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04.05 Stroke Therapeutic Management (CVA)

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Overview

  1. Remove source of decreased blood flow
    1. Stop bleed, repair leak
    2. Remove clot, prevent new clot
  2. Faster intervention = minimize damaged brain cells

Nursing Points

Therapeutic Management

  1. Ischemic
    1. Permissive Hypertension
      1. Ensure perfusion to brain
      2. See CPP lesson
    2. Antithrombotic Therapy
      1. Clot buster
      2. i.e. tPA – Tissue Plasminogen Activator (Alteplase)
    3. Carotid Endarterectomy
      1. See Arterial Disorders lesson in Cardiac Course
    4. Percutaneous Thrombectomy
      1. Access via carotid artery in interventional radiology
      2. Remove clot from inside
  2. Hemorrhagic
    1. Aneurysm
      1. Coiling – interventional radiology
      2. Clipping – craniotomy
    2. Craniotomy
      1. Physical evacuation of clot
    3. External Ventricular Drain
      1. Drain blood from ventricles
      2. Monitor ICP
    4. Vasospasm
      1. Triple “H” Therapy
        1. Hypertension, Hypervolemia, Hemodilution
      2. IV fluids (Crystalloid)
      3. Calcium Channel Blocker – Nimodipine
        1. Acts locally on cerebral vessels
  3. Timeline Goals
    1. Patient presents with stroke-like symptoms
    2. Door-to-Physician → 10 minutes
    3. Determine onset time (as close as possible)
      1. “Last Known Normal”
      2. NIHSS
    4. Door-to-Stroke Team Notification → 15 minutes
    5. Door-to-CT Scan → 25 minutes
      1. Read within 45 minutes
    6. Door-to-tPA → 60 minutes
      1. tPA within 3-4.5 hours of onset of symptoms
    7. Improving times with Stroke Team = pre-hospital alerts, and stroke toolkits available in the emergency department
  4. Medications
    1. Nimodipine
      1. Prevents vasospasm
    2. Statins
      1. Improves atherosclerosis

Reference Links

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Video Transcript

So we’ve talked about hemorrhagic and ischemic strokes and how they present, now let’s look at how we manage these patients medically.

So our major goals with ischemic strokes are two-fold. One is to ensure good perfusion to the brain, the other is to get rid of the clot! One of our strategies is to use what we call permissive hypertension. This means we allow their blood pressure to be way higher than what you would consider normal – possibly even into the 200’s. If you remember from the Cerebral Perfusion Pressure lesson, the Mean Arterial Pressure, minus the Intracranial Pressure is our Cerebral Perfusion Pressure – the higher our MAP, the better our CPP. We can also give antithrombotic therapy. This would be thrombolytics like tPA or alteplase – they will go in and bust up this clot to open up the vessel. Just keep in mind, they’ll also bust up every other clot in the body. There are also a couple of surgical options like carotid endarterectomy, which we talked about in cardiac, and percutaneous thrombectomy where they go in through the arteries to clear out the clot. And then of course when these patients are discharged home they will need to be on Statin medications to decrease the plaque buildup within their arteries so that they don’t get another clot.

When it comes to hemorrhagic strokes, treatment options will vary based on the source of the bleeding. If it’s an aneurysm, we will either clip, or coil the aneurysm. In this image you can see the outpouching of the vessel here is the aneurysm. In coiling, the doctor will enter through the Carotid artery and go into the aneurysm and insert little coils of wire into the outpouching. What will happen is that that aneurysm will clot off so blood can’t flow into the weakened part of the vessel. We could also clip the aneurysm where surgeons will go in externally and place an actual clip right here below the aneurysm so that the weakened portion of the vessel can’t burst. We could also do an open craniotomy or an external ventricular drain like we talked about in the ICP lesson.

Then, one of the things we need to treat and manage in hemorrhagic strokes is the risk for vasospasm. To prevent vasospasm caused by blood irritating the vessels, we use what’s called Triple H therapy. That stands for hypertension, hypervolemia, and hemodilution. So we give these patients lots of fluids and increase their blood pressure to fill these vessels up and keep them from spasming. The other thing we give is a medication called nimodipine, or Nimotop. It is a calcium channel blocker that acts directly on the vessels in the brain to relax that smooth muscle and prevent spasm. This is one of the most important medications that you will give a patient who’s had a hemorrhagic stroke.

So we’ve said multiple times now that treatment for stroke needs to happen fast, but what does that look like in real time? Well the American Stroke Association has actually set goals on what the time line should be once a patient presents with stroke symptoms. We want them to see a physician within 10 minutes, specifically a neurologist who can do a detailed assessment and an NIH Stroke Scale. The other thing that we need to know is when they were last known normal. This will affect what treatment they qualify for. If they woke up with symptoms, then their last known normal is whatever time they went to bed. We will activate the stroke team and get the patient to CT scan right away with the goal of having the CT read by a radiologist within 45 minutes. The ultimate goal for this timeline is to be able to give the antithrombotic medication within 60 minutes of presentation. Patients whose symptoms began more than four and a half hours ago, or who have an obvious bleed on that CT scan, do not qualify for tPA. But, studies show that the sooner they receive it, the higher their chance for a full recovery. Most hospitals will have systems and teams in place to make this process happen rapidly. The facility where I currently work has an average 47-minute door to TPA time because of the systems that they put in place. Now I know this says door to physician, door to CT, etc., but we’re really talking about the moment they present with symptoms. That’s when the clock starts, even if they’re already in the hospital.

So remember our goal of therapy for an ischemic stroke is to remove the clot, either with a clot-busting medication or surgically. For a hemorrhagic stroke we need to stop the bleeding either buy coiling or clipping an aneurysm or through an open craniotomy to repair the bleed. And then remember we have a timeline for the goals of therapy so we need to act fast and get help as quickly as possible because time is tissue.

Make sure you check out the nursing care lesson in this module to see the big picture of your role and caring for patients who have strokes. There’s also a care plan and case study within that lesson that can help with detailed interventions and rationales. Now, go out and be your best selves today. And, as always, happy nursing!

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