Obtain O₂ saturation, treat O₂ per NC. Titrate to keep saturations equal to or greater than 94%
Vital signs q 15 minutes while in the Emergency Department
Obtain patient's weight in kg. Estimation per family or medical personnel acceptable only if patient is unable to stand with minimal assist.
ED nurse to perform and document neuro assessment on arrival and with any change in condition
Stroke Team to perform and document baseline NIH Stroke Scale ASAP.
If patient meets IV thrombolytic criteria, proceed with IV tPA administration.
Neuro Radiology to notify Neurovascular team of large vessel occlusion
Distal Intracranial ICA, M1, M2, basilar, and vertebral occlusion.
ASPECTS Score > 6.
Patients with treatable large vessels occlusion by CTA to be evaluated in Neuroendovascular team for possible endovascular therapy.
Stroke Team MD to initiate “Neurology Acute Ischemic Stroke Order Thrombolytic Treatment” order set for eligible patients.
CRITERIA FOR THROMBOLYTIC AND REPERFUSION THERAPY
Verbal consent for IV thrombolytic therapy up to 4.5 hours and intra-arterial mechanical reperfusion will be documented in the electronic medical record along with the patient/family risk/benefit discussion.
Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit [see Warnings and Precautions (5.1)]:
Current intracranial hemorrhage
Active internal bleeding
Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma
Current severe uncontrolled hypertension.
WARNINGS or Relative Exclusion Criteria
When Activase is prescribed in the following conditions, the risks of bleeding are increased and should be weighed against the anticipated benefits:
Recent major surgery or procedure, (e.g., coronary artery bypass graft, obstetrical delivery, organ biopsy, previous puncture of non-compressible vessels)
Concurrent medical illness requiring hospitalization
Evidence of CNS infection
MEDICAL/SURGICAL PROTOCOL FOR MALIGNANT CEREBRAL EDEMA
The Stroke Team will clarify the family’s wishes for an aggressive level of care which may include potential surgical intervention. This should be done in conjunction with clarifying the resuscitation status of the patient on admission.
PICC line or central line placement
Consider serial imaging with non-contrast Head CT
Osmotherapy with Mannitol or 3% hypertonic saline at a dose sufficient to reach a serum osmolality of 315-320 mOsm
Initial dosing of Mannitol of 0.5 – 1 gm/kg IV
Caution: Slowly withdrawal osmotic therapy to avoid rebound cerebral edema
Daily monitoring of serum Na+ and osmolality
Serum Na+ and K+ every 4-6 hours while employing osmotic therapy
Correction of Na+ more than 0.5mmol/L per hr (12mmol/L in 24h) may require a decrease in rate/volume/dose of osmotic therapy
Intubation and mechanical ventilation:
If the patients Glasgow Coma Score is less than 9 or
Hyperventilation as a rescue measure in the event of further neurological deterioration or an uncontrolled increase in intracranial pressure.
Target pCO2 of 28-32 mmHg.
Hyperventilation is to be used as a temporary measure until other modalities can be instituted (i.e. osmotic therapy, CSF drainage, decompressive surgery).
Invasive monitoring of intracranial pressure, preferably on the same side as the infarct can be considered.
Sedation in the case of mechanical ventilation or further neurological deterioration is discouraged unless an ICP monitor is in place.
Treatment of blood pressure higher than 220/120 mmHg with anti-hypertensive agents.
Treatment of hypotension or a reduction of cerebral perfusion pressure to maintain CPP greater than 60 mmHg.
Elevation of the head to 30-45 degrees.
Maintenance of normothermia, normoglycemia, and normovolemia.
Initiate early nutrition with special attention to osmotic concentration of tube feeds. Consider free water restrictions to keep serum Na+ stable and normal.
INDICATIONS FOR DECOMPRESSIVE CRANIECTOMY IN PATIENTS WITH ISCHEMIC STROKE
Hemispheric/supratentorial stroke (MCA stroke with malignant cerebral edema)
Hemispheric stroke involving the middle cerebral artery territory with onset within 96 hours
The anterior cerebral artery and the posterior cerebral artery territories may be involved.
Ischemic changes on CT that affect two-thirds or more of the territory of the MCA, the formation of space-occupying edema and displacement of midline structures on imaging (volume 145 – 210 mL)
Note: In patients with hemispheric stroke with volume > 210mL, the fatality rate is 100% without decompressive craniectomy.
Good pre-stroke functional status (Karnofsky score > 80)
Written informed consent by the patient or a legal representative
Relative Contra Indications: Dementia
Multiple vascular risk factors
Pre-stroke score on the modified Rankin scale of greater than 1 or less than 95 on the Barthel index
Decrease in consciousness from causes other than the formation of edema, such as metabolic disturbances or medication
In patients with malignant cerebral edema from a hemispheric stroke with any of the above relative contra indications, the overall outcome is very poor even with aggressive non-surgical edema/ICP management. Therefore, a palliative-care approach should be considered.
No significant brainstem infarction (e.g. small posterolateral medullary stroke, Wallenberg’s, has relatively good prognosis so a patient with this stroke would be considered for surgery)
Age is less of a factor in the outcome of patients with cerebellar stroke treated with decompressive surgery. Patients with low GCS should be considered for surgery, but the clinical goal is to perform decompressive surgery prior to onset of brainstem compression or coma.