Lori Massaro, RN, MSN, CRNP

Bethanne McCabe, RN, MSN, CNRN

Sue Underwood, RN, MSN, CNRN

Required Annual Nursing Education

Primary Stroke Center

For ICU, Step-Down and Floor

• RN’s caring for stroke patients will demonstrate evidence

of initial and ongoing training in the care of the Acute Stroke Patient

– New Hire Orientation

– Annually via a minimum of 8 hours continuing education with focus on

Stroke/Stroke Care

Requirement

2

This educational requirement includes information

on: •Care of the Acute Ischemic Stroke patient

•Care of the Intracerebral Hemorrhage patient

•Care of the Subarachnoid Hemorrhage patient

•Nursing care priorities on Stroke by type

•Primary Stroke Center Performance Measures

•Post-test completion

Stroke is the leading cause of Disability in the US

Stroke is the 4th leading cause of Death in the US

• The approach to acute stroke and urgent treatment has evolved

over the past 15 years

• Primary stroke Centers are recognized by the State of PA & DOH

– EMS are instructed to bring patients to the closest stroke center

• A partnership with the UPMC Stroke Institute is in place for transfer

of patients who require neurointerventional or neurosurgical

vascular services beyond what is available at the Primary Stroke

Center to UPMC PUH or UPMC Mercy

Stroke Overview

3

• Risk factors

– Hypertension

– Hyperlipidemia

– Cardiac conditions

• Atrial fibrillation

• Cardiomyopathy with low EF (< 25%)

– Diabetes

– Smoking

– Large artery atherosclerosis

• Anterior circulation

– Carotid artery – intracranial or extracranial

– Middle cerebral artery

• Posterior circulation

– Vertebral – basilar arterial system

Acute Ischemic Stroke

4

• Symptoms usually occur suddenly

• May be accompanied by a headache

• Depending on area of brain affected/experiencing

ischemia

– Anterior versus posterior

– Left versus right

– Cerebral dominance

Acute Ischemic Stroke

Anterior circulation: ACA and MCA Posterior circulation: PCA and Cerebellar arteries

6

• Anterior Circulation

– Unilateral hemiparesis (may

range from mild weakness to

complete paralysis)

– Unilateral sensory disturbance

(numbness, tingling, loss of

sensation)

– Speech abnormality (aphasia,

dysarthria)

– Visual loss (quadrant loss,

homonymous hemianopsia)

– Incoordination or arm, hand or

leg

– Neglect syndromes, sensory or

visual are most common in right

hemisphere strokes

Symptoms by Location

7

• Posterior Circulation

– Balance or Gait changes

(dizziness, spinning sensation,

vertigo, lightheadedness)

– Ataxia

– Diplopia

– Dysarthria

– Hemiparesis

– Hemi sensory symptoms

– Alternating weakness or

sensory symptoms

– Nausea and Vomiting

Symptoms by Location

8

Cerebral Dominance

• Left Hemisphere is dominant in 90% of adults for motor function, 96% of adults for language functions – Speech/language function

– Right body control for sensory/motor function

– Right visual field

• Left middle cerebral artery strokes result in right hemiplegia,

aphasia and right visual field cut

• Right hemisphere is dominant in only 6-10% of adults

• Right hemisphere is considered non dominant hemisphere

Left Middle Cerebral Artery Functions

• Aphasia can range from expressive to receptive or global

aphasia

• Intellectual impairment (difficulty reading, writing, or

calculating)

• Right sided hemiparesis or hemiplegia

• Right sided sensory loss

• Right visual field defect

Right Middle Cerebral Artery Functions

• Motor and sensory control of left side of body

• Left visual field

• Visual and/or sensory neglect syndromes

• Much higher fall risk with right middle cerebral artery (MCA)

stroke patient because they are unaware of deficits

• NIHSS is the standard quantitative assessment use for

stroke patients

• Assessment should also include

– Cranial nerves

– Orientation

– Motor strength evaluation

– Sensory evaluation

– GCS

– Gait if able to assess

Neurologic Assessment

12

Imaging in Acute Ischemic Stroke: What are the Options?

• CT Scan

– CT angiography

– CT perfusion

• MRI Scan

– Diffusion Weight Imaging (DWI) for acute changes

– MR angiography

– MR perfusion

Imaging Priorities and Time Parameters

• < 3 hours - 4.5 hours

– Goal to exclude hemorrhage and assess for ischemic changes

– CT non contrast

• Performed in the ED initially to rule out evidence of hemorrhage

or early ischemic changes

• Frank hypodensity in 1/3 or more of MCA territory is a strong

contraindication for IV t-PA

– MRI obtained for same reason if doesn’t cause a delay in treatment

– CTA/MRA may be obtained to determine large artery patency if it

doesn’t cause delay in treatment

– CT perfusion/MR perfusion may be obtained to determine if there is

a mismatch between area infarcted versus what is at risk if doesn’t

cause a delay in treatment

Imaging Priorities and Time Parameters

• >4.5 hours is used when assessing for large artery

occlusion/stenosis and need for intervention

- CT with vessel study (CTA)

- MRI with vessel study (MRA/P)

• Assessing for tissue viability

- Perfusion diffusion mismatch

Left Posterior Parietal Lobe Hypodensity

16

Hyperdense Left Middle Cerebral Artery Sign

17

CT at 3 Hours - Hypodensity

Left Posterior Cerebral Artery (PCA) Occlusion

CT Perfusion

• Performed over 2 cuts of brain tissue

• 3 pieces of information can be obtain to develop quantitative

maps of:

– Cerebral blood flow (CBF)

– Cerebral blood volume (CBV)

– Mean transit time (MTT)

• Measure of circulatory dysfunction

vessel

occlusion

tissue at risk

hypoperfused

tissue

infarct core

Mismatch

MRI Imaging in the Acute Phase

• Available 24/7 at PUH, SHY and Mercy for acute stroke

evaluation

– Patient stability and cooperation are sometimes a factor

• More sensitive to detecting early ischemic changes

– Diffusion weighted imaging (DFI) sequence

• Also able to obtain vessel information MR angiography

(MRA) and MR perfusion (MRP) information

• Contrast enhanced with gadolinium

– Newer and more accurate to determine if arterial and

venous vessel patency

Gadolinium Enhanced MRA - Left MCA Branch Occlusion

MR Perfusion or Perfusion Weighted Imaging

• Used to evaluate infarcted tissue versus tissue at risk if

perfusion is not restored

• Perfusion diffusion mismatch

vessel

occlusion

tissue at risk

hypoperfused

tissue

infarct core

Mismatch

Calculate Diffusion Perfusion Mismatch –

the higher the number - more likely to intervene

with Intra-Arterial (IA) therapy Pink = area infarcted Green = area at risk

No mismatch: large core infarcted area compared to area at risk = Poor IA candidate

Large mismatch: small core infarction with large area at risk = Excellent IA candidate

Nursing Care Priorities across the Continuum

• Know how to perform a complete neurological examination

– Know the patients baseline

– Recognize and report changes ASAP

• Read the chart and understand the diagnosis, etiology of

stroke/TIA

• Understand potential complications for the neuroscience

patient and intervene to prevent them

• Perform NIHSS and neurologic assessment according to

orderset/unit protocol to determine baseline exam

• Assess for neurologic changes and communicate to medical

team

• Implement secondary stroke prevention measures

– Antithrombotic, anticoagulant and statin

• Implement measures to prevent complications related to

stroke

– Dysphagia screening and speech evaluation

– DVT prophylaxis and early mobilization

– Rehabilitation evaluation

• Education for patients and families

Nursing Care Priorities across the Continuum

30

Stroke Mimics

• Seizure

– Todds’ paralysis or post ictal focal neurologic symptoms

• Hypoglycemia

– Low circulating glucose = lack of glucose getting to brain cells

causing cellular dysfunction

• Metabolic disturbance

– Elevated ammonia in liver disease, elevated Cr in renal failure

• Narcotics/sedatives

• Establish last known normal time

• Prioritize diagnostics – CT imaging and lab testing

• Perform and monitor NIHSS/neurologic exam

• Obtain IV access, obtain 2 peripheral IV’s

• Continuous cardiac monitoring, identify rhythm

• BP and SaO2 monitoring

• Administer weight based thrombolytic therapy if indicated

• Monitor the post tPA patient every 15 min with vital signs

and NIHSS

• Observe for bleeding complications, neurologic changes

• Report and hand-off to ICU nursing team

ED RN Care Priorities

32

ED Priorities

• Minimize door to CT time

– Target is 25 minutes or less

• Minimize time to results

– Target order to CT results and Lab results < 45 minutes

• Minimize door to treatment times (IV tPA)

– Target is 60 minutes or less

• Earlier treatment with thrombolytics goal is to restore blood

flow and improve patient outcomes

Inclusion Criteria

• Check blood sugar and treat if

abnormal

• Present w/in 3 hours symptom

onset (witnessed onset)

• CT of head to rule out

hemorrhage

• Review patient history for

contraindications

• Treatment of patients with rapidly

improving symptoms NOT

RECOMMENDED

• Normal coagulation profile

Exclusion Criteria

• Evidence of hemorrhage

• Recent trauma, stroke or MI

• Brain or spine surgery with in last

3 months

• BP>185/110

Ok to start IV infusion to lower BP prior to IV

t-PA and continue during and after infusion

for optimal BP control

• Seizure at onset of stroke

• Intracranial neoplasm

• INR < 1.7 if on warfarin, use of

dabigatran (pradaxa) within 48

hours

Review Inclusion/Exclusion Criteria for Thrombolysis

34

• History of prior stroke and diabetes

• Age greater than 85

• History of previous stroke

• NIHSS greater than 25

• Age > 80

• Any anticoagulant use prior to admission (even if INR <1.7)

• CT findings involving more than 1/3 of the MCA territory

Additional Inclusion/Exclusion Criteria for tPA Administration 3-4.5 hours

35

IV Thrombolytics – Tissue Plasminogen Activase (tPA)

• IV tPA is dosed based on weight

• 0.9 mg kg total dose

– Not to exceed 90 mg

– 10% given as bolus over 1 minute

– Remainder given by infusion pump over 1hour

– Excess should always be removed from bottle

– 50-100cc NSS bag to flush line after infusion complete

Nursing Care During Thrombolytics

• No vena punctures or invasive procedures

• Insert Foley catheter prior to IV tPA or wait 1 hour after completion

• NIHSS/neuro checks and vital signs every 15 minutes for 2 hours, then every 30 minutes X 6 hours then every 1hour for remaining of 24 hour time period

• Watch for potential adverse reactions such as: – Bleeding

– Angioedema,

– Neurologic decline

– New onset headache

• Types of Patient who need ICU care

– Patients who may need more aggressive monitoring or who are

unstable hemodynamically

– Post IV tPA

– After Intra-arterial intervention

• Mechanical clot removal

• Manual aspiration

• Intra-arterial tPA

ICU Nursing Care

38

• Perform NIHSS and complete neurologic exam

• Follow Post tPA orders when appropriate

• Recognize and communicate

– Changes in neurologic status

– Hemodynamic parameters to maintain cerebral blood flow

– Neurologic or hemodynamic changes associated with increased

intracranial pressure

• Prevention of complications

– DVT

– Pneumonia

– Recurrent stroke

– Skin breakdown

• Initiate patient and family education for stroke

ICU Care Priorities

39

BP Management in the Acute Phase - Ischemic

• If treated with thrombolytics you must aggressively control

BP for first 24 hours to reduce risk of hemorrhagic

conversion

• Agents to consider

– Beta Blockers such as IV Labetalol

– Calcium Channel Blockers such as IV Nicardipine

• Avoid Nipride if possible

BP Management in the Acute Phase - Ischemic

• If no thrombolytics, in general, may let BP run a little higher

until vessel patency established

– In the setting of large artery occlusion or stenosis, higher blood

pressure may be needed to perfuse brain

– May allow SBP to rise to 220 mmHG temporarily

• Perform NIHSS and complete neurologic exam

• Recognize and communicate changes in neurologic status

• Prevention of complications from stroke/immobility

– DVT

– Pneumonia

– Recurrent stroke

– Skin breakdown

• Assessment and facilitate transition post hospital

– Rehabilitation or home

– Family or caregiver support/capacity

– Safety

• Education for patients and family/caregiver

Stroke Unit Priorities

42

Patient and Family Education

• Education should be ongoing from entry to discharge

• Organized system of providing information to patients/family

– SKAT documentation form located in ERecord

• Document that education is personalized

• Education must include

– Signs and symptoms of stroke

– The need to activate 911

– Education on risk factors and strategies for modification

– Education on medications

– Need for follow up appointment

Dysphagia Screening

• Bedside dysphagia screen (BSD) must be performed on all

ischemic, hemorrhagic and TIA stroke patients and

documented prior to giving oral meds/fluids

• Presence or absence of gag is not enough

• If patient fails BSD, repeat test in 12 hours and keep NPO

• Include speech therapy consultation in admission order

• Bedside evaluation is not intended to replace speech

therapy evaluation

• Ensure results of BSD are communicated during hand off

• Form located in adhoc “Bedside Dysphagia Screen”

• All stroke nurses are required to complete dysphagia

ULearn

Hyperglycemia and Stroke

• Hyperglycemia at the time of stroke and post stroke

worsens prognosis for recovery

• Treat hyperglycemia aggressively

• Insulin infusion protocols widely used to maintain

therapeutic glucose range

Fevers and Stroke

• Efforts to diagnose fever and treat aggressively are important in stroke prognosis and outcome

• Fever increases the brain’s oxygen demands 6-10% for every degree above normal

• Treat fevers aggressively with external cooling measures, Acetaminophen, and Ibuprofen

• Do not rely on axillary temperatures, rectal or core temperatures preferred

Neurologic Decline after Stroke

• May be due to increased intracranial pressure – Edema due to stroke

– Extension of stroke

– Hemorrhagic transformation

• Other potential causes – Seizures

– Fever/Infection

Diagnostic Work-up for Source of Stroke

• To examine arterial patency and/or rule out large artery

stenosis/occlusion

– Non-invasive carotid duplex

– CT angiography (CTA)

– MR angiogram (MRA)

– Cerebral angiogram

Diagnostic Work-up for Source of Stroke

• To rule out cardioembolic source

– TTE – transthoracic echocardiogram with bubble study

– TEE – transesophageal echo with bubble study

– 24 hour holter monitor

• Fasting lipid profile

• Hgb A1C

• Hypercoagulable profile is limited to patients without

detected etiology and higher degree of suspicion

• Responsible for 20% of all stroke types

• Symptoms often mimic those of an ischemic stroke

presentation

• May also present with headache and elevated BP

• Urgent neuroimaging is needed to determine if hemorrhage

is present

Intracerebral Hemorrhage

50

Intracerebral Hemorrhagic

• Patient with intracerebral hemorrhage may present similar to

ischemic stroke

– Lateralized weakness, sensory symptoms, aphasia, visual field cuts

– Headache is often present also

– Vomiting

– Elevated Systolic Blood Pressure

– Coma and/or decreases LOC

– Progressive decline in LOC

Right parietal Intracerebral Hemorrhage

Right Occipital Intracerebral Hemorrhage

53

Intracerebral Hemorrhage Care

• Medical Priorities are to prevent hematoma expansion

– Reverse anticoagulants

• Vitamin K, FFP, Factor VIIa

– Blood pressure management

• If SBP > 200 mm HG or MAP > 150 mm Hg consider infusion

• If SBP > 180 mm Hg or MAP > 130 mm HG with suspected

increase in ICP consider intermittent or continuous agents

• Maintain cerebral perfusion pressure> 60 mm Hg if monitoring ICP

– If concern for high ICP, consider ICP monitoring and target BP 160/90

and MAP 110 while maintaining CPP 60

• BP management continued

– If SPB > 180 or MAP > 130 and no evidence if elevated ICP

• Modest BP reduction using intermittent or Infusions

• Clinically re-examine patient every 15 minutes

• Toxicology screen in young or middle age patients

– Cocaine

– Sympathomimetic drugs

Intracerebral Hemorrhage Care

55

• Frequent neurologic exams and hemodynamic monitoring

– ICP monitoring

– CPP monitoring

• Fever prevention – maintain normothermia

• Maintain therapeutic glucose levels

• Seizures – treat if clinically present

• Prevention of complications

– Aspiration

– DVT

ICH Care

56

• Cerebellar hemorrhage

– Larger than 3 cm in diameter

– Neurologic deterioration

– Brainstem compression with or without hydrocephalus

• Hemispheric hemorrhage

– Lobar clots > 30cc that are more superficial

• Minimally invasive clot removal techniques

– Endoscopic aspiration

ICH – Surgical Clot Evacuation

57

• Hypertensive vasculopathy

– Basal ganglia, thalamus, brainstem

• Cerebral amyloid angiopathy

– Seen in older patient with history of dementia

– Lobar location of ICH

• Anticoagulation associated

– Lobar and/or intraventricular

Cause and Location of ICH

58

Hypertensive ICH

59

52 yo male with

HTN, Smokes

2 PPD. Not seen

For 2 days. Found

down by sister

SBP 230 mmHg

DBP 110 mmHg

Cerebral Amyloid Angiopathy Hemorrhage

60

• Incidence of aneurysmal SAH ranges depending on

ethnicity

– 9.7 per 100,000 adults in the US

• Increased incidence in women

• Risk factors

– Hypertension

– Smoking

– Alcohol abuse

– Use of sympathomimetic drugs (cocaine)

– History of familial aneurysms

– Autosomal dominant polycystic kidney disease

– Type IV Ehlers-Danlos Syndrome

Aneurysmal Subarachnoid Hemorrhage

61

Subarachnoid Hemorrhage

• Patient presentation is classic – Sudden severe headache “worst headache of life” or thunderclap

headache

– May have loss of consciousness, brief or sustained

– Nuchal rigidity or stiff neck

– Focal neurologic deficits or cranial nerve palsies

– Photophobic, photophonic

– Nausea/vomiting

• 12% of patients die before receiving medical attention

• Non contrast CT scan of Brain

– If non diagnostic – consider LP

• Lumbar puncture

– Analysis of spinal fluid to identify Xanthochromia (red blood cell

breakdown)

• MRI – more sensitive than previously

– Use fluid attenuated inversion recovery, proton density, DWI, and

gradient echo sequences

• CTA to detect aneurysm

• Cerebral angiography is the gold standard for aneurysm

detection

SAH – Diagnostic Evaluation

63

Aneurysmal Subarachnoid Hemorrhage

64

Subarachnoid Hemorrhage

65

• If hydrocephalus present – may require EVD insertion

• Blood pressure monitoring and management

– To prevent re-bleeding

– Prevent vasospasm

– Balance risk of stroke

– Maintain cerebral perfusion

• Frequent neurologic assessment and monitoring

• Anticonvulsants to prevent seizures in the early post bleed

period

• Transport to center where ICU care and treatment is

available

Nursing Care of the SAH Patient

66

• Cerebral Vasospasm

– Occurs 4-14 days post SAH in 40-70% patients

– Prevention: Triple H Hypertention /Hypervoemia /Hemodilution

– Nimodopine : Calcium Channel Blocker to relax vessels

– Neurointervention to open vessels if spasm present

• Fluid and Electrolyte disturbances

• Hydrocephalus

– Caused by blood in the subarachnoid blocking re-absorption of CSF

– EVD to drain CSF

– tPA may be injected into EVD by MD to clear blood

• Increased Intracranial Pressure

– Monitor with EVD in place

Complications of SAH

67

• GOAL is complete obliteration of aneurysm

• Endovascular coiling is accomplished in the interventional

suite

• Surgical clipping in the OR with open craniotomy

Medical Management of Aneurysmal SAH

68

69

6 mm R PCA

aneurysm

70

R PCA

aneurysm

post coil

with EV3

platinum

coils

Open Surgical Aneurysm Clipping

71

Patient and Family Education

• Organized system of providing information to

patients/family – SKAT documentation form

ERecord

• Document that education is personalized

• Education must include

– Signs and symptoms of stroke

– The need to activate 911

– Education on risk factors and strategies for modification

– Education on medications

– Need for follow up appointment

• Assessment of family/caregiver capacity

• Care giver and stroke survivor support group information

• Options for respite care

• Post hospital care services

– Home health

– SNIF

– Rehabilitation

– PT/OT/Speech language therapy

Post Hospital Care

73

Patient and Family support

• Important to us as nurses and health care providers to look

at the family needs and develop a plan to meet the needs of

the patient/family unit

• Families respond to the stress of illness and unexpected

nature of stroke differently

• Venous Thromboembolism Prophylaxis for ischemic or

hemorrhagic stroke, DVT prophylaxis initiated and

documented by day 2

• Discharged on Antithrombotic Therapy for ischemic

stroke or TIA

• Anticoagulation Therapy for Atrial fibrillation/flutter on

ischemic stroke or TIA

• Thrombolytic Therapy for ischemic stroke for patients who

present within 2 hours of symptom onset tpa is provided. If

not eligible/excluded document reason why

Performance Measures for Primary Stroke Centers

75

• Antithrombotic Therapy is initiated by the end of hospital

day 2 for ischemic stroke

• Discharged on a Statin Medication for ischemic stroke

and TIA patients if LDL > 99

• Stroke Education provided for all patients and must include

5 components

• Assessed for Rehabilitation prior to discharge for

ischemic and hemorrhage patients

• Dysphagia screening prior to PO medications on all

patients with persistent neurologic symptoms

Performance Measures for Primary Stroke Centers

76

• Door to CT times

• Door to tPA times

• Outcomes after tPA

– Symptomatic intracranial hemorrhages

– 90 day modified Rankin scores (disability scores)

Additional Measures to Review and Report

77

• Comprehensive Overview of Nursing and Interdisciplinary

Care of the Acute Ischemic Stroke Patient: A Scientific

Statement from the AHA - Stroke 2009;40;2911-2944.

• Guidelines for the Management of Spontaneous

Intracerebral Hemorrhage: A Guideline for Healthcare

Professionals from the AHA/ASA Stroke 2010;41;2108-

2129.

• Guidelines for the Management of Aneurysmal

Subarachnoid Hemorrhage: A Guideline for Healthcare

Professionals from AHA/ASA Stroke 2012;43;1711-1737.

References

78