This page intentionally left blank Acute Stroke Care Second Edition Acute Stroke Care A Manual from the University of Texas-Houston Stroke Team SECOND EDITION Ken Uchino, . . M D Jennifer Pary, . . M D James Grotta, . . M D CAMBRIDGE UNIVERSITY PRESS Cambridge,NewYork,Melbourne,Madrid,CapeTown, Singapore,SãoPaulo,Delhi,Tokyo,MexicoCity CambridgeUniversityPress TheEdinburghBuilding,CambridgeCB28RU,UK PublishedintheUnitedStatesofAmericabyCambridgeUniversityPress, NewYork www.cambridge.org Informationonthistitle:www.cambridge.org/9780521184847 ©K.Uchino,J.Pary,andJ.Grotta2011 Thispublicationisincopyright.Subjecttostatutoryexception andtotheprovisionsofrelevantcollectivelicensingagreements, noreproductionofanypartmaytakeplacewithoutthewritten permissionofCambridgeUniversityPress. Firsteditionpublished2007 Secondeditionpublished2011 PrintedintheUnitedKingdomattheUniversityPress,Cambridge AcatalogrecordforthispublicationisavailablefromtheBritishLibrary ISBN978-0-521-18484-7Paperback CambridgeUniversityPresshasnoresponsibilityforthepersistenceor accuracyofURLsforexternalorthird-partyinternetwebsitesreferredto inthispublication,anddoesnotguaranteethatanycontentonsuch websitesis,orwillremain,accurateorappropriate. Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateandup-to- dateinformationwhichisinaccordwithacceptedstandardsandpracticeatthe timeofpublication.Althoughcasehistoriesaredrawnfromactualcases,every efforthasbeenmadetodisguisetheidentitiesoftheindividualsinvolved. Nevertheless,theauthors,editorsandpublisherscanmakenowarrantiesthatthe informationcontainedhereinistotallyfreefromerror,notleastbecauseclinical standardsareconstantlychangingthroughresearchandregulation.Theauthors, editorsandpublishersthereforedisclaimallliabilityfordirectorconsequential damagesresultingfromtheuseofmaterialcontainedinthisbook.Readersare stronglyadvisedtopaycarefulattentiontoinformationprovidedbythe manufacturerofanydrugsorequipmentthattheyplantouse. Contents Preface page xi Listofabbreviations xv 1 Stroke in the emergency department 1 Isthisastroke? 1 Whattypeofstroke? 6 2 What to do first 7 Airway–breathing–circulation(ABCs) 7 Whatwasthetimeofonset? 8 Howbadarethesymptomsnow? 9 Doanon-contrastheadCT 9 IftheCTshowsnoblood,trytogetthearteryopen 10 Recommendeddiagnosticevaluation 10 3 Ischemic stroke 12 Definition 12 Etiology 12 Diagnosis 12 Thefourcomponentsofischemicstrokecare 13 v vi Contents Acutetherapyandoptimization ofneurologicalstatus 13 Etiologicalwork-upforsecondaryprevention 21 Preventionofneurologicaldeterioration ormedicalcomplications 25 Recoveryandrehabilitation 28 Ischemicstrokeoutcome 29 Generaltimeline 31 4 TPA protocol 32 TPAindications 32 Contraindications 33 Procedure 38 Dose 39 Samplepost-TPAorders 39 Risksvs.benefitsofTPA 41 Unproventherapies 44 5 Neurological deterioration in acute ischemic stroke 50 Probablecauses 50 Initialevaluationofpatientswithneurological deterioration 51 Strokeenlargement 51 Dropinperfusionpressure 52 Recurrentstroke 52 Cerebraledemaandmasseffect 54 Hemorrhagictransformation 58 Metabolicdisturbance 60 Seizure 61 Contents vii Symptomfluctuationswithoutagoodcause 62 Theuncooperativepatient 62 6 Ischemic stroke prevention: why we do the things we do 63 Investigations 63 Ischemicstrokeprevention:generalmeasures 67 Atrialfibrillation 73 Carotidstenosis 77 Acutecarotidocclusion 81 Intracranialstenosis 83 Lacunarstrokes 84 Cervicalarterialdissection 86 Patentforamenovale 88 7 Transient ischemic attack (TIA) 90 Definition 90 Etiology 90 Presentation 91 Differentialdiagnosis 91 Clinicalapproachtoapatientwith suspectedTIA 91 PrognosisafterTIA 94 8 Intracerebral hemorrhage (ICH) 96 Definition 96 Etiology 97 Presentation 98 Diagnosisandevaluation 99 viii Contents Management 100 Prognosisandoutcome 106 9 Subarachnoid hemorrhage (SAH) 109 Definition 109 Epidemiology 109 Presentation 110 Diagnosis 110 Rupturedaneurysms:management 112 Prognosis 117 Admissionsequence 118 Unrupturedaneurysms 119 10 Organization of stroke care 122 Timelycare 122 Strokeunits 123 Strokecenters 123 Stroketeams 124 11 Rehabilitation 126 Take-homemessages 126 Secondarystrokeprevention 127 Preventionofmedicalcomplications 127 Multidisciplinaryrehabilitationteam 127 Dischargeplanning 134 Appendix1.Numbersandcalculations 137 Appendix2.IVTPAdosingchart 139