ischemic stroke

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Grossmont College *

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5192

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Medicine

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Apr 3, 2024

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You are working as an NP for the inpatient neurology team today at a tertiary care facility. You are asked to evaluate Josh, a 48 year old male patient who presented with 90 minutes of left sided extremity weakness. Initially the patient believed the weakness was due to dehydration because he works in a hot manufacturing plant, but when symptoms did not resolve with hydration and cooling, he called 911. The patient denies medical history, no allergies, and only takes a daily vitamin. He does not regularly see a health care provider. The Emergency Department team has already ordered lab work and a STAT non-contrast Head CT. Vitals 195/95, HR88, RR16, t96.4, 98% CBC – WBC 9.4, Hemoglobin 13.8, Hct 46%, Platelets 250, Normal Differential CoAgs – Normal CMP -Glucose 44, BUN 16, Creatinine 1.3, All other values WNL CT of Head 1. Given the assessment findings and the above CT slice, what type of stoke is the patient most likely experiencing? (5 points) Based on the assessment of the left sided weakness and hypertension in this patient, the initial differential diagnosis is a right-sided stroke. Strokes can be subdivided into two main categories; infarctions and hemorrhages (Papadakis et al., 2022) and it is important to differentiate one from the other using a CT scan. When evaluating this CT scan, a hemorrhagic stroke can immediately be ruled out. Although this scan is in the early-acute stage, a small right-middle infarct with a slight shift is

observable. A right-middle infarction correlates to the patient’s symptoms of contralateral extremity weakness. Clinical findings in middle cerebral artery occlusion can be seen as contralateral hemiplegia, hemisensory loss, homonymous hemianopia (Papadakis et al., 2022). 2. When evaluating the patients previously ordered studies and assessments what findings need immediate intervention? How would you address these findings? (5 points) Based on the findings that are given here, there are two things that need to be immediately addressed: hypoglycemia and hypertension. First, the patient’s hypoglycemia should be treated. Hypoglycemia symptoms can mimic those associated with stroke, and it is important to rule out hypoglycemia as a factor. In this case, the CT scan confirms a stroke. Therefore, in order to assist in maintenance of collateral blood flow, it is recommended to maintain serum glucose greater than 60 mg/dL, but less than 180 mg/dL (Jameson et al., 2018). Second, the patient’s blood pressure is 195/95. Since thrombolytic therapy is anticipated, blood pressure should be lowered and maintained less than 185/110 (Jameson et al., 2018). This can be done by lowering the heart rate with a β-blocker which will decrease cardiac work and therefore maintain the blood pressure (Jameson et al., 2018). 3. On your evaluation the patient also has aphasia. Last known well time is 90 minutes ago. It would be at least an additional 90 minutes before interventional radiology would be available for any procedures. Is this patient a candidate for thrombolytic therapy (assuming all other contraindications are negative)? Why or why not? (10 points)

This patient is still considered to be in the acute phase of an ischemic stroke. In the United States, the use of thrombolytic therapy (such as tPA) may be used within 3 hours of stroke onset (Jameson et al., 2018). 4. If you were going to choose TPA, is there anything that needs to be addressed with this patient before administering TPA? (5 points) Since tPA is weight dependent, it is first important to obtain an accurate weight on this patient. It would also be crucial to rule out any contraindications or exclusion criteria. Lastly, at least 2 large bore IVs should be confirmed for proper tPA administration. tPA requires a dedicated line, but a back-up line is recommended as well (Hughes et al., 2018). 5. What is the appropriate dose for and how would you direct the administration of TPA? (5 points) TPA is dosed at 0.9mg/kg, to a maximum of 90mg. 10% of the dose should be administered as an initial bolus over one minute, with the rest remainder infused over 1 hour (Papadakis et al., 2020). The infusion should be stopped if there are any signs of intracerebral hemorrhage, such as a decline in neuro status, sudden rise in blood pressure, or complaint of headache (Marino, 2014). 6. The patient has improved symptoms, in fact almost resolved. You elect to admit the patient to the neuro-ICU for further workup and monitoring. What additional diagnostic testing is indicated for this patient? Please list at least 3 exams and why each is appropriate. (15 points) Supportive measures and observation are still necessary in the post-acute phase for this patient. Certain diagnostic tests are indicated to ensure proper recovery. CT head and neck - to monitor improvement of stroke post tPA administration and to identify any possible large vessel occlusions that were not responsive to endovascular therapy (Papadakis et al.,

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2020). Echocardiogram - to assess for or to exclude any valvular disease, non-PFO closure, right to left shunting, cardiac thrombus (Papadakis et al., 2020), or left-sided endocarditis (Marino2014). Continuous EKG monitoring and 12 lead EKG - monitor for possible a-fib or other cardiac arrythmia, and to rule out possible recent MI (Papadakis et al., 2020). 7. How would you manage the patient’s blood pressure in the acute phase, post administration of TPA? (5 points) Blood pressure must be maintained at or below 180/105 for the first 24 hours post tPA administration. This can be maintained using IV labetalol, nicardipine, or clevidipine as first-line agent choices (Maïer et al., 2020). According to NIH guidelines, the blood pressure should be monitored every 15 minutes for the first 2 hours after treatment, then every 30 minutes for the next 6 hours, then every 24 hours (Hughes et al., 2018). This patient has been admitted to a neuro ICU, so they will most likely have continuous blood pressure monitoring using arterial line.

References Hughes, R. E., Tadi, P., & Bollu, P. C. (2018). TPA therapy. Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (2018). Harrison's principles of Internal Medicine (20th ed.). McGraw-Hill, Health Professions Division. Maïer, B., Desilles, J. P., & Mazighi, M. (2020). Intracranial hemorrhage after reperfusion therapies in acute ischemic stroke patients. Frontiers in Neurology , 11 , 599908. Marino, P. L. (2014). Marino's the Icu book (4th ed.). Wolters Kluwer Health. Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2022). Current Medical Diagnosis & Treatment 2022 . (K. R. McQuaid, Ed.) (61st ed.). McGraw-Hill.

ischemic stroke

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