Acute stroke

Clinical Presentation

• ACA: contralateral leg > arm
  • Gait, bladder incontinence, amnesia
• MCA
  • Contralateral sensorimotor
  • Contralateral homonomous hemianopsia
  • Gaze deviation
  • Aphasia, dysarthria, hemineglect
• PCA
  • Contralateral homonymous hemianopsia
  • Sensorimotor
  • Aphasia
  • Memory defects
  • Disorientation
  • Behavioural disturbance
  • Visual agnosia
  • Prosopagnosia
• Cerebellar: ataxia, vertigo, dysarthria, nystagmus, headache/nausea/vomiting, rapid deterioration in LOC
• Vertebroasialar stroke: loss of consciousness, nausea/vomiting, cranial nerve deficits, Horner syndrome, crossed sensory loss, crossed motor deficits, ataxia
• Thalamic stroke: contralateral sensory and/or motor loss, aphasia (if dominant side), executive dysfunction, decreased LOC, memory impairment
• Lacunar stroke
  • Pure motor hemiparesis
  • Pur sensory stroke
  • Sensorimotor stroke
• Ataxic hemiparesis: ipsilateral leg
• Clumsy hand syndrome

Differential Diagnosis

• migraines, seizures, todd paresis, malignancy, MS, SAH, ...

Investigations

• BW:
• Imaging: CT + CTA

Management

• If CT head negative for ICH
  • Antiplatelets
  • Carotid revascularization: consider if stenosis 50-99% on symptomatic side fo TIA/stroke
  • Anticoagulation
  • Something else

Thrombolysis

• Indicated for >18 years with symptoms within 4.5 hours of presentation
• Contraindications
  • Absolute:
    • Any active bleeding or any condition that raises the risk of major bleeding (but not anticoagulation, that’s relative)
    • Any hemorrhage on brain imaging
  • Relative:
    • On history
      • Prior ICH, ever
      • Stroke or head trauma in the last 3 months
      • Major surgery in the last 14 days
      • Non-compressible arterial puncture in the last 7 days
    • On exam
      • Symptoms of SAH
      • Another cause of stroke syndrome (e.g. Todd’s paralysis or hypoglycemia)
      • Blood pressure ≥180/105 (must be controlled first)
      • Taking DOACs
    • On imaging
      • Signs of early extensive infarction
    • On bloodwork
      • Sugar <2.7
      • Elevated PTT
      • INR >1.7
      • Platelets <100
• No benefit if NIHSS 0-5 based on PRISMS RCT
• Dose is alteplase 0.9 mg/kg, given as 10% bolus over 1 min then 90% over 1 hour
  • Max of 90 mg
• Outcomes
  • Better function at 3 to 6 months
  • Risk of major bleeding 5 to 7%, with 2% fatal
  • Risk of angioedema

Endovascular Thrombectomy

• Indicated within 6 hours of onset
• Functionally independent with life expectancy over 3 months
• Small to moderate ischemic core with ASPECTS ≥6
• Proximal large vessel, or distal ICA/MCA
  • Less clear with basilar artery
• Maybe within 24 hours of onset based on CT perfusion or MRI

Admission Orders

Admission Orders With TPA

• Admit to ICU for 24 hours
• IV (before TPA)
• Foley and other catheters
• BP <185/110 at time of bolus then 180/105 for infusion
• Frequent neurovitals and BP monitoring
• Repeat CT head at 24 hours
• No anticoagulation/antithrombotics for 24 hours
• Transfer to Stroke Unit after ICU

Admission Orders Without TPA

• Admit to Stroke Unit
• Different BP parameters

Post-Admission Management

• Need to workup while in hospital to decrease further risk of stroke
• Establish etiology
• Blood pressure management:
  • Ischemic stroke: start antihypertensives after 24 to 48 hours of permissive hypertension
  • Non-TPA ischemic stroke >220/120: reduce by 15-25% within 24 hours
  • Hemorrhagic: target 140-160 in hemorrhagic
• Antiplatelets
  • ASA as first-line
  • Dual antiplatelets ASA + clopidogrel for 90 days for minor stroke (NIHSS ≤3) or TIA within 24 hours (based on CHANCE and POINT trials)
  • ASA plus rivaroxaban may be helpful in patients with peripheral arterial disease (COMPASS trial)
    • Excludes previous ICH, recent stroke, lacunar strokes
  • If occurred while on antiplatelet, may be helpful to switch
• Consider 2 week Holter monitor for cryptogenic stroke to diagnose atrial fibrillation
• For atrial fibrillation:
  • Start after 1 day in minor stroke
  • Start after 6 days in severe stroke?
• Carotid endarterectomy
  • Refer if woman with 70-99% obstruction or man with 50-99% on symptomatic side
  • Could be considered for women with 50-69% obstruction
• Vertebral artery stenosis
  • Medical treatment preferred
  • Intracrainial artery stenosis 70-99%: 3 months of DAPT with ASA+Plavix then monotherapy, plus high dose statin
  • Cervicocephalic artery dissection: antithrombotics
• PFO
  • Increased risk of stroke with 18 to 60 year olds with cryptogenic stroke and presumed paradoxical embolism, especially if
    • Atrial septal aneurysm (6-fold increase in stroke risk)
    • Larger PFO and right to left shunt, ≥2 mm, more microbubbles >20
    • Hypercoagulable state
  • Consider ruling out atrial fibrillation
  • Consider PFO closure in <60 years old with minimal risk factors
• Risk factor targets
  • Blood pressure <140/90, or 130/80 in lacunar and hemorrhagic strokes
    • Preferred ACE inhibitors and thiazides
  • LDL <1.8, using statins and ezetimibe
  • HbA1c ≤7%

Further Reading

• Canadian Stroke Best Practice Recommendations for Acute Stroke Management 2018. doi: 10.1177/1747493018786616