10/26/2023 Stroke

You are working a shift in trauma critical care (TCC) when you receive a stroke page - “65 YO M with R side weakness.” You rush to the CT scanner where you meet EMS. As your charge RN takes the patient’s weight and vital signs, EMS relays that the patient was in his normal state of health until 30 minutes ago, when he suddenly couldn’t move his right side. The patient denies other symptoms and endorses a history significant for tobacco dependence and atrial fibrillation on warfarin. He is unsure what his last INR was and has been taking his medications as prescribed.

Initial vital signs include: BP 205/110 mmHg, HR 110 bpm, RR 14 bpm, 98 % RA, 98.6 F. The patient is in NSR on the monitor. The RN calls out that the glucose is 90 mg/dL and asks if you want any point-of-care labs. You astutely ask for an INR.

You examine the patient on the CT table. He is alert and oriented X3, in no cardiorespiratory distress, and exhibits a right-sided facial droop as well as dense right hemiparesis. There are no vision changes, sensory loss, ataxia, dysarthria, aphasia, or neglect. You speedily calculate an NIHSS of 10 and order a CT, CTA, and CT perfusion studies after conversing with your neurology resident colleague at the bedside. The non-contrast CT is negative for intracranial hemorrhage. INR is 1.4

What is the next best step in management?

You recognize that this patient is a potential thrombolysis candidate given their subtherapeutic INR and order labetalol 20 mg IV. Your RN asks you if you want her to pull anything else while she is there, so you request that a nicardipine infusion be brought to the bedside.

The CTA reveals an acute M1 occlusion on the left, and repeat BP after the labetalol is 180/95 mmHg after the labetalol. The nurse starts the nicardipine drip while the neurology resident discusses the risks and benefits of Tenecteplase (TNK) with the patient. Consent is obtained, and the repeat BP is 160/90 mmHg. TNK is administered, and the patient’s symptoms begin to improve.

What can we learn from this case?

Efficient and effective stroke care requires that we designate clear roles for our ED and neurology team. For those of us who may graduate and move elsewhere after residency, we may not always be blessed with a team who already knows their roles. Thus, verbalizing what specific tasks you would like accomplished and in what order by whom is essential. In this case, if it is the ED’s day to perform the NIHSS, the neurology resident should be reviewing the patient’s chart for TNK contraindications and obtaining collateral history (when necessary). The RN should be obtaining a weight followed by a glucose and placing an IV for contrast, resuscitation (if needed), point-of-care labs, and TNK (if the patient is a candidate). The glucose and INR should be vocalized as soon as they result, loud enough for the room to hear, as these results change management. You need to know the BP right away to determine whether antihypertensives are needed before thrombolysis. Only send your RN to the Pyxis once; it takes time! Ensure that he or she grabs not only push-dose antihypertensives, but also an agent for infusion. It can always be returned if it isn’t used. If there aren’t enough people present to complete all of the tasks that need to be done, ask for help early.

Everyone in the room needs to know the NIHSS in order to have a sense of what the plan will be. Thus, it is critical that the NIHSS be obtained prior to CT, that it is verbalized out loud, and that it is written on the whiteboard in the CT scanner. The radiology techs do not want to have to chase you or the neurology resident down for the NIHSS when they communicate with the radiologist!

In addition to a BP <180 mmHg systolic/<105 mmHg diastolic (Powers et al., 2019), patients on anticoagulation must meet the following criteria in order to be TNK candidates:

- INR ≤ 1.7 (Mazya et al., 2013)

- If on a factor Xa inhibitor, the last dose must have been ≥ 24 hours prior to ED presentation (or a point-of-care factor Xa assay that shows no residual anticoagulant activity (Hankey et al., 2014)

One key point that was raised during this case is that we need to be able to provide patients with accurate data in order for them to give informed consent for thrombolysis. Though the risk of intracranial hemorrhage (ICH) based on study data is ~6% (Lansberg et al., 2007), our institution’s internal ICH rate after thrombolysis is only 3%. Providing this information could change the patient’s mind about whether they are willing to receive thrombolytics.

Take-Home Points:

• Establish team roles immediately in stroke cases

• Don’t forget the glucose!

• Obtain the INR and last time of anticoagulant ingestion

• Aim for a BP <180/105 mmHg

• Batch your orders to avoid Pyxis delays

• Provide appropriate data to your patients to aid in shared decision making process

References:

1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; on behalf of the American Heart Association Stroke Council. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare rofessionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418 doi: 10.1161/STR.0000000000000211.

2. Mazya MV, Lees KR, Markus R, et al. Safety of intravenous thrombolysis for ischemic stroke in patients treated with warfarin. Annals of Neurology. 2013;74(2):266-274.doi:10.1002/ana.23924

3. Hankey GJ, Norrving B, Hacke W, Steiner T. Management of acute stroke in patients taking novel oral anticoagulants. Int J Stroke. 2014 Jul;9(5):627-32. doi:10.1111/ijs.12295. Epub 2014 Jun 2. PMID: 24891030; PMCID: PMC4149783.

4. Lansberg MG, Albers GW, Wijman CA. Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: a review of the risk factors. Cerebrovasc Dis. 2007;24(1):1-10. doi: 10.1159/000103110. Epub 2007 May 22. PMID: 17519538

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