SOAP. – Stroke – SỔ TAY LÂM SÀNG

Stroke

Jill C. Cash and Cheryl A. Glass

Definition

Strokes are a medical emergency. Treatment for hypertension (HTN) is effective for the reduction of strokes across all ages and populations and is a major component of primary and secondary stroke prevention.

A.Because of the aging population, it is estimated that by the year 2030 approximately 4% of the population in the United States will have had a stroke. The risk of having a stroke increases with age 65 and older and is especially prominent in the population older than or equal to 80 years.

B.Strokes are the fifth leading cause of death for men, but the third leading cause of death in women.

C.Strokes are the leading cause of disability in the United States:

1.Nearly half of stroke survivors have residual deficits, including weakness or cognitive dysfunction 6 months after stroke.

D.Stroke mortality varies by geographic location. The United States has a Stroke Belt in the southeastern states. Within this Stroke Belt there is an area described as the buckle region that has an approximate 40% increase in strokes. Georgia, North Carolina, and South Carolina are considered in the Stroke Belt Buckle area. The Pacific Northwestern states also have high stroke mortality rates.

E.Types of stroke include the following:

1.TIAs (see section Transient Ischemic Attack of this chapter).

2.Ischemic stroke (87% of all cases):

a.Cerebral thrombosis.

b.Cerebral embolism.

3.Hemorrhagic (13% of stroke cases—intracerebral hemorrhage or subarachnoid hemorrhage [SAH]):

a.Aneurysm.

b.Arteriovenous malformation (AVM).

Incidence

A.The incidence of stroke differs by gender, race, and ethnicity:

1.Ischemic stroke is greater in Hispanics/Latinos and Blacks:

a.Hispanic women and men have the highest rates of diabetes, HTN, and obesity. Stroke is the third leading cause of death in Hispanic women. The average age for a stroke among non-Hispanic Whites is 80 years of age, but among Hispanics, it is 67 years of age.

b.African American men and women are more likely to have a stroke than any other population in the United States. These men and women are more likely to have strokes at a younger age and have more severe strokes related to HTN, sodium intake, sickle cell anemia, smoking, obesity, and diabetes.

c.Stroke is the fifth leading cause of death in men, killing almost the same number of men each year as prostate cancer and Alzheimer’s disease (AD) combined in White males.

d.One in five women in the United States will have a stroke in her lifetime:

i.Nearly 60% of stroke deaths are in women, and strokes kill twice as many women as breast cancer.

ii.Pregnancy-related HTN is the leading cause of both hemorrhagic and ischemic stroke in pregnant and postpartum women.

iii.Presence of migraine with aura, contraceptive use, and smoking has a seven-fold higher odds of stroke in women.

B.One out of four people will have another stroke within 5 years.

C.The history of a stroke and/or TIA averages 10% yearly risk for a stroke.

D.The risk of a stroke within 90 days of a TIA may be as high as 17%, with the greatest risk during the first 7 days.

E.The rate for ischemic stroke for patients with atrial fibrillation (AFib) is 5% yearly.

F.Hemorrhagic strokes account for 13% of strokes.

G.Brain AVMs occur in less than 1% of the general population, and are estimated to be in about one in 2,000 to 5,000 people. AVMs are more common in males than in females.

Pathogenesis

A.Ischemic strokes are a complication related to atherosclerotic deposits. Plaque builds up and occludes the blood flow. The lack of blood flow to the brain causes ischemic changes. The symptoms exhibited are dependent on the location and severity of the ischemia. Ischemic strokes are also a complication of a cerebral embolism.

B.Hemorrhagic strokes are related to an aneurysm/rupture of a blood vessel or an AVM.

Predisposing Factors

A.Cardiac causes:

1.AFib (increases risk for stroke five-fold).

2.Mitral and aortic valve disease.

3.Rheumatic heart disease.

4.Atrial and ventricular septal defects.

5.Carotid artery stenosis.

6.Thrombosis.

7.Embolism.

B.Modifiable risk factors:

1.HTN.

2.Smoking/exposure to smoke.

3.Diabetes.

4.Dyslipidemia.

5.Obesity is an independent risk factor for stroke.

6.Physical inactivity.

7.Sickle cell disease.

C.Nonmodifiable risk factors:

1.Age:

a.The age of stroke onset is older for women, with the majority occurring after age 70.

2.Gender:

a.Several factors are noted to increase the stroke risk for women:

i.Pregnancy.

ii.Preeclampsia/eclampsia (twice the risk factor for stroke).

iii.Hormone therapy (HT).

iv.Contraceptive use.

v.Migraine with aura.

3.Race/ethnicity:

a.Stroke risk is increased in Blacks and Hispanic/Latinos.

4.Family history/genetic predisposition:

a.Inherited coagulopathies

D.TIA.

E.Migraine with aura.

F.Iatrogenic anticoagulation.

G.Illicit drug use (i.e., cocaine or methamphetamines).

H.Postsurgical complications.

I.Cerebral amyloidosis.

Common Complaints

Signs and symptoms depend on the affected vessel and surrounding brain tissue.

A.Acute onset of focal neurologic deficit:

1.Partial or total loss of consciousness.

2.Headache (often described as the worst headache ever).

3.Limb weakness or numbness.

4.Contralateral hemiparesis.

5.Facial weakness/drooping.

6.Speech difficulty (ranges from a total loss of speech to the inability to express and comprehend).

7.Dysphagia (ranges from an inability to chew and swallow to swallowing liquids that may lead to aspiration).

8.Visual changes (loss of vision, blurring, and double vision).

9.Ataxia.

Other Signs and Symptoms

A.Cognitive changes.

B.Behavioral changes.

C.Nausea and vomiting.

D.Fatigue.

E.Seizures.

Potential Complications

A.Long-term sequelae are dependent on the location and severity of the ischemia or hemorrhage.

B.Death.

Subjective Data

A.Ask detailed questions about symptoms before, during, and after the incident:

1.Review the exact timing of onset of symptoms.

2.How intense were the symptoms?

3.What were the duration and the presence of any fluctuation of symptoms?

4.Has there been a pattern that is becoming more frequent or escalating in symptoms?

B.Interview the patient, family members, witnesses, and emergency personnel for their description of behavior, speech, gait, memory, and movement:

C.Review the medical history:

1.Previous TIA or stroke.

2.Previous/recent surgeries, specifically carotid or cardiac surgeries and any procedures such as coronary artery bypass graft (CABG) or stents.

3.AFib.

4.HTN.

5.Pregnancy or recent delivery history.

6.Migraine headaches.

7.Seizures.

8.Central nervous system (CNS) infection.

9.Illicit drug use.

10.Presence of any metabolic disorders.

11.Recent trauma (blunt or torsion injury to the neck).

D.Focus on precipitating factors and state of consciousness after the acute event.

E.Review all medications, including anticoagulants, oral contraceptives, HT, over-the-counter (OTC), and particular review of substances not prescribed, as well as illicit drugs such as cocaine.

F.Herbals that alter bleeding time and interact with warfarin:

1.Feverfew.

2.Garlic.

3.Ginkgo biloba.

4.Ginger.

5.Ginseng.

Physical Examination

Patients presenting with acute symptoms should be quickly assessed for the need to call emergency services 911 for immediate transport to the hospital. Time is of the essence for treatment with the drug tPA (tissue plasminogen activator).

A.Check blood pressure (BP), pulse, respirations, pulse oximetry. Weight and height should be obtained to calculate body mass index (BMI).

B.General observation:

1.Observe overall appearance, level of consciousness (LOC), ability to interact, language, difficulty swallowing, tremors, and spasticity, as well as memory skills.

2.Observe the patient walking (cerebellar system).

C.Inspect:

1.Dermal exam:

a.Overall hydration status.

b.Look for postcarotid endarterectomy scars, presence of a pacemaker, implantable cardioverter defibrillator, or other cardiac surgical scars.

2.Check pupil size and reactivity to light.

3.Perform a fundoscopic exam to evaluate optic disk margins, retinal plaques, and pigmentation. A cherry red spot may be evident in the macula in patients with central retinal artery occlusion.

D.Auscultate:

1.Heart for rate, rhythm, murmurs, or rubs.

2.Lungs: Note respiratory rate and pattern.

3.Carotid arteries for the presence of bruit.

E.Palpate:

1.Palpate extremities for pulses and peripheral edema.

F.Neurologic exam:

1.Cranial nerve (CN) testing:

a.Wrinkle forehead/raise eyebrows.

b.Smile and show teeth.

c.Stick out the tongue/lateral tongue movement.

d.Ocular movements.

e.Visual field.

2.Motor strength:

a.Shrug shoulders.

b.Test muscle strength: Grasp hands and squeeze.

c.Check reflexes of biceps, triceps, patellar, brachioradial, and Achilles.

3.Sensory testing: Pinprick.

4.Gait and posture (cerebellar system evaluation):

a.Ocular movements.

b.Gait.

c.Finger-to-nose test.

d.Heel-to-knee test.

Diagnostic Tests

There is no gold standard for the diagnosis of CNS infarction.

A.CT scan.

B.MRI.

C.Other imaging:

1.Computed tomographic angiography (CTA) to look for abnormalities including aneurysm.

2.Magnetic resonance angiography (MRA) to locate a cerebral aneurysm.

3.Cerebral angiography/cerebral arteriography to locate size and location of blockages.

4.Duplex Doppler studies.

D.Laboratory tests:

1.Emergent labs:

a.Glucose.

b.Serum chemistry profile.

c.Coagulation and hypercoagulability testing.

d.Complete blood count (CBC).

2.Urgent labs:

a.Erythrocyte sedimentation rate (ESR).

b.Cardiac enzymes.

c.Lipid profile.

3.Other laboratory tests based on history:

a.Urine drug screen.

b.Blood alcohol level.

c.Antiphospholipid antibodies.

E.ECG to identify cardiac dysrhythmia.

Differential Diagnosis

A.Cardiovascular accident:

1.Ischemic stroke.

2.Hemorrhagic stroke.

B.TIA.

C.AVM.

D.Aortic dissection.

E.Thrombosis.

F.CNS infection.

G.Trauma.

H.Brain tumor.

I.Demyelination.

J.Intoxication.

Plan

A.General interventions:

1.Patient teaching:

a.Therapeutic lifestyle changes (TLCs), including physical activity, diet, weight management, and smoking cessation are recommended for all patients.

b.Physical activity:

i.All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits.

ii.The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on lifestyle management include physical activity recommendations advising adults to engage in 40 minutes of aerobic physical activity three to four times a week. The aerobic exercise should involve moderate to vigorous intensity to reduce BP, low-density lipoprotein-cholesterol (LDLC), and non-high-density lipoprotein-cholesterol (HDL-C).

iii.Refer to section Exercise of Chapter 3 for information related to exercise in older adults and adults with disabilities.

iv.Physical therapy or cardiac rehab at least on initiation of an exercise regimen may be considered for individuals with disability after ischemic stroke.

B.Dietary management:

1.Advise the patient that diet modification is the first line of therapy for hyperlipidemia.

2.Explain cholesterol-lowering diet. Give dietary recommendation sheets. See Appendix B for low-fat/lowcholesterol and DASH dietary approaches to stop HTN.

C.Weight reduction:

1.Explain that weight reduction in patients greater than 20% over ideal body weight can lower LDL-C and triglyceride levels. Start by setting small, realistic, attainable goals such as losing 5 to 10 pounds, which encourages successful attempts.

D.Other key dietary recommendations include the following:

1.Counsel patients with a history of stroke or TIA to follow a Mediterranean-type diet instead of a low fat diet. The Mediterranean-type diet emphasizes vegetables, fruits, and whole grains and includes low-fat dairy products, poultry, fish, legumes, olive oil, and nuts. It also limits intake of sweets and red meat.

2.Patients with ischemic stroke, TIA, or hemorrhagic stroke who are heavy drinkers should eliminate or reduce their consumption of alcohol. Limit intake of alcohol to light to moderate amounts. One drink per day for women and up to two drinks per day for men may be reasonable. Nondrinkers should be counseled not to start drinking.

3.Lower sodium intake. Consume no more than 2,400 mg/d of sodium. Further reductions to 1,500 mg/d of sodium are associated with greater reduction in BP. Even a modest reduction in salt intake for more than or equal to 4 weeks leads to a reduction in BP.

4.See Section III: Patient Teaching Guide Nicotine Dependence.

E.Pharmaceutical therapy.

1.Reperfusion therapy with intravenous thrombolytic drug Alteplase intravenous (IV) recombinant tissue plasminogen activator (r-tPA) for ischemic stroke is considered the gold standard. r-tPA is utilized in the hospital setting. Use of r-tPA reduces the effects of stroke if administered within 3 hours of symptom onset. Delayed hospital arrival is the single most important reason for the failure to administer tPA within the window of 3 or 4.5 hours:

a.The 2012 American College of Chest Physicians Guidelines for Antithrombotic and Thrombolytic Therapy for Ischemic Stroke recommends the following:

i.r-tPA to be initiated within 3 hours of symptom onset for patients with an acute ischemic stroke.

ii.r-tPA can be initiated within 3 to 4.5 hours of acute symptom onset.

iii.In patients with acute ischemic stroke in whom treatment cannot be initiated within 4.5 hours of symptom onset, the College recommends against r-tPA therapy.

2.Antiplatelet therapy is used for both the management of acute ischemic stroke and for the prevention of stroke:

a.Aspirin (ASA) is the most commonly used antiplatelet therapy. Administration of aspirin is recommended in acute stroke patients within 24 to 48 hours after stroke onset. For patients treated with tPA, aspirin administration is generally delayed for 24 hours:

i.High-dose aspirin 150 to 325 mg/d.

ii.Lower dose of aspirin 75 to 100 mg daily.

iii.Lower doses of aspirin are associated with milder GI symptoms and less GI hemorrhage.

b.Clopidogrel (Plavix) 75 mg once daily as monotherapy.

c.For patients with recently symptomatic atherosclerotic intracranial large artery stenosis, dual platelet therapy with aspirin plus clopidogrel for 90 days followed by antiplatelet monotherapy is recommended:

i.Clopidogrel 300 mg loading dose, then 75 mg daily for 90 days, plus aspirin 75 mg daily for the first 21 days.

ii.Dual antiplatelet therapy with aspirin and clopidogrel is not recommended for stroke prevention.

d.Dipyridamole as monotherapy or as dual therapy for secondary stroke prevention:

i.Immediate-release 50 to 100 mg three times a day is not routinely recommended for secondary prevention of ischemic stroke.

ii.Aspirin plus extended-release dipyridamole 25 mg/200 mg twice a day is used as an alternative for patients intolerant to aspirin.

e.Ticlopidine 500 mg daily for secondary stroke prevention is not considered as a first-line antiplatelet therapy for stroke prevention because of cost and side effects. The most serious side effect/complication with ticlopidine is severe neutropenia requiring biweekly to weekly CBCs for the first 3 months of therapy.

f.Cilostazol 100 mg twice a day. Cilostazol, a phosphodiesterase 3 inhibitor used mainly for intermittent claudication in patients with peripheral artery disease, has also been found effective for preventing cerebral infarction in Asian ethnic groups. There is a lack of high-quality data regarding the use of cilostazol for secondary stroke prevention in non-Asian ethnic groups.

g.Long-term anticoagulant therapy is required for the secondary prevention of AFib (see Chapter 13 for an in-depth review of AFib). Note: The CHA2DS2-VASc score evaluates the risk of ischemic stroke in patients with AFib. To calculate a CHA2DS2-VASc score, go to www.clincalc.com/cardiology/stroke/chadsvasc.aspx. In general, the lower the score, the stronger the consideration for oral anticoagulation. The one exception to this is when the patient has a score of 1 due to gender alone.

3.Statin therapy with intensive lipid-lowering effects is recommended to reduce the risk of stroke and cardiovascular events among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin and a LDL-C level ≥100 mg/dL with or without evidence for other clinical atherosclerosis cardiovascular disease (ASCVD; see section Atherosclerosis and Hyperlipidemia of Chapter 13 ).

4.Initiate or resume BP therapy for prevention and reoccurrence of TIA or ischemic stroke to achieve a systolic pressure less than 140 mmHg and a diastolic pressure less than 90 mmHg (see section Hypertension of Chapter 13).

5.Further adjuvant therapy must be managed under the direction of a neurologist after a full evaluation.

F.Surgery:

1.Mechanical thrombectomy.

2.Carotid endarterectomy (CAE).

3.Carotid angioplasty and stenting (CAS).

4.Extracranial-intracranial (EC/IC) bypass.

5.Endovascular stenting.

6.Open surgical procedures, including vertebral artery endarterectomy and vertebral artery transposition.

Follow-Up

A.Follow-up is determined by patient’s needs, severity of stroke, and whether complications are present.

B.Cardiac rhythm studies for more than 24 hours should be considered for nonvalvular AFib (NVAF).

C.Sleep apnea is present in approximately half to three quarters of patients with stroke or TIA. Consider a sleep study and treatment with continuous positive airway pressure (CPAP).

D.The AHA/ASA recommends that patients with sickle cell disease and prior strokes/TIA have chronic blood transfusions to reduce hemoglobin S to less than 30% of total hemoglobin.

E.Evaluate for depression at each office visit.

F.Stroke rehabilitation may include the following:

1.Speech therapy.

2.Occupational therapy.

3.Physical therapy.

G.Rehabilitation sites include the following:

1.Nursing facility.

2.Skilled nursing facility (SNF).

3.Assisted living facility.

4.Home.

H.Identify area support groups for the patient and/or caregivers.

I.Fitness for driving varies by state.

Emergent Issues/Instructions

If a stroke is suspected, call 911; symptoms of a TIA and a major stroke are not always distinguishable.

Consultation/Referral

A.Neurology.

B.Cardiology, if applicable.

C.Hematologist.

D.Maternal–fetal medicine for high-risk pregnancy.

Individual Considerations

A.Women:

1.Women older than 85 years of age have one of the highest risks of ischemic stroke. The increased risk may be accounted for by women living longer than men.

2.Women have a higher rate of SAH as well as a higher risk of rupture.

3.Two major risk factors for stroke in women are oral contraceptives and pregnancy.

4.Prepregnancy HTN increases the risk for pregnancy-induced hypertension (PIH) and stroke during pregnancy.

5.The highest risk for stroke occurs in the third trimester of pregnancy.

6.Postmenopause:

a.Research indicates that natural menopause is not associated with a risk of stroke.

b.Women with hysterectomy with bilateral oophorectomy have a slightly elevated risk of total stroke compared with women with hysterectomy with ovarian conservation.

c.The 2014 AHA/ASA guidelines for the prevention of stroke in women’s HT recommendations include the following:

i.HT, conjugated equine estrogen (CEE) with or without medroxyprogesterone should not be used for primary or secondary prevention of stroke in postmenopausal women.

ii.Selective estrogen receptor modulators, such as raloxifene, tamoxifen, or tibolone, should not be used for primary prevention of stroke.

7.Women with asymptomatic carotid stenosis should be screened for other treatable risk factors for stroke, and appropriate lifestyle changes and medical therapies should be instituted.

B.Geriatrics:

1.Worldwide the elderly population is quickly growing and in America geriatrics ≥85 years of age constitute 2% of population and this is predicted to double by year 2060. Incidence of strokes doubles in octogenarians making preventive measures a prominent focus for clinicians regarding the very elderly.

2.10% of intracerebral hemorrhages from cerebral amyloidosis occur in the elderly.

SOAP. – Stroke