User:Christiandelery/Stroke

Article Draft
=== Stroke is very common but managing stroke is still controversial and many methods are employed to improve patient outcomes. Not only that, but also “Stroke is the leading cause of long- term disability in developed countries and one of the top causes of mortality worldwide” (Phipps & Cronin, 2020). But what are the standard protocols for the treatment and management of stroke these days? Turning to the World Health Organization and the American Stroke Association as well as the American Heart Association are key to understanding current guidelines. The common imaging is a non-contrast head CT but can be combined with DWI, CT perfusion, and FLAIR (Phipps & Cronin, 2020). The prominent treatments for managing stroke are hemodynamic stability techniques, tissue plasminogen activators combined with Dual Antiplatelet therapy as well as coagulants, interventional mechanical thrombectomies, and various neurosurgeries to control intracranial pressure (WHO, 2020; Wang et al., 2019). === The World Health Organization guidelines set in 2020 for stroke management at primary health facilities focus on 3 main steps-- stabilizing the patient, providing preliminary treatment, and quickly identifying patients who should be shifted to a higher center (WHO, 2020). In stabilizing the patient standard protocol is to alert the doctor/health worker immediately once a stroke is suspected (WHO, 2020). The guidelines state “The doctor should quickly assess the general condition of the patient, including airway, breathing, and circulation (ABC)” (WHO, 2020). The guidelines state “Assess consciousness level; ask the patient simple commands such as name, opening their mouth, or extend the protruding tongue” (WHO, 2020). During this time other staff should check vitals like BP, pulse,

temperature, and random blood glucose levels and all vitals should be monitored every 15-20 minutes (WHO, 2020). Giving nothing by mouth and setting up one large-bore IV cannula is the final step for stabilizing the patient (WHO, 2020). In step two preliminary treatment is provided in 3 ways (WHO, 2020). The three types of preliminary management are management of blood sugar, (ABC), and blood pressure (WHO, 2020). First, we will look at the blood sugar type. “Hypoglycemia can sometimes present with stroke-like symptoms, therefore blood glucose should always be checked” (WHO, 2020). Patients having blood glucose of 60mg/dl or less should immediately be given 50 ml of 50% dextrose solution through an IV (WHO, 2020). Next, we will look at the Airway breathing and circulation management. In this step we assess the airway by opening the patient's mouth and removing any foreign bodies, then “listen for snoring, gurgling sounds, or if absent breathing sounds, this could indicate airway obstruction” (WHO, 2020). When patients talk the airway is probably clear and poor oxygen supply creates bluish discoloration. After airways are checked then breathing is next. Observing the patient's breathing pattern looking for signs of difficulty like sweating, labored breathing, or use of abdominal muscles (WHO, 2020). Finally counting respiratory rate and checking a peripheral oxygen saturation with a pulse oximeter is needed (WHO, 2020). “[A] drop in oxygen saturation implies decreased oxygen reaching the body tissues” (WHO, 2020). Then the Circulation is assessed by touching the patient's hands and assessing temperature, cold, clammy hands [indicate] poor circulation (WHO, 2020). Finally, we will manage (ABC) by providing gentle oral suction if in respiratory distress or pooling of secretions, as well as oxygen nasal prongs or face mask at 2-5L, and lastly, intubation if not enough oxygen saturation is detected by pulse oximeter. “If [this is unavailable] then make the patient lie on one side and prepare for urgent transport to a higher [center] with facilities” (WHO, 2020). The last preliminary treatment is blood pressure management. “Antihypertensives should be given only in case of very high BP recordings because excessive lowering of blood pressures can result in decreased perfusion of the brain which can worsen the stroke or cause another stroke” (WHO, 2020). Next, keep BP under 220 with a beta blocker like labetalol 10

mg IV bolus and check BP 10-15 minutes, and repeat if the patient still has high BP (WHO, 2020). “Calcium channel blockers and sublingual antihypertensives should not be given as they can lead to a sudden drop in blood pressure and worsen stroke” (WHO, 2020). “If the patient has hypotension, IV fluids should be rushed through an IV cannula. If hypotension persists... then inotropic supports such as noradrenaline or vasopressin should be started” (WHO, 2020). The third main step, “quickly identifying patients who should be shifted to a higher center”, involves investigations of blood tests for CBC, PT, APTT, INR, and a 12-lead EKG, ECG, and interviewing the patient (WHO, 2020). Learning the Last known well or symptom onset is used as the last time someone was awake if occurred during sleep (WHO, 2020). If symptom onset is less than 4.5 hours then the patient should be transferred to a higher center for a CT scan and clot-busting treatment (WHO, 2020). Interviewing for current anticoagulants, co-morbid conditions and history of drug overdose or intoxication should be recorded (WHO, 2020).

“Acute ischemic stroke and intracerebral hemorrhage cannot be distinguished clinically, and treatment with thrombolytics is efficacious in the first and detrimental to the second” (Phipps & Cronin, 2020). Basically, if there's a burst blood vessel you don't want to give clot-busting medication because the burst blood vessel will get worse(Cook & Clements, 2011). Most of the time patients suspected of Acute ischemic stroke need a non-contrast head CT to diagnose and ideally within 20 minutes (Phipps & Cronin, 2020). Patients who meet endovascular clot retrieval criteria should do non- invasive intracranial vascular imaging if it doesn't delay intravenous thrombolysis. (Phipps & Cronin, 2020). Contrast-induced nephropathy can be an issue with CTA (Phipps & Cronin, 2020). “However, evidence shows that the risk of doing CTA before obtaining a creatinine concentration in patients without known renal failure is low, and many radiology guidelines recommend that delays should not occur because of concerns about creatinine. The Alberta Stroke Program Early CT Score (ASPECTS) is a prospectively validated score that gives points for each of the 10 middle cerebral artery (MCA) territory regions that do not show early ischemic changes. “ASPECTS of 6-10 [has been] used as an

inclusion criterion in acute stroke endovascular trials... to select patients with a relatively small core... infarct” (Phipps & Cronin, 2020). MRI or CT perfusion has been used to select patients for treatment ... outside... [the] 4.5 hours for intravenous alteplase [or] 6 hours for endovascular therapy” (Phipps & Cronin, 2020). MRI and CT perfusion measure blood flow using contrast and the amount and timing of blood flow to specific brain regions to look for areas that are permanently damaged or are at risk of damage without reperfusion (Phipps & Cronin, 2020). IV thrombolysis has been used with high efficacy. A meta-analysis in 2004 of patient-level data from all previous studies with IV alteplase for AIS showed that the odds ratio for favorable outcomes crossed 1.0 at 4.5 hours from the last known well (LKW) (Phipps & Cronin, 2020). IV alteplase is approved in Europe for patients with a time of onset of less than 3 hours. “...The proportional benefits of intravenous alteplase treatment [are] similar irrespective of age or severity” (Phipps & Cronin, 2020). Diffusion-weighted imaging and perfusion- weighted imaging can be used to see “...responses to treatment with [IV] alteplase at 3 to 6 hours from LKW” (Phipps & Cronin, 2020). A prospective observational trial called the DEFUSE trial “defined a “target mismatch” profile that identified patients with a favorable response to reperfusion...” (Phipps & Cronin, 2020). “Another observational trial found that the presence of DWI-positive lesions without corresponding lesions on fluid-attenuated inversion recovery (FLAIR) correlated with patients known to be less than 4.5 hours from symptom onset” (Phipps & Cronin, 2020). Another trial called the WAKE-UP trial used DWI to FLAIR mismatches to identify patients with unknown time of onset for randomization to IV alteplase or placebo (Phipps & Cronin, 2020). This trial mismatch was found effective and was given a class IIa or moderate recommendation in the AHA/ASA stroke guidelines for the management of AIS in 2019 (Phipps & Cronin, 2020). Tenecteplase is another commonly used tissue plasminogen activator (TPA) that “has been shown to have a higher affinity for fibrin and a longer half-life than alteplase” (Phipps & Cronin, 2020). Two common complications to look for with thrombolytic therapy are intracerebral hemorrhage and angioedema (Phipps & Cronin, 2020). Angioedema of the oropharynx can cause airway compromise and must be quickly treated with

steroids, antihistamines, and intubation if needed (Phipps & Cronin, 2020). Finally, Mechanical thrombectomy can be used as an intervention in less than six hours (Phipps & Cronin, 2020). If interventions are in a greater than the six-hour window data from DAWN and DEFUSE 3 trials provide better outcomes (Phipps & Cronin, 2020). This trial used patients without large areas of established infarct (Phipps & Cronin, 2020). Using software called RAPID to analyze CT of MRI perfusion to compare a ratio of core infarction and penumbra areas to check for salvageable tissue (Phipps & Cronin, 2020). “...[This] showed a large improvement in functional outcome in patients...” (Phipps & Cronin, 2020). Intubation versus conscious sedation should be considered for patients before performing a mechanical thrombectomy and “...we are still not sure the optimal way to manage anesthesia during endovascular treatment” (Phipps & Cronin, 2020). Finally, secondary prevention is important to minimize disability from the acute event and decrease the chances of another stroke (Phipps & Cronin, 2020). Reverting to the national clinical guidelines for Stroke in 2016 which have the guidelines for the management of acute ischemic stroke by the Royal College of Physicians in the UK is important as well as the American Heart Association and American Stroke Association guidelines published in 2019 (Phipps & Cronin, 2020).

The standard protocol starts in the ED with a patient with a suspected stroke reaches a higher center or advanced stroke facility (WHO, 2020). Confirming diagnosis and last known well and performing a National Institute of Health Stroke Scale (NIHSS) within 10 minutes of arrival in the ED by a stroke physician is required as well as securing two intravenous lines, administering 0.9% normal saline (NS) at 75-100 ml/hour and avoiding glucose solutions if not hypoglycemic (WHO, 2020). “Put on oxygen by mask if oxygen saturation is less than 95%” (WHO, 2020). “Brain CT scan within 25 minutes of arrival in the ED if a patient reaches within the 4.5-hour window” (WHO, 2020). Conduct an EKG, test random blood sugar by glucometer, and test serum electrolytes, glucose, creatinine, complete blood count (CBC), INR, and Activated PTT as well as pregnancy test if applicable (WHO, 2020). If BP is greater than 220/120 mmHg then bring down BP, if thrombolysis is planned then BP

must be lower than 180/110 mmHg, and for hemorrhagic stroke, BP should be lowered to less than 140/90 mmHg (WHO, 2020). Discussing risks and benefits with family is important at this stage (WHO, 2020). Foley catheters can be used and must be inserted before treatment (WHO, 2020). CT scans can be used to identify ischemic versus hemorrhagic strokes and should be performed within 25 minutes (WHO, 2020). thrombolysis should be done within 45 minutes (WHO, 2020). Alteplase bolus followed by infusion in eligible patients less than 60 minutes is recommended and the earlier the better (WHO, 2020). MRI can be done at 4.5 hours after symptom onset and “...this gives a better picture of the parenchyma and the extent of tissue damage” (WHO, 2020). “If the time of symptom onset is less than 4.5 hours then the decision for clot bursting injection, known as thrombolysis, is taken by the doctor after informed consent from relatives” (WHO, 2020). “If the time of symptom onset is more than 4.5 hours thrombolysis is not given...[and the] patient is managed with anti-platelet drugs and statins” (WHO, 2020). Treating hemorrhagic strokes involves craniotomies and small boreholes for reducing pressure as well as equipment to suck up a bleed and any clots (WHO, 2020). “If the patient was taking anticoagulants before the stroke, treatment may be needed to reverse the effects of the medicine and reduce the risk of further bleeding” (WHO, 2020). Patients should not get out of bed for 24 hours and should be medically stable first (WHO, 2020). “Multiple short sessions of out-of-bed mobilization tailor-made for patient needs are essential” (WHO, 2020).

Patients with minor strokes and TIA have a high risk of thrombosis and ischemic brain damage which increases bleeding risk (Wang et al., 2019). The CHANCE, POINT, and dual antiplatelet therapy (DAPT) trials compared using clopidogrel plus aspirin against aspirin in patients with strokes less than 3 on the NIHSS (Wang et al., 2019). This showed 21 days of dual antiplatelet therapy is effective and safe (Wang et al., 2019). “Approximately 75-80% of recurrent strokes occur in the first two weeks after onset of the index stroke or transient ischemic attack [(TIA)]” (Wang et al., 2019). “...DAPT should be started as soon as possible within 24 hours of minor ischemic stroke or high-risk TIA and should be continued up to 21 days” (Wang et al., 2019). “An expert panel from the MAGIC group recently

produced a strong rapid recommendation in The BMJ for starting DAPT within 24 hours of symptom onset and continuing for 10-21 days compared with aspirin alone” (Wang et al., 2019).

The Face Arm and Speech Test (FAST) is a simple, three-item recognition tool to aid screening for stroke in the community” (Hankey & Blacker, 2015). Acute facial paresis, arm drift, or abnormal speech is indicative of stroke while the absence of these is contraindicative (Hankey & Blacker, 2015). This test can miss posterior cerebral strokes (Hankey & Blacker, 2015). A lumbar puncture and Cerebrospinal fluid (CSF) exam can be done to check for subarachnoid blood (Hankey & Blacker, 2015). Conditions that mimic stroke are seizure, positive symptoms, loss of awareness, amnesia, tumors, metabolic, neuropathy, and peripheral vestibular disorders to name a few. (Hankey & Blacker, 2015).

=== When diagnosing a stroke one must check facial droop which means that both sides of the face move equally (Cook & Clements, 2011). If both are not equal this is a sign of stroke (Cook & Clements, 2011). Both arms should be moving the same and if not this is called arm drift and is indicative of stroke (Cook & Clements, 2011). Patient speech slurs, incorrect words, or no speech indicate stroke (Cook & Clements, 2011). Contraindications to rt-PA use to treat ischemic stroke are minor or rapidly improving symptoms, a seizure at the onset of stroke, stroke or head trauma within the past 3 months, major surgery within the last 14 days, known history of intracranial hemorrhage to name a few (Cook & Clements, 2011). “One-quarter of patients who have a stroke will experience neurologic worsening during the initial 24 hours after the event” (Cook & Clements, 2011). Smoking cessation and other lifestyle modifications should be encouraged in stroke patients (Cook & Clements, 2011). These articles mention the basic treatment strategies used today to treat blood clots (ischemic stroke) and burst blood vessels (hemorrhagic stroke) and provide an up-to-date collection of protocols that can be used to improve stroke patient outcomes. The strategies in these articles are useful for treating stroke patients and even more strategies will be available soon with advancements in health care technologies. === WORKS CITED

1.

World Health Organization. (2020). STROKE MANAGEMENT AT PRIMARY HEALTH FACILITY. In Integrating stroke services in health-care systems: A practical approach (pp. 17–23). World Health Organization.

2.

Phipps, M. S., & Cronin, C. A. (2020). Management of acute ischemic stroke. BMJ: British Medical Journal, 368, 1–15. https://www.jstor.org/stable/27232838

3.

'World Health Organization. (2020). MANAGEMENT AT AN ADVANCED STROKE FACILITY. In Integrating stroke services in health-care systems: A practical approach (pp. 24–44). World Health Organization. http://www.jstor.org/stable/resrep44977.9

4.

Wang, Y., Johnston, S. C., Bath, P. M., Grotta, J. C., Pan, Y., Amarenco, P., Wang, Y., Simon, T., Kim, J. S., Jeng, J.-S., Liu, L., Lin, Y., Wong, K. S. L., Wang, D., & Li, H. (2019). Acute dual antiplatelet therapy for minor ischaemic stroke or transient ischaemic attack. BMJ: British Medical Journal, 364. https://www.jstor.org/stable/26958107

5.

Hankey, G. J., & Blacker, D. J. (2015). Is it a stroke? BMJ: British Medical Journal, 350. https://www.jstor.org/stable/26517916

6.