March 18th, Stroke

Quick mention on stroke

Consider other causes if decreased LOC, hypoglycemic? low BP? seizure?

Remember FAST exam, facial droop, arm weakness/drift, speech slurring/ timing (4.5 hours!)

First test - CT head without contrast, looking for a bleed - if present... can't give TPA

Neurology should be called ASAP, we will often perform NIH stroke scale score, if scores are too low we may not give as we know they have little gain but still have a chance to bleed. If scores are very high, they also may be at risk of hemorrhagic conversion.

6% of patients given TPA as per initial NINDS trial. From this original trial there was no mortality benefit but better outcomes in regards to morbidity.

Before TPA, must go through checklist as similar to PE to check for contraindications.

So you've decided they can't get TPA, but they've had a stroke... what's next?

If a large MCA, "malignant MCA" - with edema, call neurosurg as they may benefit from a hemicraniectomy.

Now we consider causes of the stroke, most commonly afib, ECG, HTN, artery-artery, and when nothing comes up.. consider stranger things like vasculitis or paradoxical emboli.

Things to order MRI/MRA - looking for plaque in carotids (benefit from endarterectomy if done within 2 weeks)

Echo - looking for thrombus, calcification on valves, apical hypokinesis as a cause of the stroke

ECG - afib

HbA1c, lipid profile

Start high dose statin as per the SPARCL trial (although individuals had LDL >2).

If a large stroke and afib- might just start aspirin, repeat Ct head in 24 and 48 hours to ensure no bleeding.

If the cause is thought to be related to atherosclerosis, may consider aspirin and plavix for 3 weeks and then plavix after as per the CHANCE trial, which was studied in asian patients, slightly younger age.

Neurologists may have their own opinion about what to do in specific situations.

Refer to stroke rehab!

Also - blood pressure, we let them permissively go high (upto around 220) as to increase cerebral perfusion for ~3-5 dys.