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Management of Stroke
in the Neurocritical
C O N T I N UU M A UD I O
I NT E R V I E W A V AI L A B L E
Care Unit
ONLINE
S U P P L E M E N T AL D I G I T A L
CONTENT (SDC) By Chethan P. Venkatasubba Rao, MD, FNCS; Jose I. Suarez, MD, FNCS, FANA
A VA I L A B L E O N L I N E
ABSTRACT
PURPOSE OF REVIEW: This article provides updated information regarding the
diagnosis and treatment (specifically critical care management) of acute
Downloaded from http://journals.lww.com/continuum by BhDMf5ePHKbH4TTImqenVNY7U4bpjOf5fYwXstOqDhVJ3GC1J59mRyucD0jkPUBLms86zAi7FVU= on 12/06/2018
RECENT FINDINGS: Stroke is the leading cause of disability in the United States.
CITE AS:
CONTINUUM (MINNEAP MINN) A significant proportion of patients with acute ischemic stroke require
2018;24(6, NEUROCRITICAL CARE): critical care management. Much has changed in the early evaluation and
1658–1682.
treatment of patients presenting with acute ischemic stroke. The
Address correspondence to introduction of embolectomy in large vessel occlusions for up to 24 hours
Dr Chethan P. Venkatasubba Rao, post–symptom onset has resulted in one in every three eligible patients
Baylor College of Medicine, MS
NB 124, One Baylor Plaza,
with acute ischemic stroke with the potential to lead an independent
Houston, TX 77030, lifestyle. These patients increasingly require recognition of complications
cprao@bcm.edu. and initiation of appropriate interventions as well as earlier admission to
RELATIONSHIP DISCLOSURE:
dedicated neurocritical care units to ensure better outcomes.
Dr Venkatasubba Rao has
received personal compensation SUMMARY: This article emphasizes issues related to the management of
as an editorial board member
of Brain Disorders & Therapy. patients with acute ischemic stroke undergoing mechanical thrombectomy
Dr Suarez has received research/ and thrombolysis and addresses the complex physiologic changes
grant support from the National
affecting neurologic and other organ systems.
Institute of Neurological
Disorders and Stroke and
as co-investigator in the
SETPOINT2 (Stroke-related Early
Tracheostomy Versus Prolonged INTRODUCTION
A
Orotracheal Intubation in cute ischemic stroke is a neurologic emergency. A recent report from
Neurocritical Care Trial) study
from the Patient-Centered
the American Heart Association has shown that acute ischemic
Outcomes Research Institute. stroke affects an average of 800,000 people annually in the
Dr Suarez is the current president United States, the majority of whom experience their first event.1
and a member of the board of
directors of the Neurocritical This translates into one person having a stroke every 40 seconds.
Care Society. About 7.2 million Americans older than 20 years of age report having had a stroke,
and the prevalence is estimated to be 2.7%.2 Recent studies have noted that acute
UNLABELED USE OF
PRODUCTS/INVESTIGATIONAL ischemic stroke affects men and women equally overall but has variable influence
USE DISCLOSURE: in different ages and ethnic groups. Acute ischemic stroke has a higher incidence
Drs Venkatasubba Rao and
Suarez report no disclosures.
in American Indians/Alaskan Natives (5.4%), non-Hispanic blacks (4.5%), and
other races and multiracial people (4.7%) compared to non-Hispanic whites (2.5%).3
Acute ischemic stroke remains the number one cause of morbidity and
© 2018 American Academy disability in the United States, costing an unprecedented $33.9 billion, which is
of Neurology. 14% of annual health care expenditure. Several disturbing trends are
CONTINUUMJOURNAL.COM 1659
care for a patient with an ICAT score of more than 2 was 13 times higher than
for a patient with a score of less than 2. A score of 5 or more predicts critical
care needs with a 94% specificity and 45.8% sensitivity. Factors that can
independently influence the need for critical care in patients with stroke are
summarized in TABLE 4-2.
u Assess circulation and, if needed, perform cardiopulmonary resuscitation per the basic
life support method
u Assess and secure airway and breathing (ventilation)
u Initiate a call for rapid response of a critical care team (obtain help)
u Point of care testing for glucose, coagulopathy
u Perform a standardized and complete neurologic assessment (NIHSS, see below).
Male sex
Yes 0
No 1
Black race
No 0
Yes 1
<160 0
160–200 2
>200 4
≤6 0
7–12 1
≥13 2
a
Reprinted with permission from Faigle R, et al, Crit Care.8 © 2016 Faigle et al.
Factors Increasing the Risk of Requiring Critical Care Interventions in TABLE 4-2
Patients With Acute Ischemic Strokea
a
Data from Faigle R, et al, Crit Care.8
CONTINUUMJOURNAL.COM 1661
CONTINUUMJOURNAL.COM 1663
Neurologic Indications
Perhaps the most common reasons for admission to the neurocritical care unit are
neurologic indications, which are detailed below.
Neurologic Indications
◆ Hemodynamic management
◇ Post-thrombectomy
◇ Post IV thrombolysis
◇ Need for continuous hemodynamic support
◆ Cerebral edema
◇ Cerebellar stroke involving more than 25% to 33% of hemisphere
◇ Involvement of more than 50% of middle cerebral artery territory
◇ Signs of herniation
◆ Hydrocephalus
◆ Symptomatic hemorrhagic transformation and coagulopathy
◆ Coma with Glasgow Coma Scale score of <9
◆ Seizures requiring continuous IV medications
Cardiac Indications
◆ Hemodynamic augmentation
◆ Acute myocardial infarction requiring monitoring and hemodynamic support
◆ Cardiac rhythm abnormalities (such as atrial flutter/fibrillation)
◆ Congestive cardiac failure requiring continuous IV infusions
◆ Cardiac mechanical hardware on anticoagulation with moderate to large strokes
Respiratory Indications
◆ Respiratory failure requiring endotracheal intubation and mechanical ventilation
◆ Hypoxic respiratory failure
◆ Hypercarbic respiratory failure
◆ High suspicion of aspiration pneumonia
◆ Central respiratory failure
Infectious Indications
◆ Signs of sepsis or septic shock
Renal Indications
◆ Renal failure requiring renal replacement therapy
IV = intravenous.
CONTINUUMJOURNAL.COM 1665
SEIZURES. Clinical ictal events following acute ischemic stroke are relatively rare
and may occur in about 1.3% of cases.33 Males with an NIHSS score of greater
than 10 are at risk, and the seizures themselves portend an independent poor
outcome (twofold to threefold increase in odds).
Cardiac Indications
Patients with acute ischemic stroke are prone to cardiac complications, which
need neurocritical care unit management, as detailed below.
Respiratory Indications
Respiratory complications that indicate admission to the neurocritical care unit
are detailed below.
Neurologic Management
Neurologic complications that follow acute ischemic stroke need diligent
management, as is detailed below.
CONTINUUMJOURNAL.COM 1667
Post-thrombolytic/ Neuromonitoring
post-thrombectomy
care Hemodynamic management See cardiac, cerebral perfusion control, and
hemorrhagic transformation for specific
management
Cerebral perfusion Hypertension (for goals <185/110 mm Hg Short-acting injectable agents such as metoprolol,
control prethrombolysis and <180/105 mm Hg labetalol, enalaprilat, and hydralazine, or a
post-thrombolysis) continuous agent such as nicardipine
IV = intravenous.
CONTINUUMJOURNAL.COM 1669
CONTINUUMJOURNAL.COM 1671
FIGURE 4-1
Imaging of the patient in CASE 4-1. A, Head CT showing a hyperdense right middle cerebral
artery sign (arrow). B, Cerebral angiogram showing a distal right internal carotid artery
occlusion. C, Cerebral angiogram obtained after thrombectomy demonstrating Thrombolysis
in Cerebral Infarction (TICI) grade 3 recanalization. D, MRI of the brain showing no
abnormalities suggestive of cerebral infarction on diffusion-weighted imaging (DWI).
This case demonstrates the need for individualization of care, using COMMENT
noninvasive monitoring devices to optimize hemodynamics, and highlights
coordination of management between care teams. The patient was not
eligible for IV recombinant tissue plasminogen activator as his intake of oral
anticoagulants was uncertain and no laboratory test was available to
determine the activity of his anticoagulant. Hence, he was treated with
embolectomy. Despite complete recanalization, subsequent
compromised hemodynamics resulted in worsening of his neurologic
deficits. He was initially supported by vasopressors that likely resulted in
congestive cardiac failure due to systolic failure of the left ventricle caused
by increased afterload. He likely developed non–ST segment elevation
myocardial infarction due to Takotsubo cardiomyopathy and pump failure.
Noninvasive cardiac monitoring was used to determine optimum
vasopressor and inotrope dosage to perfuse the brain while not
exacerbating cardiac decompensation.
This case also illustrates cautious use of anticoagulants in the setting
of acute ischemic stroke. In the setting of an acute ischemic stroke,
anticoagulation is usually not recommended. In this case, the patient
developed troponinemia with non–ST elevated myocardial infarction on
ECG, which necessitated the use of anticoagulation. After ensuring the
absence of any parenchymal injury on MRI, the patient was started on a
heparin infusion with lower anticoagulation goals (PTT of 50 to 60 seconds
instead of the standard 60 to 80 seconds). Noninvasive monitoring of
cardiac and neurologic status in patients can be very helpful in optimizing
personalized care for patients who are critically ill.
CONTINUUMJOURNAL.COM 1673
CASE 4-2 A 68-year-old man presented to the emergency department with a left
hemiplegia, hemianesthesia, and right gaze preference that began
2 hours before presentation. His head CT was remarkable for a right
middle cerebral artery hyperdense sign. He received IV recombinant
tissue plasminogen activator (rtPA), and CT angiography demonstrated a
right middle cerebral artery occlusion (FIGURE 4-2A). With a National
Institutes of Health Stroke Scale (NIHSS) score of 12, he underwent
thrombectomy with a resultant Thrombolysis in Cerebral Infarction (TICI)
grade 3 recanalization (FIGURE 4-2B and FIGURE 4-2C).
FIGURE 4-2
Imaging of the patient in CASE 4-2. CT angiogram (A) and cerebral angiogram (B) demonstrating
an occlusive thrombus (arrows), and post-thrombectomy cerebral angiogram showing
Thrombolysis in Cerebral Infarction (TICI) grade 3 recanalization (C). Noncontrast head
CTs showing intraparenchymal hemorrhage (D, arrow) and right hemispheric edema, and
after right hemicraniectomy for malignant right hemispheric edema (E).
CONTINUUMJOURNAL.COM 1675
CONTINUUMJOURNAL.COM 1677
carefully considered as these entail the use of dual antiplatelet agents and
should be carefully coordinated with cardiologists.
Tachyarrhythmias and bradyarrhythmias are frequently seen in patients with
acute ischemic stroke. Atrial fibrillation is commonly seen and is best managed
with rate control aiming for less than 110 beats/min.59 Short-acting IV
beta-blockers and calcium channel blockers, digoxin and amiodarone, should be
considered. Atropine, cardioselective beta-agonists, and electrical pacing should
be the mainstay of treating bradyarrhythmias. Patients with mechanical implanted
devices pose an immediate need for resumption of anticoagulants, which should
be balanced against the risk of hemorrhagic transformation. Coordinated
management along with an experienced cardiac team is recommended.
Pulmonary complications usually stem from altered mentation and the
inability to protect the airway, aspiration pneumonia, and underlying primary
pulmonary pathology. In the neurocritical care unit, the incidence of pneumonia
in patients with stroke is variably reported between 10% and 56%.36 With the
increasing incidence of obstructive sleep apnea, there has been an increase in
the use of noninvasive positive pressure ventilation. In a meta-analysis, no
significant difference in secondary stroke or other vascular morbidity or
mortality was seen in patients treated with noninvasive positive pressure
ventilation, but there seemed to be an overall improvement in the
clinical outcomes.60
Many centers perform routine endotracheal intubation for patients
undergoing mechanical embolectomy. However, post hoc analysis of the MR
CLEAN study demonstrated clearly worse outcomes in the routine use of general
anesthesia in patients undergoing mechanical thrombectomy compared to
patients undergoing conscious sedation.61 In the SIESTA (Sedation Versus
Intubation for Endovascular Stroke Treatment) study, the primary outcome
was defined as a neurologic improvement within 24 hours. In that respect, no
difference was found between patients undergoing general anesthesia and
conscious sedation. However, many complications occurred in the general
anesthesia group, such as delayed extubation, hypothermia, and pneumonia.
Surprisingly, 3-month outcomes as measured by mRS were significantly better
in the general anesthesia group.62
In a case series, as many as 14% of patients with acute ischemic stroke had
respiratory insufficiency requiring mechanical ventilation.63 Furthermore, when
compared to patients without respiratory insufficiency, patients who were
ventilated had 1.4 times higher risk of 1-year mortality. This risk was further
exemplified if the patients were stuporous (2.6 times) or if they had absent
corneal reflexes or ischemic heart disease (3.4 times).64 The authors of this
article discourage the routine use of endotracheal intubation and mechanical
ventilation in the management of patients with acute ischemic stroke.
In patients who are intubated, it is unclear if early tracheostomy can
facilitate early mobilization and enhance early recovery. The SETPOINT2
(Stroke-related Early Tracheostomy Versus Prolonged Orotracheal Intubation
in Neurocritical Care Trial) study is actively enrolling patients to address
this question.65
CONCLUSION
This article is meant to highlight the main points in the critical care management
of patients with acute ischemic stroke and supplement the information in the
Continuum series addressing the management of acute ischemic stroke.66
Significant advances have been made in the treatment of patients with acute
ischemic stroke over the last decade. In 1995, initiation of thrombolysis was once
the only mainstay of treatment. The armamentarium to tackle stroke has taken a
significant step forward with the interventional trials, which have extended the
treatment windows from 4.5 hours through 24 hours. Despite these strides, we
still are left with many unanswered questions in the management of patients
with acute ischemic stroke. Peri-interventional anesthetic and hemodynamic
management still need further clarification. A large population still exists who
are not eligible for thrombectomy or thrombolysis who will need novel treatment
strategies. We are still unsure about the optimal hemodynamic management in
patients with acute ischemic stroke with or without thrombectomy. Clinical
management is driven by the symptom-based response, but no clear
neuromonitoring strategies have been developed to predict neurologic
worsening. A noninvasive measurement such as dynamic autoregulation seems
to have promising potential to intervene prior to neurologic decompensation.
Further research should be conducted to optimize stroke outcomes based on
hemodynamic management.
It is still unclear how to identify patients who will develop symptomatic
intracerebral hemorrhage. The management of such hemorrhages currently is
reflexive use of plasma products without clear evidence for improvement in
outcomes. Especially in patients with mechanical cardiac valves and support
devices, balancing between symptomatic intracranial hemorrhage expansion and
cardiac protection is a tough clinical decision. Clarity for management is very
much desired here.
Cerebral edema has been conventionally managed with osmotherapy and
surgical decompression. Newer approaches to reduce edema formation and
prevent secondary cerebral injury are warranted, especially in patients who
CONTINUUMJOURNAL.COM 1679
USEFUL WEBSITE
NEUROCRITICAL CARE SOCIETY: EMERGENCY
NEUROLOGICAL LIFE SUPPORT
Refer to the Emergency Neurological Life Support
website to obtain further information on initial
management of neurologic emergencies.
neurocriticalcare.org/enls
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