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Stroke Identification and Treatment: "Time Is Brain" Case Presentation This presentation addresses the importance of rapid identification and treatment of acute stroke in order to improve patient outcome. The management of several types of stroke are addressed as well as strategies for treating stroke patients. Introduction Prognosis and Mortality Stroke is a leading cause of death. Fifteen to thirty percent of patients with ischemic stroke die within 30 days. The mortality for hemorrhagic stroke is even higher with a 40-84% mortality within 30 days. Stroke is the leading cause of disability. The estimated annual cost of stroke in the United States is approximately $30 billion per year. These imposing statistics manifest the need for more effective stroke management strategies. Strokes are broadly classified into several categories which elucidate etiology and guide specific management. More than 80-85% of strokes are ischemic (thromboembolic), 10%-15% are intracerebral hemorrhages, and 6%-7% are subarachnoid hemorrhages. The spectrum of stroke clinical presentations is broad and ranges from isolated motor or sensory deficits to coma. Several classical stroke syndromes are well recognized and correspond to the anatomic region of the brain which is affected. While the initial management of stroke is not dependent on identifying the exact anatomic distribution of the stroke, it is necessary to quickly determine into which broad type it falls in order to guide emergency management. The physician must be able to distinguish between ischemic stroke, intracerebral bleed, subarachnoid hemorrhage, cerebellar stroke, and transient ischemic attack. Management The initial emergency department (ED) role in managing a patient with a suspected intracranial event is the prompt stabilization and evaluation of the patient. There must be a rapid assessment of the patient*s airway, breathing and circulatory status. The stroke patient requires close monitoring of vital signs with particular attention to the blood pressure. There is insufficient data defining optimum blood pressure levels in the patient who has had a stroke. While there is concern about the detrimental effect of higher blood pressure there is also concern that rapid lowering of elevated blood pressure can cause deterioration due to the stroke-induced loss of cerebral autoregulatory mechanisms. Guidelines have been established by the National Stroke Association which were determined by committee consensus. In general, it is recommended that the blood pressure not be treated urgently unless the systolic pressure exceeds 220 mmHg or the diastolic pressure exceeds 120 mmHg on three repeated measurements made at 15 minute intervals. The stroke patient requires cardiac monitoring and an electrocardiogram (ECG) performed because of the coincidence of dysrhythmias and myocardial ischemia with stroke. If fever is present it should be promptly reduced with antipyretics since experimental evidence suggests that lowering temperature reduces infarct size. The presence of fever warrants a search for a cause and consideration of an infectious etiology of the neurologic deficit. Determination of serum glucose is important. Hypoglycemia may mimic stroke producing focal neurologic findings. Hypoglycemia must be promptly corrected with glucose administration. However, excess glucose administration in patients with stroke should be avoided. Some studies have correlated poor stroke outcome with elevated blood glucose. A causal relationship has not been established. Stroke intervention is dependent upon what type of stroke is involved and the emergency physician must attempt to delineate this. Another important objective of the emergency departments work-up is to uncover non-stroke conditions that produce a stroke-like presentation. A thorough history, and general physical and neurologic examination are required. Focal neurological deficits should be carefully documented so that any change can be recognized. The presence of possible co-morbidities which may have caused or contributed to the stroke, including carotid bruits, heart murmurs and dysrhythmias should be noted. Initial evaluation should include an ECG, chest X-ray, complete blood count, coagulation profile, serum electrolytes and glucose. An emergency head CT must be performed. Early neurologic consultation is recommended. While seizures are a potential complication of acute stroke during the first 24 hours, routine prophylaxis is not recommended. When seizures do occur they are managed initially with lorazepam with consideration given to phenytoin loading. Elevated intracranial pressure is a serious complication of stroke. Patients with neurologic compromise secondary to increasing intracranial pressure are candidates for intubation and hyperventilation. Stabilization using mannitol osmotic therapy is best guided by intracranial pressure monitoring. Immediate neurosurgical consultation must be obtained in all cases of suspected elevated intracranial pressure. Special Situations Cerebellar stroke:
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