Brigham and Women's Hospitals

Acute Stroke

Acute stroke work-up and management

  1. Diagnostic work-up for acute stroke:
  1. Check ABCs, obtain vitals (HR, BP, temperature, SpO2), place on telemetry
  1. Blood pressure management should be discussed with neurology. General recommendations:
  1. If tPA/intra-arterial therapy (IAT) candidate, initial goal BP < 185/110
  2. If not a tPA/IAT candidate, initial goal BP < 220/120
  1. Address stroke mimics:
  1. STAT finger-stick blood glucose; correct if < 50, > 400 and reassess
  2. Correct SaO2 < 90% as able and reassess
  1. While performing above, page acute stroke pager (BWH ED: p31381; BWH inpatient: p31382 [stroke fellow] and p30342 [stroke consult resident]).
  1. Try to establish accurate “last seen well” time as soon as possible
  2. Perform NIHSS, neurology will also perform on arrival.
  1. Order STAT non-contrast head CT and CTA of head and neck. Clarify which scanner the patient will be going to.
  2. Ensure the patient has at least one 18 gauge IV in an upper extremity for contrast scan and prepare patient for transport
  3. Draw labs as below if not performed within 24 hours (scan should not be delayed for lab draw)
  4. Keep patient NPO, HOB > 30°, prepare patient for imaging (e.g. supinate if proned, place sling under patient if needed)

  1. Ischemic Stroke Work-up: Discuss with neurology consultant for tailored recommendations based on clinical presentation

Imaging work-up

Lab work-up

  • Vessel imaging: CTA head and neck preferred. If unable to obtain, consider MRA head and neck or carotid US/TCDs
  • Defer MRI unless likely to change short-term management
  • TTE:
  • Defer until patient off precautions unless likely to change short-term management (e.g. concern for endocarditis)
  • Consider with bubble in patients < 60 years old
  • Consider with LV contrast particularly if high concern for LV thrombus as embolic source
  • EKG
  • Telemetry while inpatient
  • If stroke confirmed and mechanism unclear, consider 30 day mobile cardiac telemetry or LINQ (if no known AFib)
  • FSBG
  • CBC with differential, BMP, LFTs
  • PT/INR, PTT, D-dimer
  • Lipid panel, HgbA1C, TSH
  • Troponin, NT-proBNP
  • ESR, CRP, fibrinogen, ferritin, procalcitonin
  • Blood cultures

  • Consider hypercoagulability work-up in patients < 60 years old:
  • Homocysteine
  • Lupus anticoagulant, DRVVT
  • Anti-cardiolipin Ab (IgG and IgM)
  • Beta-2-glycoprotein Ab
  • Protein C, Protein S
  • Anti-Thrombin III
  • Factor V Leiden
  • Prothrombin Gene Mutation (G20210A)‎

  1. Management
  1. Ischemic stroke
  1. tPA and IAT inclusion and exclusion criteria

tPA inclusion criteria

tPA exclusion criteria

IAT inclusion criteria

IAT extended window inclusion criteria

  • Last see well < 4.5 h
  • Age > 18
  • Disabling neurologic deficit
  • Plt > 100K
  • INR < 1.7
  • SBP <185/110
  • Use of DOACs within 48h
  • Current / prior intracranial hemorrhage
  • Hypodensity > ⅓ cerebral hemisphere on CT
  • TBI/stroke/brain surgery < 3 months
  • Major surgery < 2 weeks
  • GI hemorrhage < 3 weeks
  • Vascular malformations
  • Intracranial neoplasm
  • Last seen well < 6 h
  • Age > 18
  • Large Vessel Occlusion (LVO) present
  • NIHSS ≥ 6
  • MRS ≤ 1 (varies)
  • ASPECTS score ≥ 6
  • SBP < 185/110
  • Last seen well ≤ 24 h
  • Life expectancy > 12 mo
  • Advanced imaging criteria (with neurology, consider MRI, CT perfusion)

  1. Medications:
  1. If tPA not given and not on anticoagulation or at high risk of bleeding: give aspirin 325 mg PO (or 300 mg PR)
  2. High-intensity statin, e.g. atorvastatin 80 mg PO QHS (ok to defer if no enteral access), goal LDL < 70
  3. Discuss with neurology ongoing antiplatelet therapy or anticoagulation based on clinical presentation
  4. Ensure on DVT prophylaxis if clinically appropriate
  1. Post-stroke monitoring:
  1. If intubation required for IAT, patients will not be extubated in the OR, but in negative pressure room in intensive care
  2. NPO until RN documents swallow screen, consider nasogastric tube if needed for enteral access
  3. Neurologic exam and vital signs:
  1. Follow existing institutional guidelines regarding frequency of vital signs and neurologic exams post-tPA or post-IAT
  2. If no tPA/IAT:
  1. Patient stable: neuro exams and VS Q4H x 24 h then Q8H if remains stable
  2. Patient unstable or high-acuity insult (large territory MCA infarct, posterior fossa stroke): neuro exams and VS Q1-2H x 24H then Q4H if stable
  1. Maintain telemetry
  2. Blood pressure goals should be discussed with neurology. General guidelines:
  1. If given tPA: BP < 180/105
  2. If successful IAT: SBP < 140
  3. If no tPA/IAT: SBP < 220 x 24 h then decrease by ~20% per day to inpatient goal SBP < 160
  4. Outpatient goal SBP < 130-140
  1. STAT non-contrast head CT for change in neurologic exam
  1. If intracranial hemorrhage identified < 24 h post-tPA, draw STAT fibrinogen to guide possible tPA reversal (see intracranial hemorrhage management)
  1. Post-tPA considerations:
  1. Post-tPA exam frequency: q15 min for first 2 hours, q 30 min for subsequent 6 hours, q1h for subsequent 16 hours; if stable q4h - q8h thereafter
  2. Bedrest x 8 h post-tPA administration
  3. Defer if able until 24 h post-tPA: venous / arterial puncture, bladder catheterization, nasogastric tube placement
  4. Hold pharmacologic DVT prophylaxis and antithrombotics until confirmed absence of intracranial hemorrhage on 24 h post-tPA non-contrast head CT
  5. Obtain non-contrast head CT 24 h after administration
  1. If no hemorrhage, can start pharmacologic DVT prophylaxis and antiplatelet / anticoagulation per discussion with neurology
  2. If ICU beds are limited, consider prior to 24 h: check fibrinogen and if > 150 can expedite post-tPA head CT in order to facilitate floor transfer
  1. General post-stroke care:
  1. Recommend PT/OT/SLP consults if appropriate
  2. Goal euthermia, use antipyretics as needed. If unable to control fever consider cooling blanket
  3. Goal euglycemia (FSBG 80-140)
  4. Magnesium goal >2
  5. Smoking cessation counseling and nicotine replacement therapy if needed
  1. Intracranial Hemorrhage:
  1. Consult neurology. Consider neurosurgical consultation, especially for:
  1. Any rapidly expanding hemorrhage
  2. Intraparenchymal hemorrhage in cerebellum or with significant mass effect
  3. Intraventricular hemorrhage
  4. Subarachnoid hemorrhage
  5. Subdural hemorrhage > 1 cm or with significant mass effect
  6. Epidural hemorrhage
  1. Blood pressure control:
  1. Goal SBP < 140 x 24 h then SBP < 160 if stable
  2. Attempt IV pushes:
  1. Labetalol 5-20 mg IV Q4H PRN (if HR allows)
  2. Hydralazine 5-20 mg IV Q4H PRN
  1. If BP very elevated and/or refractory to IV pushes, consider continuous infusions:
  1. Nicardipine 0-15 mg/h, or
  2. Labetalol 0-4 mg/min, or
  3. Nitroglycerin 0-200 mcg/min
  1. If requiring continuous infusion, place arterial line to facilitate monitoring and recommend ICU level of care
  2. Start and/or up-titrate PO antihypertensives as needed in conjunction with above
  1. Reverse any anticoagulants:

  1. Medications:
  1. Antihypertensives as above
  2. Hold all antiplatelets and anticoagulants; discuss timing of resumption with neurology / neurosurgery
  3. Hold pharmacologic DVT prophylaxis until 48 h after radiographic stability
  4. Prophylactic AED recommended for traumatic subarachnoid hemorrhage and traumatic subdural hemorrhage
  1. If normal renal function, keppra 500 mg x 7 days. Adjust dosing for renal impairment in discussion with pharmacy or neurology
  1. Monitoring and further workup:
  1. Additional imaging:
  1. CTA head to evaluate for vascular abnormalities (except for isolated subdural hemorrhage)
  2. STAT non-contrast head CT for any change in neurologic exam
  3. Repeat non-contrast head CT 4-6 h after initial scan to assess stability
  1. If clinically or radiographically worsening, contact neurology / neurosurgery consultant
  1. Consider non-urgent MRI brain either during admission or within 3 months if etiology unclear (e.g. to evaluate for supporting evidence of cerebral amyloid angiopathy or underlying tumor)
  1. Patient stable and small hemorrhage: neuro exams and VS Q4H x 24 h then Q8H if remains stable
  2. Patient unstable or high-acuity insult (large hemorrhage, cerebellar hemorrhage, significant intraventricular hemorrhage): neuro exams and VS Q1-2H x 24H then Q4H if stable
  3. Consider transfer to neurosciences ICU if patient: requires neurosurgical intervention, at high risk of elevated ICP, has rapidly worsening neurologic exam, or has expanding hemorrhage
  1. Post-intracranial hemorrhage care: see general post-stroke care