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HEMISPHERE IV-RAPID STROKE RESPONSE
Onset of symptoms to thrombolytics time 4.5 hours Onset of symptoms to thrombectomy time 24 hours Stroke Center designations Comprehensive Stroke Center (CSC) Thrombectomy-capable stroke center (TSC) Primary Stroke Center (PSC) Acute Stroke Ready Hospital (ASRH) Door to door transfer time <= 60 min hospital to hospital transfer associated symptoms of stroke *especially with cerebellar and hemorrhagic stroke vomiting, nausea SBP > stiff neck Photophobia Coma and decreased level of consciousness Overlooked symptoms of stroke dizziness headache general weakness or fatigue nausea, vomiting disorientation, confusion, or memory problems Door to doctor time ASAP - 10 min BP parameters
do not treat elevated BP unless concurrent myocardial infarction, heart failure, aortic dissection, or confirmed hemorrhagic stroke Door to stroke team time (neuro expertise) ASAP - 15 Prior to thrombolytic Noncontract CT or MRI to exclude hemorrhage Blood glucose level - to rule out hypoglycemia BP under 180/ When to repeat CT in Hosp to hosp transfers
60 minutes since last CT Baseline labs CBC, electrolytes, Renal function creatinine, troponin and ecg to evaluate MI and arrhythmias Coag studies if on anticoagulants Advanced imaging if considering mechanical thrombectomy Airway management Swallow screen should be performed on all stroke patients npo until complete How long is BP elevated after stroke 24 - 48 hrs Increased cardiac risk with stroke Arrhythmias (including A-fib) observed in about 25% of patients within 72 hrs of stroke Cardiac troponin may elevate from autonomic dysfunction in acute MI/heart failure Blood glucose and stroke Persistent hyperglycemia 24 hours following stroke is associated with worse outcomes Hypoglycemia can mimic stroke symptoms Maintain glucose >60 and < When to raise bed 30 degrees
Initial imaging (CT) stroke rules out cerebral hemorrhage and establish IV thrombolytic eligibility Advanced imaging stroke To identify candidates for mechanical thrombectomy or pinpoint cause of hemorrhage Noncontract computed tomography More widely available than MRI Quickly detects acute brain hemorrhage May not identify ischemia in the first few hours following stroke MRI more expensive and less accessible than CT Can detect hemorrhage and more sensitive than CT in early ischemic stroke detection, especially w diffusion weighted imaging Ischemic tissue on cT less dense or hypodense, so appears darker than normal Acute hemorrhage on CT bright white CT interpretation - Blood Can Be Very Bad Blood - no hematoma/hemorrhage Cisterns-no blood in spaces/symmetrical brain tissue - no tissue hypo/hyper densities and no masses, Ventricles - symmetrical and midline Bone - no skull fracture ASPECTS score Alberta Stroke Program used to quantify the extent of ischemic changes in the MCA territory on NCCT and determine eligibility for mechanical thrombectomy ASPECTS explained 10 point scoring tool with one point for each region of MCA circulation. One point is subtracted for each region with ischemia/hypodensity
Aspects scoring Subcortical structures are allotted 3 points (caudate, lentiform nucleus, internal capsule MCA cortex areas are allotted 7 points (insular, M1, M2, M3, M4 M5 M6) Aspects score of => indicates small to moderate ischemic core area Patient would benefit from mechanical thrombectomy Aspects score of < extensive infarct and tissue damage patient would not benefit from mechanical thrombectomy, may be harmful aspects maps 1 see maps learn maps love maps aspects maps 2 aspects maps 2 aspects maps 3 aspects maps 3 MRI T1 Weighted Used as map of normal anatomy for comparison of others in series Fat gives off high signal and appears white Water gives off low signal and appears dark, so CSF appears dark MRI T2 Weighted Used to visualize ventricles and subdural spaces Higher signal for more water content, so CSF appears brighter in T2 images Fluid attenuated Inversion Recover (FLAIR) MRI sequence used to detect edema, inflammation, and plaque Adjusted T2 weighted sequence to conceal CSF so it appears darker Diffusion-weighted imaging (DWI) MRI sequence
DW-MRI
MRI sequence that identifies what is already damaged Part of standard MRI protocol Can be used with MRP or other sequences like FLAIR to predict what patients have salvageable brain tissue DWI flair mismatch DWI shows a bright area indicating acute infarction and the FLAIR image does not show it, indicates a fairly acute stroke DWI/Flair Mismatch meaning DWI positive/FLAIR negative mismatch is used to select patients that may benefit from thrombolytic administration when within 4.5 hours of stroke symptom recognition and woke up with stroke or have unclear time of onset Blood pressure before thrombolytics less than 185/ Blood pressure following thrombolytics less than 180/ BP management before reperfusion Labetalol 1-20 mg IV over 1-2 min, May repeat 1x Nicardipine 5 mg/hr IV, titrate up by 2/5 mg/hr every 5-15 min max dose 15 mg/hr Clevidipine 1-2 mg/hr IV, titrate by doubling the dose every 2-5 minutes until desired BP, max dose 21 mg/hr BP management during/after reperfusion Maintain systolic BP <180/105 for at least 24 hrs Monitor BP every 15 min for 2 hrs from initiation of therapy then every 30 min for 6 hrs, then every hr for 16 hrs Tenectaplase dose 0.25 mg/kg based on accurate weight of patient Max dose is 25 mg Dual verification by two qualified STM Different dose than MI
Tenectaplase administration administer as a single IV bolus over 5 seconds BP monitoring with thrombolysis Monitor BP every 15 min for 2 hrs from initiation of therapy then every 30 min for 6 hrs, then every hr for 16 hrs Goal <180/ Perform Neuro assessments following thrombolytic To monitor of Intracranial hemorrhage Every 15 min for 2 hrs starting at administration Every 30 min for 6hrs Every hr for 16 hrs for 24 hrs Signs/symptoms of intracranial hemorrhage Change in level of consciousness Acute neurological deterioration Pupillary changes New headache Nausea or vomiting sudden hypertension Systemic hemorrhage Monitor for and report blood in urine, stool, saliva, or gastric contents if vomiting Monitor for and report S/S of retroperitoneal, GI, or GU hemorrhages (back or abdominal pain) Delay use of urinary catheters, NG tubes, arterial catheters and central venous catheters for 24 hrs unless absolutely necessary Use gentle care and minimal handling of patient to prevent bleeding and bruising Orolingual angioedema Unexplained swelling of the tongue or lips not caused by bleeding Monitor for swelling of tongue face lips or respiratory distress Hemorrhage after thrombolysis outcome Pts with symptomatic intracranial bleeding based on clinical deterioration and 2- 4 NIHSS increase have high mortality risk Symptoms of Intracranial bleeding following thrombolysis
Epinephrine 03 mg sub1 or 0.5 mg via nebulizer for continuing: icatibant 30 mg subq C1 esterase inhibitor 20 IU/kg Thrombectomy eligibility <6 hrs Age => Occlusion of ICA or M1 segment of MCA MRS 0- 1 Aspects - => NIHSS score => treatment can begin w/in 6 hrs of symptom onset Can consider in M2 or M# Prestroke mRS >1. Aspects <6. or NIHSS score < Occlusion of anterior cerebral, vertebral. basillar, or posterior cerebral arteries Exclusion criteria for thrombectomy Intracranial hemorrhage Uncontrolled BP (SBP >185 or DBP >110) Criteria w 6- 24 Age => Failed or ineligible for treatment with IV thrombolytic Occlusion of ICA or M1 segment of MCA MRS 0- 1 Aspects - => NIHSS score = Infarct involving less than 1/3 of MCA on CT or MRI treatment can begin w/in 6-24 hrs of symptom onset Mismatch between clinical deficit severity and infarct volume according to age identified on dw-MRI Mismatch on DW MRI for thrombectomy 6- 24 <21 mL core infarct and NIHSS =>10 and age => 80 <31 core infarct and NIHSS => 10 and age < 80yrs) 31 - 51 mL core infarct and NIHSS > 20 and age < 80 yrs) DAWN exclusion criteria
active or recent hemorrhage within 30 days Severe head injury within 90 days with deficit Uncontrolled persistent BP >185 or D> Baseline glucose <50 or > Coagulopathy or anticoagulant use with INR >3 or PTT> 3 times normal abn. baseline electrolytes and creatinine Occlusion in multiple vascular territories Significant mass effect with midline shift Door to skin puncture time ASAP to <90 min When transferred, <60 min modified thrombolysis in cerebral infarction (mTICI) scale 0 no reperfusion 1 Flow beyond occlusion, without distal branch reperfusion 2a Reperfusion <50% of downstream target arterial region 2b Reperfusion>50% but incomplete of downstream target arterial region 3 complete reperfusion of downstream target arterial region and distal branches
