Stroke

Background

  • Former, nonpreferred term: cerebrovascular accident
  • Sudden onset, focal (usually one-sided) neurologic deficits: weakness, sensory loss, vision loss, ataxia/unsteadiness, vertigo, double vision, facial droop, dysarthria, aphasia
  • Differential:
    • stroke (ischemic or hemorrhagic)
    • seizure or post-ictal paralysis
    • headache phenomena
    • cervical spinal cord lesions, though these more commonly cause bilateral symptoms
  • Stroke-like symptoms can also develop as recrudescence – previous stroke or brain lesion symptoms worsening with systemic toxic/metabolic/infectious processes (or hypotension)

 

Evaluation

  • Critical decision-making information: last known normal (LKN), time symptoms first observed, anticoagulation status, why pt is admitted, recent surgeries, history of bleeding (severe GIB or ICH), recent medications, last platelet count, and baseline neuro exam
  • If symptoms developed with LKN within 24 hours -> stroke alert!        
    • VUMC: call 11111 and tell the operator stroke alert and current pt location
  • NAVA: call an RRT and stat page 835-5137, include in the page 911 at the end of the call back number to signal it is a stroke alert
  • Stat head CTP (order CTH/CTA) for consideration of tPA or endovascular therapy
    • If renal fx is abnormal, discuss with neurology
    • Generally, go for CTA if the pt is a thrombectomy candidate
    • MRI/MRA is an option but takes longer (MRAs are also better with Gadolinium)
    • Neurology service should be leading this portion

 

Management

  • Blood pressure goals
    • Ischemic stroke: in general SBP <220
    • Pts with intracranial atherosclerosis may require higher BP to maintain perfusion, which may necessitate discontinuing BP meds
    • Hemorrhagic strokes (which will be obvious on CTH): SBP < 140 (BP management is key)
      • These pts are managed in Neuro ICU
      • Reverse coagulopathies and keep platelets >100,000