initial stroke management

Stroke Notes

Initial management

Code Stroke

  • CT head wo to rule out bleed
  • MRI after 24 hours if no bleed
  • Call neurosurgery and repeat CT head in 24 hours if hemorrhagic stroke

Tier 1

  • tPA within 3-4 hours
  • Observation in ICU for 24 hours then transfer to floor
  • BP goal: <180 in 1st 24 hours, then normotension once on floor
  • After 24 hours: statin only, repeat CT, then add antiplatelet or anticoagulation

Tier 2

  • Thrombectomy within 24 hours
  • BP goal: <180 in 1st 24 hours, then normotension once on floor
  • Antiplatelet and anticoagulation?

No intervention

  • Permissive HTN 160-180 in first 48 hours, then normotension

Types of Strokes

  1. Small vessel disease
    1. Usually from process of atherosclerosis
    2. Risk stratification: lipids, A1C, TSH
    3. Imaging: CTA, MRA
  2. Large vessel disease
    1. From carotid plaques
    2. Imaging: CTA, MRA, carotid US, transcranial doppler
  3. Cardioembolic: more likely when stroke in two different vascular territories 4. From arrythmia or DVT with cardiac shunt 5. Telemetry, EKG, TTE with bubble to look for shunt, lower extremity doppler if shunt present, ziopatch on discharge
  4. Others 7. Cerebral amyloid angiopathy 8. Embolic stroke of undetermined source (ESUS) 9. Cryptogenic

Routine workup: CT head, then CTA/MRA, transcranial doppler with carotid US, TTE with bubble, lipid profiles, A1C, TSH

Antiplatelet and anticoagulation

  • ESUS: ASA only
  • Intracranial disease s/p stenting: DAPT
  • 1 vessel disease or TIA: DAPT for 21 days, then ASA only
  • Afib with new stroke: AC
  • Cardioembolic: AC