Managing the ischemic stroke patient

The earlier the intervention in stroke patients, the better the outcome. But are you confident managing a suspected case of stroke to avoid further damage? In this video, we look at the complicated care of cerebral ischemia, the initial steps that should be followed to manage a stroke patient, and how to make sure you're not actually dealing with another pathology altogether.

After taking this course, you'll be able to handle neurological emergencies with confidence! Many clinicians are intimidated by cases of neurological dysfunction, particularly when they are acute. This course will demystify neurological emergencies so you can handle them with confidence. You’ll learn how to localize the affected region of the nervous system, order appropriate diagnostic studies, and initiate intervention fast so you can improve outcomes and save lives. Find out what’s wrong with your patient and treat them fast!

What cerebral ischemia and ischemic stroke mean

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Cerebral ischemia occurs when a volume of brain tissue loses sufficient blood flow to maintain normal physiological function. Ischemic stroke occurs when oxygen delivery to a region of the brain drops to a level that causes the affected brain cells to die. The treatment of ischemic stroke has changed rapidly in the 21st century; multiple aggressive interventions have become the standard of care, and new diagnostic and interventional technologies and techniques keep bursting onto the scene.

Why suspected ischemic stroke requires emergency evaluation

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Thousands of patients every year are now saved from severe neurological deficits or death. A patient with a suspected stroke should therefore be treated as an emergency and given priority and attention and evaluation. The earlier the intervention, the better the potential outcome in stroke. A patient's initial evaluation should take less than an hour.

When to contact a regional stroke center

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Care for a stroke patient can be somewhat complicated and is ever-changing. So, unless you frequently care for stroke patients, don't go it alone. Check in with your regional stroke center about how to progress with your patients. There are initial steps, however, that you can follow for every stroke patient.

Initial ABC assessment in ischemic stroke

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First, attend to the patient's ABCs; that is, make sure the patient has a patent airway, is respirating effectively, and has normal to moderately elevated blood pressure. Hypotension and/or hypoxia have dire consequences in the stroke patient. Start oxygen and start IV normal saline at a rate of 75 to 120 milliliters per hour.

Managing glucose and blood pressure in ischemic stroke

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Glucose should not be in the IV fluids, as elevated serum glucose may actually worsen a stroke. Realize that severe hypertension can convert an ischemic stroke into a hemorrhagic stroke. Thus, treat systolic blood pressures greater than 220 millimeters of mercury. Labetalol and a nicardipine are currently very popular agents.

Monitoring and metabolic laboratory tests

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Make sure you monitor vitals and EKG and pulse oxygenation; treat hyperthermia; draw stat serum glucose; definitely treat severe hypoglycemia or hyperglycemia. Normoglycemia, that is, 90 to 180 milligrams per deciliter, is the goal. Also order serum metabolic panels to include calcium levels, chloride, creatinine, glucose, potassium, sodium, and blood urea nitrogen.

Additional laboratory tests for suspected stroke

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Obtain a complete blood count, erythrocyte sedimentation rate, coagulation profile including prothrombin time and partial thromboplastin time, a syphilis test, and the lipid profile. Also include your analysis and arterial blood gases. Also obtain cardiac opponents; the more elevated the troponins, the worst the prognosis. Obtain a pregnancy test and women of childbearing age.

Establishing last known well and symptom onset

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Recognize that the clinical manifestations of an ischemic stroke can vary widely depending on the location and size of the stroke. Identify when the patient was last healthy and when they first noticed their symptoms.

Documenting acute ischemic stroke symptoms

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The time course of a stroke is absolutely critical information. If the patient awoke with their symptoms, document when they went to sleep. Then go ahead and document their actual stroke symptoms, such as acute speech difficulty, acute weakness, acute numbness, acute visual changes, acute gait disturbance, acute severe headache, acute dizziness or vertigo, nausea or vomiting, and any loss of consciousness.

Performing a rapid NIHSS neurological exam

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Then perform a rapid but specific neurological exam. Note, many stroke centers currently prefer evaluation by the National Institute of Health Stroke Scale, or NIHSS score. This is a variation of the standard neurological exam, which examines the level of consciousness, vision, facial palsy, arm and leg motor function, limb ataxia, sensory function, language, dysarthria, extinction, and inattention.

Interpreting NIHSS stroke severity scores

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An NIHSS score of zero indicates no stroke; a level of 1 to 4 is considered a minor stroke. A score of 5 to 15 is a moderate stroke, a score of 15 to 20 is a moderate to severe stroke, and a score of 21 to 42 is considered a severe stroke.

Obtaining a noncontrast CT scan for suspected stroke

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Next, obtain a noncontrast CT scan of the brain. Do not leave the patient unattended to run monitored in the CT suite, however. Ideally, the CT scan should be completed within 20 minutes of presentation. Make sure you ask radiology to prioritize their scan and the reading of the scan.

Identifying intracranial hemorrhage on CT

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On CT scan, look initially for hemorrhages. These will be blotches of white, that is, increased density, that may or may not distort the brain and result and shift.

Recognizing subarachnoid hemorrhage on CT

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Next, check the spaces around the brainstem, between the hemispheres, and over the convexities for faint strings of the increased density. This would represent subarachnoid hemorrhage and strongly suggest cerebral aneurysmal rupture. Note all regions that show suspicious areas of low brain density.

Detecting hemorrhage within an ischemic stroke

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Now, look for faint or blotchy areas of increased density in a region of decreased density. This could represent hemorrhage into a stroke. Often some hemorrhage can occur in the region of the dead and dying brain tissue. If you notice any hemorrhage anywhere in the brain, it can significantly change the management of the patient's stroke.

Recognizing completed ischemic stroke on CT

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Look for areas of significant decrease density, particularly if wedge-shaped and involving the cortex. This likely represents regions of completed stroke. Generally, in early strokes, the CT scan findings will be subtle, if identifiable at all. Completed stroke can be much more definitive. As you look at the scans, be aware of other potential pathologies.

Considering stroke mimics on CT imaging

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Lesions such as tumors or abscesses may present with acute onset of symptoms or rapidly progressive deficits. This patient presented with stroke-like symptoms and an abnormal CT scan, but was demonstrated to have an abscess.

Identifying large-vessel occlusion and endovascular eligibility

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A sizable number of ischemic strokes involve the occlusion of a major cerebral artery by a thrombus. Such strokes are often large and severe. Some of these can be reversed if addressed quickly enough. If large vessel occlusion is suspected, the endovascular treatment team needs to be notified immediately, and further imaging will need to be carried out.

CT angiography and CT perfusion in acute stroke

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In such cases, a CT angiogram is most commonly ordered to define the location of the occlusion. The decision to proceed with CT angiography is often predicated on the patient's NIHSS score and current national and local stroke protocols. Ideally, CT angiography should be completed within 45 minutes of the patient's presentation. If an occlusion is indeed found, a CT perfusion study is often then initiated.