REM: Stroke - Cerebrovascular Accident

Cerebrovascular Accidents or Strokes are one of the most common causes of morbidity and mortality in the Western World. People having Strokes will often present through the Emergency Department and as such earlier recognition and timely treatment is crucial in preventing secondary neurological injury.

This is part of the Rural Emergency Module series (designed in particular for ACRRM Trainees).

Quick Facts

Stroke is the second commonest cause of death (10-12%)
80-85% are ischaemic (thrombotic or embolic) and 15-20% the more lethal haemorrhagic stroke (including 5% SAH), of which over 50% will die by 1 month.

Aims:

1. Rapid recognition of Symptoms and Diagnosis

Prehospital: In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA.
Early CT Scan if available within ED (ideally less than 1hr even if outside thrombolysis window)
Identifying Ischaemic vs Haemorrhagic

2. Early intervention

Antiplatelet Therapy
Thrombolysis (if a candidate within 4.5hrs of stroke onset)

3. Specialist care for people with acute stroke
4. Nutrition, hydration and rehabilitation

Initial Assessment and Management

Recognition

Recognise, send for help, gather resources and appropriate equipment.
Move to resuscitation bay.
Continuous Monitoring and observations ideally q15m
Early liaison with Stroke Specialist through phone or Telemedicine.

Airway:

Check airway. Manage airway with intubation if concerns regarding airway protection in neurologically impaired patient.
C-spine protection if any suspicion of con-current trauma.
Suction for secretions.

Breathing:

If breathing is inadequate, assist with BVM + high flow oxygen in interim. Avoid hyperventilation.
Correct hypoxia, maintain SpO2 >94%

Circulation:

IV Access
NBM until further swallow assessment and IV fluids
Blood pressure control if Systolic BP >200. Avoidance of hypotension equally important.
ECG & Cardiac Monitoring

Disability:

Level of consciousness – GCS, AVPU
Check BSL & target normoglycaemia ( < 10mmol)
Focal neurology
The three most predictive examination findings for the diagnosis of acute stroke are facial paresis, arm drift/weakness, and abnormal speech.

Exposure:

Check temp, maintain Normothermia.
Reminder to check bedside BSL + VBG if able
Correct electrolyte disturbances

Parameters should be optimised in Emergency Department before any formal radiology is done. Note that optimisation does not necessarily equal return to normal function, and definite imaging should not be extensively delayed.

History

Signs/symptoms

Sudden-onset neurological deficit
Altered level of consciousness
Sudden onset headache + vomiting, favour ICH or SAH compared to ischaemic stroke.

Allergies

To treatments (e.g. aspirin)

Meds

Anticoagulants (causing possible ICH)
Antiepileptics
Recreational drugs, drug withdrawal
Insulin therapy

PMHx:

Prev CVAs, thromboembolic events, Atrial Fibrillation, Carotid stenosis
HTN, Smoker, Dyslipidaemia
Also to consider DDx: epilepsy, drug abuse, recent trauma

Last oral intake
Events

Establishing time-course crucial (will determine if candidate for reperfusion interventions if ischaemic CVA)

Investigations

Initial

VBG – Glucose + Basic Electrolytes + Lactate, +/- POC INR (if on anticoagulants)
FBC + Chem20 (U&E + LFTs + Ck + CMP)
12-lead ECG (looking in particular for AF)
Coagulation Studies
Urine Dipstick + Formal M/C/S if indicated
CT Head

Also consider in select circumstances and as availability dictates. Bear in mind resources, clinical competence and risks with transfer.

Lipids
CXR
Lumbar Puncture (if SAH suspected and CT negative)
Prothrombotic Screen
CT Head and CT Neck Angio, CT Perfusion Studies
MRI

Management

Aim is to initiate early treatments and transfer to an appropriate Stroke Facility (ideally within 3hrs). Seek specialist input during early management phase.

Clarify treatment goals and wishes of patient, bearing in mind acute clinical picture, availability of resources and likely prognosis. Remember Palliative Care principles if a severe deteriorating stroke and not for active management.

Stroke severity should be assessed and recorded by a health practitioner using a validated tool (e.g. NIHSS).

Stroke Scores

Stroke Pathway

This is an example of a stroke pathway (modified off Logan Hospital Stroke Pathway in Queensland) for patients presenting to the emergency department with a suspected stroke within 24hrs of symptom onset. It assumes that you are constantly reassessing/re-evaluating the patient for ‘stroke mimics’, in which case you would exit the pathway. Note if initial CT Head NAD, shoulder consider DDx + risk-stratify TIA. Transfer to a higher-level facility can occur at any stage, provided ABCDE optimized.

The upshot of all this rurally is that our patients may still have time to get to meaningful interventional treatment for their ischaemic neurovascular event. Particularly as more interventional radiology sites come online.

Reperfusion Therapy

Thrombolysis

Dose is tPA 0.9 mg/kg IV (not to exceed a total 90mg dose, regardless of the patient’s weight). A 10% bolus is given intravenous push over one minute. The remaining 90% is infused over 60 minutes via an infusion pump.
Be aware of Contraindications and exclusion criteria.
Be prepared to manage complications; including ICH.

The evidence for Thrombolysis in Stroke is not as great as for it's use in Myocardial Infarction (STEMIs). It is important that you also have an appropriate discussion of risks/benefits with the patient, be their advocate, and be mindful of the complications of Lysis that YOU might have to end up managing. There are other posts which cover the controversies, however First10EM's post from 2017 is a good place to start https://first10em.com/thrombolytics-for-stoke/.

Neuro-intervention
There is increasing evidence that Endovascular Clot Retrieval (mechanical thrombectomy) can be of benefit to a subset of ischaemic stroke patients. As this is a rapidly evolving area, and a treatment strategy not performed by Rural Generalists only a short overview is provided here.

Some suggested selection criteria;

documented large vessel anterior circulation occlusion (middle cerebral artery, M1 or
carotid T)
significant clinical deficit at the time of treatment (this might be NIHSS>5 or a lower score that is functionally significant for the patient; note that even mild deficit from proven large vessel occlusion has a high risk of clinical deterioration)
lack of extensive early ischaemic change
pre-stroke functional status and lack of serious comorbidities indicating potential to benefit from treatment (note that age>80 years alone is NOT a contraindication to treatment)
thrombectomy can be performed within 6 to 24hrs
good collateral circulation (though benefit in patients with poor collaterals remains uncertain).

Eligible stroke patients should still receive intravenous thrombolysis while awaiting ECR.
Eligibility for Neuro-intervention strategies should be discussed in consultation with the appropriate tertiary specialist.

Anti-thrombotic Therapy

Aspirin 150 – 300mg / day
Should not be given if;

Haemorrhagic stroke
Thrombolysed (should not be given within 24 hours of alteplase administration)
Active GI Bleeding
Allergy, intolerance

Addition of dipyridamole 200 mg PO BD
Consider Clopidogrel as an alternative if aspirin intolerance.

Anticoagulation

Routine use of anticoagulation in patients without cardioembolism (e.g. atrial fibrillation) following TIA/stroke is not recommended.
Seek specialist input.

General Principles/Rehab

Supportive Cares

The underlying aim of stroke management is to restore or maintain homeostasis, The FAST-HUGS-IN-BED-Please is a mnemonic I like to use/consider as part of the initial management of stroke patients, before they commence on more specific rehabilitation strategies.

Fluid therapy and feeding
Analgesia, antiemetics
Sedation
Thromboprophylaxis
Head position individualise
Ulcer prophylaxis
Glucose control
Skin/eye care and suctioning
Indwelling catheter
Nasogastric tube
Bowel cares
Environment (e.g. temperature control, appropriate surroundings in delirium)
De-escalation (e.g. end of life issues, treatments no longer needed)
Psychosocial support (for patient, family and staff)

Although typically occurring outside the Emergency Department it is important to remember that coordinated rehabilitation in a Stroke Unit is one of the fundamental management strategies. Specific strategies regarding rehab are outside the scope of this post, but take a look at the Australian Stroke and American Stroke Guidelines for more information.

Blood pressure

All acute stroke patients should have their blood pressure closely monitored in the first 48 hours after stroke onset.
Patients with acute ischaemic stroke eligible for treatment with intravenous thrombolysis should have their blood pressure reduced to below 185/110 mmHg before treatment and in the first 24 hours after treatment.
Patients with acute ischaemic stroke with blood pressure > 220/120 mmHg should have their blood pressure cautiously reduced (e.g. by no more than 20%) over the first 24 hours

Cerebral Oedema

In stroke patients with brain oedema and raised intracranial pressure, osmotherapy and hyperventilation can be trialled while a neurosurgical consultation is undertaken.

Swallow Assessment/Screen

It is estimated that Dysphagia occurs in between 40-65% of stroke patients. ~50% of the patients with dysphagia go on to aspirate, and 1/3 of patients who aspirate go on to develop pneumonia. The Emergency Department is a common area for Strokes to be diagnosed and essentially your role is to identify whether the patient should be Nil by Mouth (NBM) or able to eat in and drink.
Swallowing screening tools include a range of tasks including demographics, medical history, global assessment of function, oral mechanism examination, and direct swallowing assessment.

Some screening tools are listed below;

ASSIST – Acute Screening of Swallow in Stroke/TIA
RBWH Dysphagia Screening Tool (General and not Stroke Specific)
Toronto Bedside Swallowing Screening Test

Take a look at the above options and find a test that suits your hospital/practice. Alternatively liaise with your Local Speech Pathologist and see what they recommend. Also see Safe to swallow? Assessment of the dysphagic and dysphasic patient.

Some simple questions you can ask;

Is the patient able to:
Maintain alertness for at least 20 minutes?
Maintain posture/positioning in upright sitting?
Hold head erect?
Breath freely, not tachypnoeac (RR>25) and maintain satisfactory oxygenation levels?
Cough effectively/strongly?

A swallow assessed as safe may not remain safe during the length of someone’s admission. Be on guard and reassess. Don't forget nutritional requirements if placing the patient NBM.

Intracerebral Hemorrhage Management

Reverse Anticoagulation Agents if able to do so.

Stroke patients with intracerebral haemorrhage related to direct oral anticoagulants should urgently receive a specific reversal agent where available. (Pollack et al. 2016 [132]; Connolly 2016 [133])

Liaise with neurosurgeons for possible surgical intervention.

For selected patients with large (> 3 cm) cerebellar haemorrhage, decompressive surgery should be offered. For other infratentorial haemorrhages (< 3 cm cerebellar, brainstem) the value of surgical intervention is unclear.