Cerebrovascular accident

Regimen

General

(R/O hypoglycemia—may mimic CVA) and (perform stat CT scan) and (if symptoms 3h, activate stroke team or obtain stat neuro consult) and (use NIHSS to determine severity of deficit—see NIH Stroke Scale) and (treat seizures with benzodiazepines and phenytoin) and (avoid overhydration or administration of dextrose-containing sltns).

HTN management

Goal is 10-20% max reduction, treat only if
SBP > 220, DBP > 120 or MAP > 130 mmHg with (labetalol 10-20 mg IV, then 20-40 mg IV Q 20 min prn, max total 150 mg); or (enalapril 0.625-2.5 mg IV Q 20 min, max total 5 mg).

Refractory HTN

Nitroprusside 0.5-10 µg/kg/min, titrate to desired effect. If thrombolytic candidate, goal is SBP < 185 and DBP < 110 mm Hg. If BP does not respond to labetalol 10-20 mg IV Q 20 min for max 2 doses and nitroglycerin paste 1-2, do not thrombolyse.

Transient ischemic attack

Aspirin 325 mg po QD or aspirin/dipyridamole or clopidogrel. Full anticoagulation with only heparin indicated for atrial fibrillation or if cardiac mural thrombus present.

Ischemic stroke

Evaluate for eligibility for thrombolysis—risk of intracranial hemorrhage ~6.5%. If contraindicated, treat as for TIA. Criteria for thrombolysis (must meet all): (1) time of onset < 3h, (2) no hemorrhage on CT, (3) age > 18y.o. Thrombolysis excluded for any of: (1) sustained BP > 185/110, (2) minor or improving symptoms, (3) platelet count < 100K, (4) Hct < 25, (5) glucose < 50 or > 400, (6) prolonged PT or PTT, (7) heparin given past 48h, (8) witnessed seizure at stroke onset, (9) ischemic CVA past 90d, (10) closed-head injury past 90d, (11) any prior hx of hemorrhagic CVA, (12) major surgery past 14d; (13) GI bleed past 21d, (14) recent MI, (15) LP past 7d, (16) suspicion of aortic/carotid dissection. If thrombolysis indicated: Alteplase total dose 0.9 mg/kg (max 90 mg), give 10% as IV bolus, then 90% IV over 1h. Intra-arterial administration during angiography is an alternative. Hold anticoagulation for 24h after thrombolysis. Monitor BP Q 15 min for 2h after infusion, then Q 30 min for 6h, then Q 1h for 16h. If SBP > 180 mm Hg or DBP > 105 mmHg, start labetalol as previously or if refractory nitroprusside as previously.

Hemorrhagic stroke

Supportive care, control increased ICP. Treat BP elevations as above. Consider seizure prophylaxis with phenytoin IV load/maintenance. Consult neurosurgeon—hematoma evacuation may be indicated, esp. cerebellar. Altered mental status common. Strongly associated with antecedent HTN. Fatal in ~50% of cases.

Subarachnoid hemorrhage

Consult neurosurgeon stat. Give supportive care, prevent cerebral vasospasm with nimodipine 60 mg po or per NG Q 4h.