Stroke¶
Background¶
- Preferred term: Stroke (CVA is like saying heart attack instead of STEMI)
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Sudden onset, focal (usually one-sided) neurologic deficits: weakness, sensory loss, vision loss, ataxia/unsteadiness, vertigo, double vision, facial droop, dysarthria, aphasia
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Differential:
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stroke (ischemic or hemorrhagic)
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seizure or post-ictal paralysis
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headache phenomena (complex migraine)
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cervical spinal cord lesions, though these more commonly cause bilateral symptoms
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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, recent surgeries, history of bleeding (severe GIB or ICH), recent medications, platelet count, and baseline neuro exam
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If symptoms developed with LKN within 24 hours -> stroke alert!
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If > 24 hours, can request Neuroalert Instead
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VUMC: call 11111 and tell the operator stroke alert and current patient location
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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
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Stat head CTP (order CTH/CTA) for consideration of tPA or endovascular therapy
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If renal function is abnormal, discuss with neurology
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Generally, go for CTA if the patient is a thrombectomy candidate (within 24 hrs of onset)
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MRI/MRA is an option but takes longer (MRAs are also better with Gadolinium)
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Neurology service should be leading this portion
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Management¶
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Blood pressure goals
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Ischemic stroke:
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In general aim for SBP <220
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Patients with intracranial atherosclerosis may require higher BP to maintain perfusion
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Hemorrhagic stroke:
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SBP < 140 (BP management is key)
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These pts are managed in Neuro ICU
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Reverse coagulopathies and keep platelets >100,000
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