Facilitator Version
Module #6 - CEREBRAL VASCULAR ACCIDENT
OBJECTIVES:
1. Have a clear understanding of initial assessment and management of acute stroke.
2. Have a clear understanding of commonly available imaging modalities in evaluation and
treatment of acute stroke.
3. Have a clear understanding of steps needed in treatment of patients admitted to the
hospital with acute stroke.
4. Have a clear understanding of antithrombotic therapies for secondary prevention of
stroke.
REFERENCES:
1. Harrison’s Principles of Internal Medicine, 17th Edition “Medical Management of Stroke
and TIA”
2. www. Uptodate.com “Overview of the evaluation of stroke”
3. MKSAP 16
Case
*A 63 year old male with past medical history of hypertension of 10 years duration treated with
hydrochlorothiazide is found by his wife on the kitchen floor after she returns home from
buying groceries. She had left her house 1.5 hours ago and at that time her husband was well.
She now notices that his left face is drooping and he cannot move his left arm or leg. He is
unable to sit or stand. She calls 911 and he is brought to the ED. In the ED, he is awake, alert
and follows commands. His temperature is 99 degrees Fahrenheit. His blood pressure is
170/90 mm Hg. His heart rate is 80/min and regular. His respiratory rate is 18/min and he is
saturating 96% on room air. There is no evidence of head or tongue laceration. No carotid
bruits are present. Heart rhythm is regular without gallops or murmurs. Chest is clear to
auscultation. Neurological exam demonstrates left sided neglect and a left facial droop. He has
dense left hemiparesis. Deep tendon reflexes are brisk in the left extremities. Babinski is
present in the left foot.
? What is your differential diagnosis and which tests should be ordered immediately?
-Differential Diagnosis in this case should include acute ischemic or hemorrhagic stroke,
subarachnoid/subdural hemorrhage, brain lesion of any type, and seizure with Todd’s paralysis.
-In this case, obtain CBG, Basic Metabolic Panel, PT/PTT, CBC, ECG, Troponin and non-contrast
Head CT.
-In selected patients, consider getting LFTs, Urine Drug Screen, Pregnancy Test, ABG, CXR,
Lumbar Puncture, and EEG.
-These tests should be done STAT.
? Discuss pros and cons of commonly available imaging modalities in evaluation of acute CVA?
-Head CT without contrast is the initial imaging test of choice. This can confirm or exclude a
hemorrhagic stroke. This is the first step in triaging a patient into IV thrombolytic protocol.
Routinely, in acute CVA, CT of brain is normal. Subtle signs of acute ischemic stroke include
sulcal effacement, loss of gray-white matter differentiation, and loss of insular ribbon on the
involved side. Hyperdensity can be seen in the middle cerebral artery suggesting a thrombus in
the artery.
-CT head and neck with IV contrast and with brain perfusion protocol answers all the questions
needed for any acute intervention in acute stroke setting. Many stroke centers employ this as
the initial imaging test. Acquisition protocols are rapid. It answers the question of intracranial
bleeding, localizes the clot and visualizes brain perfusion in the affected area. However, this
study uses IV iodinated contrast and many patients are ineligible due to CKD or contrast allergy.
-MRI Brain with diffusion-weighted imaging is the most sensitive study in detecting acute
ischemia. It is also exquisitely sensitive in detecting microhemorrhages, vasogenic edema or
other nonvascular lesions. However, it is not available at all centers. Imaging protocols take
longer than CT protocols. Patient has to hold still. Many patients are claustrophobic and many
patients are excluded due to metallic devices.
-MRA of intra and extra-cranial circulation can localize stenosis in the arteries of the neck and
head. It does not use gadolinium. However, Images are affected by motion and it can
overestimate the degree of stenosis.
-Carotid Artery Doppler Ultrasonography allows visualization of blood flow in the carotid
arterial system and intracranial vasculature. This test is non-invasive and does not expose
patients to ionizing radiation or iodinated contrast. However, all institutions do not have
certified ultrasonography laboratory.
-The gold standard for evaluating the cerebral vasculature remains catheter-based angiography.
It is invasive, exposes patients to contrast and is unavailable at many hospitals.
? Discuss inclusion and exclusion criteria for thrombolytic therapy in acute CVA?
-Recombinant tissue plasminogen activator (rtPA) is a fibrionlytic agent (clot dissolving agent).
-IV rtPA given within 3 hours of symptom onset in acute ischemic stroke leads to improved
functional outcome. More recent studies have shown benefit up to 4.5 hours. It should be
given to appropriate candidates as soon as possible. Door to Needle time should be less than
60 minutes. In patients who are candidate for this agent, blood pressure should be less than
185/110 mmHg for a sustained interval.
-Exclusion criteria for this agent includes minor or rapidly improving symptoms, seizure at
stroke onset, other stroke or trauma within 3 months, major surgery within last 14 days, history
of intracerebral hemorrhage, sustained blood pressure >185/110 mmHg, aggressive drug
therapy needing to control blood pressure, suspicion of subarachnoid hemorrhage, arterial
puncture at a noncompressible site within 7 days, heparin received within the last 48 hours and
elevated PTT, INR>1.7, platelet count <100K, and Plasma glucose <50 mg/dL or >400 mg/dL.
-IA rtPa (catheter based intra-arterial delivery of rtPa at the site of the clot) has been recently
explored. Intra-arterial thrombolysis has been shown to improve recanalization rates and
clinical outcomes and is recommended for middle cerebral artery infarctions up to 6 hours after
stroke onset.
-Mechanical thrombectomy using endovascular clot removal devices are under investigation for
up to 8 hours from stroke onset.
? What is the NIH Stroke Scale?
-National Institutes of Health Stroke Scale is a well validated stroke severity score. It is derived
by performing a highly focused and structured neurological exam. It correlates with short and
long term outcomes. It should be performed on all patients presenting with acute stroke. It is
a requirement for stroke center certification.
*He emergently gets a CBC, BMP, PT/PTT, ECG, Troponin and a non-contrast CT scan of the
head. His blood glucose is 120 mg/dL. His basic metabolic panel, CBC, PT/PTT, and troponin are
normal. ECG shows sinus rhythm without any ST or T wave changes. Non-contrast head CT
shows very subtle right frontal and parietal sulcal effacement and loss of gray-white matter
differentiation.
*He is given IV rtPA and admitted to the Stroke Care Unit under your care.
? What orders will you are writing at this time?
-Neurological assessment every 4 hours, NPO, IVFs, continuous cardiac monitoring (remember
that he has received rtPA and any change in his neurological exam, nausea or vomiting should
prompt STAT head CT to rule out intracranial hemorrhage)
-Consult Speech therapy for formal swallow function evaluation and until then patient should
be NPO.
-Initiate PT/OT consult for early mobilization.
-Avoid Foley if possible.
-Check Lipid Profile
-MRI brain with diffusion-weighted imaging, MRA of intra-and extra-cranial circulation, and
Trans-thoracic echocardiogram with bubble study.
-May start anti-platelet therapy and DVT prophylaxis 24 hours after rtPA administration.
-Neurology Consultation.
? Discuss blood pressure management in the treatment of acute stroke?
-Before IV rtPA infusion, blood pressure should be consistently less than 185/110 mm Hg. After
rtPA infusion, the blood pressure should be targeted to less than 180/105 mm Hg.
-In patients ineligible for IV rtPA, blood pressure up to 220/120 mm Hg is permitted in hopes of
improving cerebral perfusion to the ischemic penumbra. This is done by holding home
antihypertensive medications.
-IV Labetalol or IV Nicardipine should be used to achieve these targets. Nitroglycerine and
Nitropursside should be avoided because they may lower blood pressure excessively or raise
intracranial pressure.
-After 72 hours, blood pressure medication should be judiciously started in hopes of gradually
lowering the blood pressure.
? Discuss several things that may adversely impact in-patient care of acute CVA?
-Fever, hyperglycemia, and delay in starting rehabilitation have all been shown to adversely
affect stroke outcomes.
? Discuss anti-thrombotic therapy for secondary prevention of CVA?
-Aspirin (50-325 mg) is the initial choice of anti-platelet due to its simplicity and cost.
-Patients who have failed aspirin (already on it at the time of stroke) are candidates for either
Plavix or Aggrenox (aspirin/dipyrimidole). There is no benefit in adding aspirin to Plavix in
secondary stroke prevention but it does expose patients to increased bleeding risk. Many
patients discontinue Aggrenox due to headache.
-Patients whose strokes are felt to be secondary to atrial fibrillation may be candidates for
warfarin or other novel oral anticoagulants (direct thrombin inhibitors/factor Xa inhibitors).
This decision should be made based on patient specific factors and preference.
*He is placed on cardiac monitor. He does not have any arrhythmias. He undergoes MRI of
brain which demonstrates an acute right MCA distribution CVA. MRA of the intracranial and
extracranial circulation does not demonstrate significant stenosis. Trans-thoracic
echocardiogram with bubble study demonstrates normal LV wall motion with ejection fraction
of 65%. No left atrial thrombus or right to left shunt is seen.
*He passes the swallow evaluation and is placed on a mechanical soft/pureed diet. He is
started on physical and occupational therapy. He has residual left facial droop and left sided
weakness. He is discharged to an acute rehabilitation facility for further care on Lisinopril,
Aspirin and Lipitor.
Stroke is the third leading cause of death in the United States. It is the leading cause of
disability in the United States. Cryptogenic stroke is the most prevalent ischemic stroke
subtype for which initially no cause is identified. Recent studies have demonstrated that close
to 25% of these patients may have paroxysmal atrial fibrillation which can be identified by
prolonged cardiac rhythm monitoring.
MKSAP 16 Neurology Section Questions:
Question 15-manage elevated blood pressure after administration of rtPA
Question 17-treat acute ischemic stroke with antithrombotic therapy
Question 31-treat acute ischemic stroke with thrombolysis
Question 34-manage antiplatelet agents for secondary stroke prevention in a patient with a
previous ischemic stroke
Question 41-manage hypertension in the acute setting of ischemic stroke
Question 48-prevent VTE after stroke
Question 57-manage cryptogenic stroke
Question 65-initiate early rehabilitation after stroke
Question 79-treatment of stroke in a stroke unit
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr.
Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient curriculum
in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student