recommendation “Less well established”• After cessation of bleeding, give low-dose sc LMWH or

UFH with lack of mobility after 1 to 4 days from onset



Adults (2010)

III. Blood Pressure• Class IIa Recommendation “In favor of”

• SBP 150 – 220 lower SBP to 140• Class IIb Recommendation “Less well established”

• SBP > 200 or MAP > 150 give IV infusion• SBP > 180 or MAP > 130 ↑ICP monitor ICP,

give intermittent or continuous IV medication• SBP > 180 or MAP > 130 maintain BP 160/90 or

MAP 110 with intermittent or continuous IV medicationCopyright Nursing Brains, LLC

Management of Spontaneous Intracerebral Hemorrhage (2010)

IV. Inpatient Management • Class I Recommendation “Useful & Effective”

• ICU care

• Treat fever to maintain normothermia• Monitor glucose, maintain normoglycemia



IV. Inpatient Management (con’t)• Class I Recommendation “Useful & Effective”

• Treat clinical seizures with antiepileptic drugs

• Class IIa Recommendation “In favor of”• Continuous EEG monitoring with decreased LOC

• Class III Recommendation “Not Useful”• Prophylactic anticonvulsant medication



V. Procedures• Class IIb Recommendation “Less well established”• ICP monitoring for

• GCS ≤ 8• Herniation• IVH• Hydrocephalus

• Maintain CPP 50 to 70



V. Procedures (con’t)• Class IIa Recommendation “In favor of”

• Treat hydrocephalus with ventricular drain with ↓LOC

• Class IIb Recommendation “Less well established”• Administration of intraventricular rtPA for IVH is

considered investigational



VI. Clot Removal • Class I Recommendation “Useful & Effective”

• Surgery ASAP for ….• Cerebellar hemorrhage >3cm • Deteriorating neurologically• Brain stem compression• Hydrocephalus



VI. Clot Removal (con’t)• Class IIb Recommendation “Less well established”

• Usefulness of surgery is uncertain• Lobar clot > 30mL and within 1cm of surface• Use of minimally invasive technique

• Class III Recommendation “Not Useful”• Very early craniotomy (increase risk of rebleed)



Adults (2010)

VII. Withdrawal of Technological Support• Class IIa Recommendations “In favor of”

• Aggressive full care until at least the second full day of hospitalization



Adults (2010)

VIII. Prevention of Recurrent ICH• Class I Recommendations “Should be performed”

• Treat hypertension • Discontinue

• Smoking• Heavy alcohol use• Cocaine use



Adults (2010)

VIII. Prevention of Recurrent ICH (con’t)• Class IIa Recommendations “In favor of”• Risk factors for ICH recurrence

• Lobar location• Older age• Ongoing anticoagulation• Greater number of microbleeds on MRI


Critical Care Management of Aneurysmal

Subarachnoid Hemorrhage2011


2011 Neurocritical Care Society Recommendations

for aSAH

• Classification of Recommendations• High– “Further research unlikely to change effect”

• Moderate– “Further research is likely to change effect”

• Low – “Further research is very likely to change effect”

• Very Low – “Very uncertain of effect”Copyright Nursing Brains, LLC

Medical Measures to Prevent Rebleed

• Early aneurysm repair (High)

• Early short course of antifibrinolytic – Amicar prior to aneurysm repair (Low)

• Avoid antifibrinolytic therapy > 48 post ictus or > 3 days, concern with side effects (High)

• Screen for DVT while on Amicar (Moderate)• Discontinue Amicar 2 hours prior to treatment (Very

Low)Copyright Nursing Brains, LLC

Medical Measures to Prevent Rebleed

(con’t)

• Treat extreme hypertension in unsecured (Low)

• Do not treat modest hypertension (MAP <110) (Low)


Seizures andProphylactic Anticonvulsant

Use

• Do not use phenytoin for prophylaxis(Low)• Consider other anticonvulsants for prophylaxis

(Very Low)• Short course (3-7days) AED prophylaxis (Low)• Give anticonvulsant with seizure presentation (Low)• Consider continuous EEG (Low)


Cardiopulmonary Complications

• Obtain baseline cardiac assessment (Strong)• Monitor CO may be useful (Low)• Treat pulmonary edema by maintaining euvolemia

(Moderate)• Treat heart failure while maintaining CPP/MAP for

cerebral perfusion (Moderate)


Monitoring Intravascular Volume

• Monitor volume status (Moderate)• No specific modality is recommended• Use clinical assessment

• Vigilant fluid balance management (Moderate)• Do not place central venous lines solely for

measurement (Moderate)• Routine use of PACs is not recommended (Moderate)


Managing Intravascular Volume

• Target euvolemia (High)• Avoid hypervolemia (High)• Use isotonic crystalloid for replacement (Moderate)• Consider fludrocortisone or hydrocortisone for

persistent negative fluid balance (Moderate)


Glucose Management

• Avoid hypoglycemia (<80 mg/dL) (High)• Maintain glucose <200 mg/dL (Moderate)• May adjust serum glucose with use of microdialysis

(Very Low)


Management of Pyrexia• Frequent temperature monitoring (High)• Seek and treat infectious fever (High)• Control fever during risk for delayed cerebral ischemia

(Low)• Use acetaminophen, ibuprofen as first line agents

(Moderate)• Surface/intravascular cooling when antipyretics fail (High)• Monitor & treat shivering with cooling (High)


Deep Vein Thrombosis Prophylaxis

• Provide DVT prophylaxis (High)• Use SCDs routinely (High)• Withhold prophylaxis LMWH or UFH in untreated

patients (Low)• Start UFH 24 hours after surgery (Moderate)• Withhold LMWH or UFH 24 hours before and after

intracranial procedures (Moderate)• Duration of DVT prophylaxis is uncertain (Low)


Statins and Magnesium

Continue statin if previously on it (Low)Consider statin for statin-naïve patient (Moderate)

Do not induce hypermagnesemia (Moderate)Avoid hypomagnesemia (Moderate)


Monitoring for DCI and Triggers for Interventions

Monitor for delayed cerebral ischemia (DCI) in environment with expertise in SAH (Moderate)

Give Nimodipine 60mg every 4 hours x21 days (High)Detect DCI with TCD, DSA, CTA, EEG, PbtO2

(Moderate)


Hemodynamic Management of DCI

Maintain euvolemia (Moderate)Consider saline bolus to increase CBF (Moderate)Trial induced hypertension with DCI (Moderate)Choose vasopressor based of effects (Moderate)Augment BP based on MAP in stepwise fashion

(Poor)Change dose of nimodipine if hypotension occurs –

discontinue with persistent hypotension (Poor)Copyright Nursing Brains, LLC

Hemodynamic Management of DCI (con’t)

Consider inotropic (Dobutamine) (Low)May need to augment with vasopressor (High)

IABP maybe useful (Low)

Do not provide hemodilution (Moderate)

Caution with increasing BP in unsecured (Low)Unruptured should not influence management

(Moderate) Copyright Nursing Brains, LLC

Endovascular Management of DCI

• Consider IA vasodilators and/or angioplasty (Moderate)• Timing of endovascular treatment is unclear (Moderate)• Do not provide prophylactic angioplasty (High)


Anemia and Transfusion

• Minimize blood loss from blood draws (Low)

• Give PRBC maintain hemoglobin 8-10g/dl (Moderate)

• Higher hemoglobin may be appropriate for patient at risk for DCI – uncertain if transfusion is useful (No Evidence)


Management of Hyponatremia

• Do not fluid restrict (Weak) • Early treatment with hydrocortisone or fludrocortisone

(Moderate)• Mild hypertonic saline (Very Low)• Avoid hypovolemia if using vasopressin-receptor

antagonists (Weak)• Limit free water intake (Very Low)


Endocrine Function

• Consider hypothalamic dysfunction when not responding to vasopressor (Moderate)

• Do not give high dose corticosteroids (High)• Consider mineralocorticoids (Moderate)• Consider • Stress-dose corticosteroids with vasospasm and

no response to induced hypertension (Weak)


High Volume Centers

• Treat at high volume center (Moderate)


Stroke Care What people are writing about..


January, 2012

• Statin Use during Ischemic Stroke Hospitalization is Strongly Associated with Improved Poststroke Survival

• Flint, A. et al Stroke, 43(1) 147-154

• Statin use early in stroke hospitalization is strongly associated with improved poststroke survival, and statin withdrawal in the hospital is associated with worsened survival


February, 2012

• Female Caregivers of Stroke Survivors: Coping & Adapting to a Life that Once Was

• Saban, K and Hogan, N. Journal of Neuroscience Nursing, 44(1), 1-14

• Describe experience of female caregiver (N = 46)• Losing the life that once was• Coping with daily burdens• Creating a new normal• Interacting with healthcare providers


March, 2012• Delirium in Acute Stroke• Shi, Q. et al Stroke, 53(3), 645-649• Systematic Review and Meta-Analysis (10 studies) • Stroke patients with development of delirium have

unfavorable outcomes (high mortality, longer hospitalization, greater degree of dependence)

• Prevention and early recognition of delirium may improve stroke outcomes


March, 2012• Lumbar Drainage of CSF after Aneurysmal

Subarachnoid Hemorrhage (LUMAS)• Al-Tamimi, Y. et al Stroke, 43(3), 677-682• N = 210• Lumbar drainage of CSF showed to

• Reduce prevalence of delayed ischemic neurological deficit• Improve early clinical outcome • Failed to improve outcome at 6 months


March , 2012• Predicting the Lack of Development of Delayed

Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage

• Crobeddu, E. et al Stroke, 43(3), 697-701• N=307• Patients who will not develop DCI

• Age ≥ 68• WFNS I – III• Modified Fisher Grade 1 – 2

• Consider these patient for early transfer to the floor


April, 2012• Trends in the Hospitalization of Ischemic Stroke

in the US, 2007• Lee, L. et al International Journal of Stroke, 7(4), 195-201

• Decreased rate of ischemic stroke hospitalization

• Increased rate among young adults

• Decreased mortality Copyright Nursing Brains, LLC

April, 2012• Alcohol Consumption & Risk of Stroke in Women• Jimenez, M. et al Stroke, 43(4), 939-945

• Light to moderate alcohol consumption was associated with lower risk of total stroke.

• .83 relative risk for 5 – 14g/d (1/2 to 1 glass)

• .79 relative risk for 15 – 29.9g/d (1 to 2 glasses)

• 1.06 relative risk for 30 – 45g/d (2 to 3 glasses)


April, 2012

• Impact of Emergency Department Transitions of Care on Thrombolytic Use in Acute ischemic Stroke

• Madej-Fermo, O. et al Stroke, 43(4), 1067-1074• Stroke presentation during change of shift did NOT

delay rt-PA use • Presentation at night did result in delay of care

undergoing interventional therapy


May, 2012• Correlation between ED Symptoms and Clinical

Outcomes in the Patient with Aneurysmal SAH• Adkins, K. et al. Journal of Emergency Nursing,

38(3), 226-33• Poor clinical grade (H&H >3) and bradycardia significant

predictor of death at 30 days


May, 2012• Frontal Infarcts and Anxiety in Stroke• Tang, W. et al Stroke, 43(5), 1426-428

• Association between posttroke anxiety symptoms and frontal lobe infarcts

• N= 693• Poststroke anxiety patients were more likely to have

RIGHT frontal acute infarcts


June, 2012

• Wakeup or unclear-onset strokes: are they waking up to the world of thrombolysis therapy?

• Kang, D. et al International Journal of Stroke, 7(4), 311-320

• 25% of strokes occur as wakeup or unclear onset• Many do not receive rt-PA• Actual onset time of wake-up stroke is close to the wake-

up time• Advanced imaging can identify favorable patient


“Time is Brain”


update on stroke management cynthia bautista, phd, rn, cnrn nursing brains, llc

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