Managing the ischemic stroke patient

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.

Gary R. Simonds, MD MHCDS FAANS
Gary R. Simonds, MD MHCDS FAANS
10th Sep 2021 • 5m read

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.

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Video transcript

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.

1000s 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.

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.

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 sailne at a rate of 75 to 120 milliliters per hour.

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.

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.

Obtain a complete blood count, erythrocyte sedimentation rate, coagulation profile including pro thrombin 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 troponin's the worst the prognosis. Obtain a pregnancy test and women of childbearing age. 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.

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. 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. 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. 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. 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. 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. 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. 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.

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. 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 address 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. 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.