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KEY CONCEPTS

KEY CONCEPTS

  • imageStroke can be either ischemic (87%) or hemorrhagic (13%) and the two types are treated differently.

  • imageTransient ischemic attacks (TIAs) require urgent intervention to reduce the risk of stroke, which is known to be highest in the first few days after TIA.

  • imageIn patients with an ischemic stroke and a blood pressure (BP) <220/120 mmHg without comorbid conditions requiring acute hypertensive treatment, the acute lowering of BP in the first 48 to 72 hours after stroke onset does not improve survival or the level of dependency. In patients with intracranial hemorrhage and elevated systolic blood pressure (SBP) between 150 and 220 mmHg, the acute lowering of SBP to lower than 140 mmHg is safe and may improve functional outcomes.

  • imageThrombectomy is strongly recommended for patients with anterior circulation arterial occlusion in the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (MCA) who are within 6 hours of symptom onset and may be considered in select patients within 6 to 24 hours of symptom onset.

  • imageIn patients with ischemic stroke and 70% to 99% stenosis of the carotid artery, carotid endarterectomy or carotid stenting should be performed.

  • imageEarly pharmacologic reperfusion (initiated less than 4.5 hours from symptom onset) with intravenous alteplase has been shown to improve functional ability after ischemic stroke.

  • imageAntiplatelet therapy is the cornerstone of antithrombotic therapy for the secondary prevention of noncardioembolic ischemic stroke.

  • imageOral anticoagulation is recommended for the secondary prevention of cardioembolic stroke in moderate- to high-risk patients.

  • imageElevated blood pressure is very common in ischemic stroke patients and treatment of hypertension in these patients is associated with a decreased risk of stroke recurrence

  • imageStatin therapy is recommended for all ischemic stroke patients, regardless of baseline cholesterol, to reduce stroke recurrence.

PATIENT CARE PROCESS

Patient Care Process for Acute Ischemic Stroke

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Collect

  • Patient characteristics (eg, age, sex, race)

  • Patient medical history (personal and family)

  • Social history (eg, tobacco/ethanol use)

  • Current medications including nonprescription aspirin/nonsteroidal anti-inflammatory drug (NSAID) use, herbal products, dietary supplements, and prior antiplatelet and anticoagulant medication use

  • Medication allergies

  • Objective data

    • Blood pressure (BP), heart rate, respiratory rate, height, weight

    • Labs including hemoglobin, platelets, serum creatinine, activated partial thromboplastin time (aPTT), prothrombin time, blood glucose, troponin

    • Noncontrast computed tomography (CT) scan, magnetic resonance imaging (MRI), and/or computed tomography angiography (CTA) may be needed

    • Neurologic examination (eg, National Institutes of Health Stroke Scale [NIHSS] score)

    • Electrocardiogram (ECG) and, in some patients, transthoracic echocardiogram (TTE)

Assess

  • Hemodynamic stability (eg, SBP <110 mm Hg, DBP <185 mm Hg, if tissue plasminogen activator candidate; blood pressure less than 220/120 mm Hg otherwise; O2-sat >94% [0.94]; temperature <38ºC [102ºF])

  • Blood glucose (<60 mg/dL [3.3 mmol/L] or >180 mg/dL [10.0 mmol/L] should be treated)

  • Presence of active bleeding and/or bleeding risk factors (Table 38-8)

  • Patient's candidacy for tissue plasminogen activator treatment (Table 38-4) or thrombectomy

  • Presence of dysphagia (swallowing disorder)

Plan...

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