Ischemic Stroke Pearls

Presentation and buzz words:

• Sudden onset of focal neurological deficits.

• Recognize the "VAN" suggesting a large vessel occlusion: vision, aphasia, neglect.

One liner:

• When presenting the one liner, note patient's last known well, symptom discovery (if different), NIHSS score concerning for X stroke, if they had any interventions, and the reason why they are admitted to the NeuroICU. 

• Example: "Mr. K's LKW was on 7/12 at 5pm, symptom discovery was at 7pm by wife, initial NIHSS score 12 concerning for a L MCA stroke, s/p thrombolysis with TNK and mechanical thrombectomy for a L M1 occlusion with TICI 0. Admitted to the NeuroICU for malignant edema watch."

Diagnose etiology:

• If your patient is admitted to the NSICU, it's unlikely their stroke is undiagnosed. They are here for complex stroke care with secondary injury monitoring.

  • • • Meaning monitoring for post-mechanical thrombectomy care, malignant cerebral edema requiring hyperosmolars or decompression, treating hemorrhagic transformation or starting anticoagulation on a recently injured brain at risk for bleeding. 

      • In our institution post tPA patients go to an intermediate care unit for monitoring and not to NSICU. 

• Review their ED imaging:

  • • • Non-con head CT 

        • • • Look for early hypodensities, hemorrhagic transformation, calculate ASPECTS score.

      • CT angiography

        • • • Look for vessel occlusions, intracranial or extracranial atherosclerosis, vascular pathology such as dissections or moyamoya physiology.

• Send stroke work up to diagnose etiology of stroke: 

  • • • Lipid panel - start statin if LDL >100

      • HgbA1c

      • EKG/Telemetry daily check - look for afib or paroxysmal afib

        • • • If afib, calculate their CHADS VASc score, which tells us the risk for stroke and the need for anticoagulation. 

      • Echo with bubble - to look for shunt, severe depressed function, cardiac thrombus, or changes suggestive of afib)

      • CT angiogram and neck - to look for intracranial and extracranial atherosclerosis

• For young patients, a broader work up might be needed such as hypercoagulable work up - this is super important to be able to guide management to prevent a future stroke. 

Stroke ICU course/ possible complications: 

• Malignant cerebral edema is characterized by a rapid and significant increase in brain tissue swelling with increasing ICPs. It typically develops within the first 24 to 48 hours after stroke onset (earlier than the typical post stroke edema at 3-5 days).

  • • • Can be further complicated by AMS, coma, and herniation. 

      • Management includes reducing ICP via head-of-bed elevation, osmotic therapy, and sometime neurosurgical decompression.

• Hemorrhagic transformation refers to the conversion of an ischemic area of the brain into a region of bleeding.

  • • • Associated with worse outcomes after an ischemic stroke, as the presence of bleeding can exacerbate brain injury and increase the risk of neurological deterioration. It can also limit the use of anticoagulation or antiplatelet therapy.

Severity Scores

• NIH Stroke Score for everyone 

• Alberta Stroke Program Early CT Score (ASPECTS) to assess the extent of MCA strokes severity on CT scan

• TICI score: post thrombectomy outcome score

• Hemorrhagic transformation index: HI1/HI2/PH1/PH2

#Ischemic Stroke Plan Guidance 

• Did the patient receive thrombolysis - TNK (tenecteplase) / tPA (alteplase)? 

  • • • At what time was it administered? 

      • Who is eligible? If they weren't, why not?

        • • • <4.5 hours of LKN, last known normal

            • None of the below contraindications

      • Contraindications:

        • • • Significant head trauma or prior stroke in previous 3 months

            • SAH, ICH, intracranial neoplasm, AVM, or aneurysm

            • Recent intracranial or intraspinal surgery, active internal bleeding

            • Bacterial endocarditis

            • SBP >185 mmHg or DBP >110 mmHg

            • Glucose <50mg/dL

            • Platelet count <100 000/mm3

            • Current use of anticoagulant with INR >1.7 

            • Current use of thrombin inhibitors or factor Xa inhibitors, if last dose <48hr prior

            • CT w/ hypodensity >1/3 cerebral hemisphere

      • Complications:

        • • • Bleeding

            • Avoid foley catheter, arterial punctures 24h after administration 

            • Need 24hr stability CT

  • Did the patient receive endovascular therapy (thrombectomy)?

    • • Who is eligible?

        • • • Evidence of large vessel occlusion

            • < 24 hours of LKN

            • If patient presented after 6 hours from onset, decision is based on ASPECTS score, mRS, NIHSS and CT Perfusion 

      • Complications:

        • • • Hemorrhagic transformation, edema, reocclusion.

      • Post-thrombectomy outcome is determined by the "TICI score."

• Are they at risk for malignant cerebral edema?  

  • • • High risk factors include: 

        • • • Early swelling (within 24-48h)

            • SBP > 180

            • Young age

            • Early AMS

            • Involvement of multiple vascular territories

      • Typically treated with hyperosmolars +/- decompressive hemicraniectomy 

        • • • A decompressive hemicraniectomy may be offered based on the inclusion criteria of DECIMAL, DESTINY and HAMLET. They showed a mortality benefit (not a morbidity benefit). This is discussed with family. 

• Do they have hemorrhagic transformation?

  • • • Hemorrhage should be in the distribution of an evolving ischemic vascular territory

      • Look for Hemorrhagic Classification score based on radiology imaging. 

      • Is the hemorrhage clinically significant?

      • See ICH tab for management of "PH2" hemorrhagic transformation

• q1h neuro checks, consider spacing them out if appropriate (ask your APP/fellow).

• Maintain normothermia, euvolemia, oxygen saturation >94%

• Review telemetry for any paroxysmal afib.

  • • • If afib, calculate their CHADS VASc score, which tells us the risk for stroke and the need for anticoagulation. 

• Maintain strict glucose control (140-180 mg/dL). What is your patient's most recent glucose? What is their 24hr insulin requirement?

• Systolic blood pressure typically <160, but should be individualized to your patient depending on their cerebral perfusion and the neuroendovascular team if post-thrombectomy.

• Follow-up stroke lab work up to establish etiology and guide future prevention.

• If at risk for edema, note sodium goals and if hyperosmolars are being used, and whether patient is a decompressive hemicraniectomy candidate.

Medications:

• DAPT: aspirin and clopidogrel (or ticagrelor)

• Statin: starting a statin has been shown to be beneficial to decrease stroke recurrence, if LDL >100, then we start a high dose statin.

• Anticoagulation: typically heparin gtt initially with plans to convert to NOAC or warfarin when going to floor.

• PRN antihypertensives: how often is your patient requiring these? If they requiring continuous blood pressure drips, what is the weaning plan?

• Hyperosmolar treatment if treating cerebral edema: hypertonics and/or mannitol