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ICU Management of Acute Ischemic Stroke
10 Plays6 years ago
Acute ischemic stroke is a leading cause of morbidity and mortality worldwide. Intensive care management of strokes is focused on reducing complications related to reperfusion treatment and decreasing secondary neurological injury. In this episode of Critical Matters, we will discuss the critical care management of acute ischemic strokes.
Our guest is Dr. Sayona John, Associate Professor in the Department of Neurological Sciences at Rush Medical College. She is a practicing neurointensivist and also serves as the Head of the Section of Critical Care Neurology and Medical Director of the Neuroscience Intensive Care Unit & Neuroemergency Transfer programs at Rush University Medical Center in Chicago.
Additional Resources:
AHA 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: http://bit.ly/30TJkxL
Educational video on performing the NIH Stroke Scale: http://bit.ly/2opldcZ
Link to a pdf document with the NIH Stroke Scale: http://bit.ly/2LVtWMV
How to do a four-minute neurological examination: http://bit.ly/328IXRr
Books Mentioned in this Episode:
Lincoln's Hundred Days: The Emancipation Proclamation and the War for the Union by Louis P. Masur: https://amzn.to/2VlTTse
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
Speaker
And now your host, Dr. Sergio Zanotti.
Understanding Ischemic Strokes
00:00:33
Speaker
Ischemic strokes account for approximately 85% of all strokes.
00:00:37
Speaker
Severe strokes constitute the minority of these cases, but are responsible for a majority of disability and mortality associated with strokes.
00:00:45
Speaker
Intensive care management of strokes is focused on reducing complications related to reperfusion treatment and decreasing secondary neurological injury.
00:00:54
Speaker
With the growth of comprehensive stroke programs and neurointensive care units, many of these patients are treated in specialized units dedicated to brain injured patients.
00:01:02
Speaker
However, a large number of stroke patients are admitted to general medical and surgical ICUs.
Guest Introduction: Dr. Sayona John
00:01:08
Speaker
Today we will discuss the critical care management of acute ischemic stroke.
00:01:13
Speaker
Our guest is Dr. Sayona John.
00:01:15
Speaker
Dr. John is an associate professor in the Department of Neurological Sciences at Rush Medical College in Chicago.
00:01:21
Speaker
She is a practicing neurointensivist and also serves as the head of the section of critical care neurology and medical director of the Neuroscience Intensive Care Unit and Neuroemergency Transfer Programs at Rush University Medical Center.
00:01:34
Speaker
Her research interests include ischemic and hemorrhagic stroke.
00:01:37
Speaker
It is a great pleasure to have her as our guest today.
ICU Admission Criteria for Stroke Patients
00:01:40
Speaker
Sayona, welcome to Critical Matters.
00:01:43
Speaker
Thank you.
00:01:44
Speaker
So I think that a great place to start would be, in general, just maybe give us an introduction, an overview
00:01:51
Speaker
of who are the patients with acute ischemic stroke that need to come to the ICU?
00:01:57
Speaker
And that is sometimes a tricky question to answer because it depends on what your institution's setup is.
00:02:05
Speaker
If you have step-down units, some of the ischemic stroke patients can perhaps go to a step-down unit.
00:02:11
Speaker
But generally speaking, patients with ischemic stroke that have received IV tPA or endovascular therapies and need to be monitored quite closely
00:02:21
Speaker
do generally end up coming into the ICUs for that close monitoring.
00:02:27
Speaker
And I think that that would be the vast majority of patients that we see in general and surgical ICUs as well as neurointensive care units.
00:02:34
Speaker
But are there any other situations where you would be worried, and I think in terms of potential size of a stroke or other syndromes that might include people you would send to an ICU?
00:02:46
Speaker
Absolutely.
00:02:47
Speaker
So if patients are presenting with large hemispheric strokes or have a high NIH stroke scale, and when I say high NIH stroke scale, I mean patients who are over 10 on the National Institute of Health stroke scale, we like to monitor them closely in the ICU because of the risk of developing cerebral edema and the risk of secondary deterioration.
00:03:11
Speaker
Now, those are for the anterior circulation strokes, which are
00:03:15
Speaker
different from the posterior circulation strokes or the vertebro-basilor system.
00:03:20
Speaker
Posterior circulation strokes have a different set of risk factors that need to be monitored.
00:03:26
Speaker
For instance, their ability to protect their airway, their ability to stay awake.
00:03:32
Speaker
So these are things that will then need for them to be intubated or perhaps undergo other surgical treatments.
00:03:40
Speaker
So these are the patients that we monitor.
00:03:43
Speaker
Excellent.
00:03:43
Speaker
And before we dive in a little bit more into details about specific aspects of the critical care management, you did mention, Sayona, the NIH stroke scale.
Stroke Severity and Monitoring Needs
00:03:54
Speaker
And I know that a lot of our audience members are not neurologists or not neurocritical care trained.
00:03:59
Speaker
Could you give us a little bit more info in terms of your thoughts of who should really learn how to use this and how we can use it to communicate with our neurology colleagues in a more effective way when we talk about patients?
00:04:11
Speaker
Yes, absolutely.
00:04:12
Speaker
So the NIH Stroke Scale is the scale that is universally used to assess a stroke syndrome.
00:04:21
Speaker
And it involves the patient's level of alertness, their ability to follow commands, their ability to use language, both speak and understand, as well as their motor, sensory, and cerebellar deficits.
00:04:35
Speaker
Now, using all of these, the NIH Stroke Scale counts the extent of the neurological involvement
00:04:43
Speaker
for these patients.
00:04:44
Speaker
So across the spectrum of ischemic stroke disease process, we do use the NIH stroke scale as a means of communication.
00:04:52
Speaker
This is an easy enough scale to use, and there are online tools available for people to learn how to use the NIH stroke scale.
00:04:59
Speaker
Not everyone needs to be NIH stroke scale certified, unless, of course, you're in a stroke center.
00:05:05
Speaker
But I think it is helpful to use the tool as a method of communication, especially when you're trying to talk about
00:05:12
Speaker
this patient has gotten better or this patient has gotten worse because even neurosurgeons understand the NIH stroke scale.
00:05:19
Speaker
And I think it's an important point, and we'll definitely link some of these tools in the show notes because I believe that it can very quickly put the whole team on the same page in understanding what type of patient we are encountering up front or what are the changes that have occurred to this patient if it's somebody who's been admitted already.
00:05:38
Speaker
Correct.
00:05:39
Speaker
So I would like to start with airway issues.
00:05:42
Speaker
I mean, you mentioned some of the reasons why patients with acute ischemic stroke might come to the ICU.
00:05:49
Speaker
Clearly in the gamut of all patients coming to the ICU, usually airway requirements or airway support and hemodynamic support in all diseases are very common reasons.
00:06:00
Speaker
And I think that even though most of the patients we see with stroke don't get intubated in mechanical ventilation,
00:06:07
Speaker
There are some that do, and it might be a reason why these patients might end up in the ICU.
00:06:11
Speaker
Any comments in general of how you approach the airway in a stroke patient, Sayona?
00:06:16
Speaker
Sure.
00:06:17
Speaker
So patients with large hemispheric strokes, and when I say large hemispheric strokes, I'm talking about internal carotid artery occlusions or middle cerebral artery occlusions, or in the case of posterior circulation strokes, a basilar stroke, they all are at a risk for not being able to stay awake
00:06:37
Speaker
and protect their airway.
00:06:39
Speaker
In the case of the posterior circulation strokes, it's by virtue of the part of the brain that's affected that they are not protecting their airway.
00:06:47
Speaker
So we're constantly monitoring for any concern that these patients might be aspirating or not being able to maintain adequate oxygenation in this kind of a setting.
00:07:00
Speaker
They're also at high risk for aspiration because they cannot cough and clear their secretion.
00:07:05
Speaker
So it is not necessarily a primary respiratory failure that warrants an intubation as much as the fact that there's an impending risk for respiratory failure by virtue of their inability to manage their airway.
00:07:21
Speaker
Are there any GCS numbers that might prompt you to intubate sooner rather than later, even if somebody's before they come to the ICU?
00:07:30
Speaker
So the GCS number comes from the Traumatic Brain Injury Foundation guidelines.
00:07:34
Speaker
As such, for ischemic strokes, they have not devised a GCS.
00:07:40
Speaker
That triggers an intubation.
00:07:42
Speaker
Based on the TBI guidelines, it is a GCS of 9 or less, though we generally believe that when it gets to a GCS of 9, you're perhaps cutting it really close.
00:07:53
Speaker
So if they start to not really be able to stay awake and you have to stimulate them frequently,
00:08:00
Speaker
to keep them awake or to follow commands or whatever it is that you're looking for in a neurological exam, then they're at a high risk.
00:08:08
Speaker
And a non-invasive ventilation is not the way to go with these patients.
00:08:12
Speaker
It really is about intubating them.
Airway and Respiratory Management in Stroke Patients
00:08:14
Speaker
Excellent.
00:08:15
Speaker
And you did mention the risk of aspiration, which is obviously present in a wide variety of stroke patients, even in those who might be wide awake.
00:08:24
Speaker
Could you comment on two specific issues that I always wonder about?
00:08:28
Speaker
from your perspective, Sayuronai, is one, what type of routine evaluation would you do in all patients that you see with stroke for aspiration?
00:08:36
Speaker
And in those who you think had an aspiration event, how do you approach the use of antibiotics if you start them and when?
00:08:44
Speaker
Okay.
00:08:45
Speaker
For patients that come in with an ischemic stroke, the Joint Commission requires, and that's what guides these comprehensive as well as the primary stroke centers,
00:08:55
Speaker
The Joint Commission requires that all of these patients have to be evaluated for their swallow, and they cannot be put on any sort of oral diet until they've had either a nursing bedside screening tool evaluation or a formal speech evaluation.
00:09:12
Speaker
And the Joint Commission does monitor these and make sure that all of the stroke patients have met appropriate criteria for evaluation as well as for swallowing.
00:09:24
Speaker
So if there's any patient who even remotely shows signs of risk for aspiration, they will get a formal speech evaluation at our center.
00:09:33
Speaker
And I think all of the comprehensive and primary stroke centers function this way as well.
00:09:38
Speaker
So if they fail a swallow evaluation, they automatically become a higher risk in our minds for being at risk for aspiration.
00:09:47
Speaker
Not necessarily for food, but even for just saliva.
00:09:53
Speaker
If they aspirate to answer your second question, we don't automatically start antibiotics on these patients.
00:10:00
Speaker
I think we follow the aspiration pneumonia guidelines.
00:10:03
Speaker
And if they develop a fever, a consolidation, a white count, then we would consider and put them on antibiotics as a form of treatment as opposed to empirically putting them on antibiotics.
00:10:15
Speaker
And that's why you emphasize that point, because I do think that a lot of
00:10:18
Speaker
times I see people with a potential aspiration be start antibiotics too soon.
00:10:23
Speaker
And clearly, I mean, as you mentioned, there are guidelines that suggest that we can observe them.
00:10:27
Speaker
And then those who have a more protracted signs of possible infection is when you would start the antibiotics.
00:10:34
Speaker
And regarding the evaluation of swallowing, I think it's something that is very important for a lot of our listeners who might be embarking in some sort of accreditation journey in their hospitals.
00:10:46
Speaker
And if they don't have these processes in place, these are some of the things that the Joint Commission is going to look very closely in terms of measures of quality.
00:10:55
Speaker
So something that needs to be thought about.
00:10:57
Speaker
That is correct, yes.
Blood Pressure and Edema Management in Stroke Care
00:10:59
Speaker
So, Yonah, any comments or any thoughts on once those patients with ischemic stroke get intubated, is there anything that's particular about how you would ventilate them?
00:11:12
Speaker
In general, these patients should not have major
00:11:15
Speaker
let's say pulmonary requirements, but are there any thoughts that you want to share with us from your perspective?
00:11:22
Speaker
So with regards to the ventilator, there are two kinds of patients that in my world get intubated.
00:11:29
Speaker
One is the patient who has cerebral edema and is decompensating as a result of that.
00:11:36
Speaker
And the second is the patient that cannot protect their airway and is at impending respiratory failure and gets intubated
00:11:45
Speaker
And in that case, we're intubating them purely from an airway protection standpoint.
00:11:50
Speaker
If the patient has cerebral edema and we're monitoring them for their need for decompression or their risk for further deterioration and herniation, those are the kinds of patients that when we intubate, we sedate them and we keep them essentially on full ventilator support because we want to decrease the work that they are putting into
00:12:13
Speaker
their just existence at that point, including decreasing the cerebral metabolic rate.
00:12:20
Speaker
So these patients will either get put on propofol or fentanyl and propofol or Versa, depending on how their hemodynamics are doing.
00:12:28
Speaker
And we only lift the sedation ever so often so that we can continue to neurologically assess them.
00:12:34
Speaker
But usually these are also the kinds of circumstances where we have already consulted neurosurgery and discussed the need for decompression, which is essentially removing bone and be it an MCA stroke that needs to have a hemicraniectomy or a posterior circulation stroke like a cerebellar stroke that needs a suboccipital decompression.
00:12:56
Speaker
So once that is done with and we know that
00:13:00
Speaker
the pressure, the elevated intracranial pressure and the cerebral edema has been relieved and or the patient who has a posterior circulation stroke that simply cannot protect their airway, the moment that kind of pressure relieving techniques have been done with, we immediately wean down the ventilator because these are not patients that have, as you pointed out, a primary respiratory problem.
00:13:26
Speaker
These are neurological complications that lead to the respiratory problem.
00:13:31
Speaker
And so we try to put them on pressure support or do daily weaning trials, trying to keep them on the minimal ventilator setting that they need.
00:13:41
Speaker
So as you mentioned, I mean, for the vast majority of patients, they won't require supportive mechanical ventilation.
00:13:48
Speaker
And among those who do,
00:13:50
Speaker
a lot of them should be able to be weaned hopefully in a short amount of time as you control the main issues.
00:13:57
Speaker
But in that small subset of patients, and I presume that in those who have a hemocrionectomy, and we'll talk more about that a little bit later, the percentage is even higher.
00:14:07
Speaker
Do you have any indicators that might early on tell you this patient's probably going to require prolonged mechanical ventilation and perhaps a tracheostomy?
00:14:19
Speaker
So again, it comes down to their neurological deficits and the size of the stroke.
00:14:25
Speaker
If they have a large hemispheric infarction, and it can be left or right side, because the left-sided strokes are the ones that do not follow commands, the right-sided strokes will.
00:14:42
Speaker
In these patients,
00:14:44
Speaker
if they have continued decreased mental status even after the hemicraniectomy has been done, then we are a little bit more concerned about doing extubation on these patients, and they perhaps will move on to requiring a tracheostomy.
00:15:02
Speaker
The posterior circulation strokes, especially the ones that involve the brainstem, where the patients are quite profoundly affected neurologically, they're
00:15:14
Speaker
isn't even an option really for assessing for extubation.
00:15:18
Speaker
It really comes down to minimizing the ventilator requirements and simply moving forward with the tracheostomy because they're going to need a longer time to get better if they're going to do so.
00:15:32
Speaker
Excellent.
00:15:33
Speaker
So the second topic that I think is very common in ICUs in general for being a reason for admission is the need for hemodynamic management
00:15:42
Speaker
with basal active drugs and close hemodynamic monitoring.
00:15:46
Speaker
And I think that obviously this is something that has been of much debate and has different facets depending on what exactly is going on with a patient with acute ischemic stroke.
00:15:55
Speaker
But could we maybe start by just reviewing for the audience the whole issue of auto regulation of blood pressure, cerebral blood pressure in ischemic stroke and how it might impact patients?
00:16:10
Speaker
So every patient
00:16:12
Speaker
for the most part, that comes in with an ischemic stroke will have elevated blood pressures.
00:16:19
Speaker
And this has to do with the body trying to perfuse the brain because the pressures intracranially have gone up, even though it's probably compartmentalized, meaning it's just one portion of the brain that needs higher pressure to perfuse it in the setting of an ischemic stroke.
00:16:39
Speaker
So it comes down to
00:16:42
Speaker
whether this patient is a candidate for IV tPA or not.
00:16:47
Speaker
The IV tPA is given to these patients as long as they are coming within four and a half hours of their last known well or symptom onset.
00:16:56
Speaker
And if they are a candidate for IV tPA, then the guidelines state that the blood pressure has to be less than 180 by 105.
00:17:05
Speaker
So if they're running higher, then we will start them
00:17:09
Speaker
We can try PRN medications, and if that doesn't work, then we'll start them on a drip to consistently maintain at less than 180 by 105.
00:17:17
Speaker
Post-TPA also, these patients are maintained at that number for the first 24 hours.
00:17:23
Speaker
Sorry, go ahead.
00:17:27
Speaker
Sorry, go ahead.
00:17:29
Speaker
I was going to ask you if after 24 hours, you become more liberal with that number.
00:17:33
Speaker
That is correct, because we want them to perfuse the brain.
00:17:36
Speaker
Of course, there are other factors that go into it.
00:17:39
Speaker
If they had a vessel occlusion that has been opened up, then their risk of having a hemorrhagic transformation, because now you've opened up a vessel, which is now feeding into areas of dead tissue, and the risk for converting that into a hemorrhage is also high.
00:17:58
Speaker
So depending on how much of revascularization you've accomplished,
00:18:04
Speaker
you may want to have tighter blood pressure goals on those patients.
00:18:07
Speaker
For instance, if you have a carotid artery that was occluded and now you opened it up, that's a whole hemisphere of the brain that runs the risk of having a hemorrhagic transformation.
00:18:17
Speaker
So you may choose to go with a blood pressure goal that's less than 160.
00:18:21
Speaker
Of course, we're still talking in terms of systolic blood pressure goals and not necessarily mean arterial pressure goals because all of the guidelines are still talking about systolic blood pressure.
00:18:31
Speaker
Absolutely.
00:18:33
Speaker
And are there any drugs that you and your practice use more frequently?
00:18:38
Speaker
I know that this is not something that has been heavily studied in ischemic stroke, but I'm just curious, I mean, what would be your usual approach?
00:18:45
Speaker
Our usual approach is to go for a calcium channel blocker, and there are a couple of them available in the market.
00:18:51
Speaker
And the reason we prefer the calcium channel blocker is because of the ease of titration and the close blood pressure control that we get with it.
00:19:02
Speaker
You do have the option of using a beta blocker as well, but then you have to monitor for bradycardia along with it.
00:19:08
Speaker
The calcium channel blockers don't necessarily have the same effect as the beta blockers do.
00:19:14
Speaker
Excellent.
00:19:15
Speaker
And you did mention, obviously, that there's an important distinction in terms of whether they're getting intrauterial TPA versus not reperfusion candidates.
00:19:27
Speaker
In those patients who exceed that window that you mentioned and are not candidates for reperfusion,
00:19:32
Speaker
What would be your regular approach?
00:19:35
Speaker
With regards to blood pressure, for those patients that have not received intravenous TPA or endovascular therapy, we just let them.
00:19:43
Speaker
We just liberalize and let them perfuse their brain.
00:19:46
Speaker
So we will tolerate up to 220 systolic blood pressure or a MAP of 150.
00:19:54
Speaker
Again, in the hope that they are trying to perfuse areas that are not yet infarcted.
00:20:03
Speaker
And I guess that the only complicating aspect in those cases would be if you felt that there was ongoing acute endocrine damage in the heart or something else going on that is complicating the stroke, in which probably you would have to kind of balance that and it becomes much more difficult.
00:20:20
Speaker
Absolutely right.
00:20:21
Speaker
So it is a balance between the heart and the brain.
00:20:25
Speaker
For the first 24 hours, it consistently is just that because many of these patients that have ischemic strokes will also have
00:20:32
Speaker
some effect on the heart.
00:20:35
Speaker
And assuming that they don't have some sort of an underlying cardiac issue that they are coming in with, many a times you'll see EKG changes, you'll see mild troponin elevations, concern for ischemia, cardiac ischemia, that is.
00:20:49
Speaker
So we're taking all of this into account when we're coming up with blood pressure goals.
00:20:55
Speaker
Excellent.
00:20:56
Speaker
Now, there's clearly evidence that shows that the
00:20:59
Speaker
relationship between blood pressure and outcomes is more of a you, right?
00:21:04
Speaker
So very low or very high blood pressures can be associated with worse outcomes in stroke.
00:21:10
Speaker
Are there any cases in which you might need to raise the blood pressure?
00:21:16
Speaker
That is a controversial topic because there is really no evidence that shows that raising the blood pressure has truly helped in this kind of a setting.
00:21:28
Speaker
So the only exception we make is patients come in, have a vessel occlusion that has not been opened up, and these people may or may not have received TPA, but TPA gives you a whole set of different blood pressure guidelines.
00:21:46
Speaker
But in those patients where we're concerned that the perfusion is being affected by the fact that these patients are not mounting a blood pressure response,
00:21:55
Speaker
or the auto regulation is impaired for one reason or the other.
00:22:00
Speaker
We do try to raise the systolic blood pressure by 20 points or so, but you have to monitor these patients very closely because if they don't have a neurological improvement or an increase in the NIH stroke scale, or should I say a benefit in the NIH stroke scale by at least two points with your manipulation, then those are patients who are not responding to your treatment.
00:22:23
Speaker
So it is in those patients that improve as a result of your blood pressure augmentation, then there's some benefit to keeping them augmented for a period of time.
00:22:34
Speaker
So I think that's an important point, I mean, that you mentioned that, A, that we don't have a solid amount of evidence behind this, but B, in those cases which you do think it might work, you have to have an objective measure of success to continue it.
00:22:49
Speaker
Otherwise, you're probably not helping the patient.
00:22:51
Speaker
That is correct.
00:22:53
Speaker
Excellent.
Advancements in Stroke Treatments
00:22:54
Speaker
So you did mention earlier the whole aspect of revascularizing these patients.
00:23:00
Speaker
And I think it's obviously an area that for many years was limited to intravenous therapies.
00:23:07
Speaker
But over the last five years, there's been a wealth of evidence suggesting that we have more tools in our toolkit that might help save brain and save patients.
00:23:16
Speaker
So I wanted to talk a little bit about some of the aspects about
00:23:21
Speaker
both intravenous thrombolytics and endovascular therapies, and then the implications they have for monitoring in the ICU later.
00:23:29
Speaker
Could we start, Sayona, with maybe just reviewing for us what are the indications and the window for intravenous thrombolytics and how you usually administer it?
00:23:38
Speaker
Absolutely.
00:23:39
Speaker
So the key thing about IV thrombolytic or IV tPA, which is what we're approved to use in the United States, is knowing the last known well.
00:23:51
Speaker
And we get this wrong all the time because it's not about the patient woke up and had symptoms, so their symptoms must have started when they woke up.
00:24:00
Speaker
It is about when were they last seen normal.
00:24:03
Speaker
And TPA is indicated for up to four and a half hours from the last known well.
00:24:11
Speaker
Now, in the past few years, that window, it used to be only up to three hours.
00:24:15
Speaker
In the past few years, that window has expanded up to four and a half hours, but
00:24:19
Speaker
The time window between three to four and a half hours has some additional exclusions, which includes age greater than 80, a history of a previous stroke, and diabetes or large stroke syndromes, which means that they're coming in with an egg stroke scales that are over 20.
00:24:36
Speaker
Then those become an exclusion even for the four and a half hour window.
00:24:41
Speaker
But otherwise, up to four and a half hours, these patients are eligible for IV tPA and is the first line of treatment
00:24:50
Speaker
in this kind of a setting because we don't know that skipping TPA and going straight to endovascular therapy has any proven benefits.
00:25:00
Speaker
And I think that I want to, before you go further, I just wanted to make sure that we emphasize for our critical care and emergency medicine colleagues who may see a very short window of these patients, that the data in terms of the benefits of early TPA is not controversial.
00:25:17
Speaker
This is something that's been accepted
00:25:18
Speaker
And that if anything, we probably should be seeking to give more patients TPA in that window and that we should really be pushing to get it as soon as possible because 4.5 is the upper limit.
00:25:31
Speaker
But if I was a patient, I would rather get it at one or two hours than at four hours, right?
00:25:36
Speaker
That is correct.
00:25:37
Speaker
Because every 30 minutes of delay leads to about 10% decrease in good outcomes.
00:25:43
Speaker
So we want to get this TPA in as quickly as possible, but then it is very important to get a clear story because we also do not want to expose the patient to the risk without knowing clear time windows.
00:25:59
Speaker
So I think that just to emphasize, like you said, it's not when they woke up or when the first symptom, but really when was the last time that they were seen to be well in their usual baseline?
00:26:09
Speaker
And that can be, I mean, the time zero that really gives us an idea of
00:26:12
Speaker
what's going on.
00:26:15
Speaker
Correct.
00:26:15
Speaker
In terms of administration and what are the things that we should worry post administration in the ICU, how do you usually give TPA?
00:26:26
Speaker
So this is IV TPA and it is, the dose is 0.9 milligrams per kilogram up to a max weight of 100 kilograms.
00:26:37
Speaker
And you have to calculate out the dose and 10% of it is given as a bolus.
00:26:43
Speaker
and the remaining is given as an infusion over the next 60 minutes.
00:26:49
Speaker
Excellent.
00:26:49
Speaker
And like you mentioned earlier, these patients invariably will be admitted to a monitor setting in most hospitals.
00:26:54
Speaker
That would be an ICU.
00:26:56
Speaker
What are the major complications that our audience should be aware of post-TPA?
00:27:03
Speaker
So about 6% of patients can have or can develop
00:27:06
Speaker
an intracranial hemorrhage, which is of course the biggest concern is developing an intracranial hemorrhage because the risk of mortality, or should I say the mortality rate goes up significantly in that kind of a setting.
00:27:18
Speaker
So you want to monitor to make sure that they don't have a secondary deterioration.
00:27:24
Speaker
That's really what is being watched very closely in an ICU, which is where knowing the baseline and stroke scale and whatever improvement they've had as a result of treatment,
00:27:35
Speaker
is well and clearly established so that any deterioration can be quickly captured.
00:27:40
Speaker
So if there's any deterioration, you need to get a STAT-CT and make sure that you don't see a hemorrhage because if there is a hemorrhage, the TPA has to be reversed up to 24 hours from administration.
00:27:54
Speaker
And that reversal includes giving cryoprospitate.
00:27:58
Speaker
You have to check coax, you have to check fibrinogen, and you want to get the fibrinogen above 150 as quickly as possible.
00:28:05
Speaker
And the answer to that is to deliver cryoprospytate.
00:28:10
Speaker
And you have to give at least six to 10 units of cryoprospytate to get the fibrinogen to where you need for it to be.
00:28:16
Speaker
Not that measuring the fibrinogen is the absolute indication about whether patients get reversed with cryo or not.
00:28:24
Speaker
You have to get that cryo in irrespective of.
00:28:27
Speaker
And if you have a fibrinogen level that you can monitor, then this is what you would be looking for.
00:28:32
Speaker
A lot of places also have platelets put into their protocol, but platelets transfusion really is in the setting of these patients having received antiplatelets or are on antiplatelets for some reason prior to them getting TPA.
00:28:49
Speaker
Then there's an indication for platelet transfusions as well.
00:28:53
Speaker
The challenge with cryoprecipitate, as we all know, is the fact that you have to get it from the blood bank.
00:28:59
Speaker
It has to be matched and it has to be thought and then administered.
00:29:03
Speaker
Oftentimes there are delays associated with it and these patients do not have time for that delay.
00:29:11
Speaker
TXA or tranexamic acid as an alternative or as a bridge to getting the cryoprecipitate in is in several of our protocols and
00:29:20
Speaker
these guidelines are available based on the American Stroke Association guidelines for reversal of TPA.
00:29:27
Speaker
So as you mentioned, in 6% of these patients, we might see intracranial hemorrhage.
00:29:32
Speaker
Now, not all the bleeding that occurs is the same severity, right?
00:29:39
Speaker
Are there ways to classify those secondary bleeds in these patients?
00:29:46
Speaker
That is correct.
00:29:47
Speaker
There are ways to classify.
00:29:48
Speaker
And the hemorrhagic transformation, it has a scale of hemorrhagic transformation one and two, or a primary hemorrhage one and two.
00:29:57
Speaker
And the distinction is a hemorrhagic transformation can be little particular areas of blood, in which case it becomes an HD1 or two.
00:30:05
Speaker
And if there are clumps of blood, it can be it's a primary hemorrhage one or two.
00:30:09
Speaker
And then, of course, adding that into the NIH stroke scale and looking at the deterioration.
00:30:17
Speaker
So that might dictate also, I mean, your therapeutic conduct, right?
00:30:23
Speaker
If you see a hemorrhagic transformation within the 24 hours, that is an indication for reversal.
00:30:29
Speaker
Okay.
00:30:30
Speaker
And in terms of monitoring these patients with an NIA scale stroke, how often do you do them in your unit?
00:30:38
Speaker
So for post-DPA patients, there's a whole algorithm.
00:30:42
Speaker
There has to be neuroassessment in the beginning every 15 minutes, then moving on to every hour, and then ultimately moving on to every six hours.
00:30:52
Speaker
And that occurs within the first 24 hours.
00:30:55
Speaker
With regards to what happens after that, then there's an NIH stroke scale that's documented every shift by our nursing.
00:31:04
Speaker
Of course, any change in the NIH stroke scale will be addressed immediately.
00:31:07
Speaker
I mean, as in worsening, not improvement.
00:31:10
Speaker
And just to clarify for myself, Sayona, so the 6% number is all hemorrhages, right?
00:31:17
Speaker
That is correct.
00:31:17
Speaker
But you clearly have made a distinction in terms of we have to be much more aggressive if the hemorrhage occurs in the first 24 hours.
00:31:24
Speaker
That is correct.
00:31:25
Speaker
So I presume that there are many that might occur days later.
00:31:28
Speaker
Is that correct?
00:31:29
Speaker
That is correct.
00:31:30
Speaker
So you can have delayed hemorrhagic transformation, and this usually is because of
00:31:37
Speaker
reperfusion and the breakdown of blood-brain barrier, and not that I want to get all scientific about it, but patients can develop delayed hemorrhagic transformation as well.
00:31:47
Speaker
You don't treat them the same way that you do for the first 24 hours after TPA.
00:31:55
Speaker
In the delayed hemorrhagic transformation, if they are a small little particular hemorrhage and these patients are on antiplatelets, we don't usually stop the antiplatelets because of the risk benefit for secondary stroke.
00:32:07
Speaker
Excuse me.
00:32:08
Speaker
But if they have large hemorrhages, then you do have to hold whatever it is that you're using for secondary prophylaxis till you make sure they are stable.
00:32:18
Speaker
Excellent.
00:32:19
Speaker
And I think it's important to know because that might be the patient who might be get to routine follow-up CT scan and you find this petechia and what do you do a lot of times?
00:32:27
Speaker
Obviously, you're working with neurology team and neuroquidial care team, but I think for our audience just so they're aware that in those cases of delayed
00:32:35
Speaker
findings that are minor, you might not change your therapy at that point.
00:32:39
Speaker
Just keep monitoring.
00:32:40
Speaker
That is correct.
00:32:42
Speaker
Now, you mentioned antiplatelet therapy, and I think it's an important thing to clarify because that is something that has been studied.
00:32:50
Speaker
And I think in most places that do a lot of TPA, it's not a problem, but people who might not see these very frequently.
00:32:56
Speaker
What is your attitude toward antiplatelet therapy post-TPA?
00:32:59
Speaker
You did mention that usually you hold them for 24 hours.
00:33:03
Speaker
Is that always the case?
00:33:04
Speaker
That is always the case, unless there is some clear indication.
00:33:09
Speaker
And again, this starts to get into the complexity of stroke, acute stroke management, because on the occasion, a patient might need a carotid stent place because that's the only way to access the occluded vessel.
00:33:23
Speaker
And in those cases, we might have these patients on antiplatelets up front because you want to protect the stent.
00:33:31
Speaker
they are at a much higher risk for hemorrhagic transformation and you monitor them very closely.
00:33:35
Speaker
But that being a separate case, for most patients, we start antiplatelets within 24 hours post-TPA once we have a stability CT that shows that there is no hemorrhagic transformation or the hemorrhagic transformation is minimal.
00:33:50
Speaker
And the risk for the patient is also minimal in starting at antiplatelets.
00:33:54
Speaker
Now, if these are patients that are already on some sort of an antiplatelet, generally our go-to is aspirin.
00:34:01
Speaker
and 300 milligrams is the studied dose for the most part.
00:34:05
Speaker
We put our patients on 325 of aspirin.
00:34:08
Speaker
There are certain indications for dual antiplatelets, but those are usually if there's concern for carotid disease and you're planning to treat that at some other rate, some other point, should I say.
00:34:22
Speaker
Or if it's a TIA and there's a high, so the nuances of the dual antiplatelets, I think are perhaps a little
00:34:30
Speaker
Beyond what we can talk about, the general answer is to put them on an aspirin 325, either give it orally or give it rectally.
00:34:37
Speaker
But they have to get that aspirin within 24 hours of TPA.
00:34:42
Speaker
Excellent.
00:34:43
Speaker
And the other complication that I have never seen, which just speaks probably to the number of patients I've cared for with TPA not being high enough, is the angioedema that might be associated with TPA.
00:34:54
Speaker
Could you comment on that, Sayona, and how you would manage it?
00:34:57
Speaker
So just like you, I haven't seen it that frequently either.
00:35:01
Speaker
I've seen two patients and they had, it was the lip and the tongue that got swollen.
00:35:08
Speaker
So we treat it like any other angioedema, give Benadryl, give steroids, and usually they respond to that.
00:35:15
Speaker
Okay, excellent.
00:35:18
Speaker
Can you tell us a little bit about endovascular therapies?
00:35:21
Speaker
This is something obviously that in the last
00:35:23
Speaker
five or more years has really exploded.
00:35:25
Speaker
And I'm sure that a lot of our listeners are getting exposed to it very recently.
00:35:31
Speaker
But if you could just give us a brief overview and then what are the implications for care in the ICU?
00:35:36
Speaker
Absolutely.
00:35:37
Speaker
So about 20 to 30% of ischemic strokes are related to large vessel occlusions.
00:35:44
Speaker
And that is the catchphrase here, large vessel occlusions.
00:35:48
Speaker
And when we say large vessel occlusions, we mean
00:35:52
Speaker
either the internal carotid artery or the middle cerebral artery, and of course the basilar artery.
00:35:59
Speaker
So the advances in endovascular therapy in the past couple of years, several studies have come out that have shown much better outcomes in patients who undergo endovascular therapy to open up these vessels.
00:36:16
Speaker
And what needs to happen in these kinds of situations is that
00:36:21
Speaker
they get TPA if they're within that window, and then they get some sort of vascular imaging that shows you that there is large vessel occlusion.
00:36:30
Speaker
Now for the anterior circulation and by that in the middle cerebral artery, the time window for treatment has generally been up to six hours, except now we've started to extend that window up to 24 hours in certain cases.
00:36:47
Speaker
But then we'll talk about that in a minute.
00:36:51
Speaker
In your patient that comes in within that window for that IV tPA, they get some sort of vascular imaging, usually a CT angiogram that shows the large vessel occlusion and they go in for endovascular therapy.
00:37:05
Speaker
Now, endovascular therapy really has advanced in that stent retrievers are being used to just suck out the clot as quickly as possible because the timing of this matters as well.
00:37:16
Speaker
And comprehensive stroke centers are,
00:37:18
Speaker
really being monitored very closely about how much time they are taking to get the patient in and to get the vessel opened up.
00:37:27
Speaker
So that is just standard of care now.
00:37:31
Speaker
For those patients that are coming in beyond the six-hour window, there has to be additional ways of evaluating them for endovascular therapy, and that's where perfusion studies are coming in.
00:37:43
Speaker
Some places look at CT scans and there are ways to score the infarct volume.
00:37:50
Speaker
And the score that is used is called the aspect score.
00:37:55
Speaker
And based on the aspect score, you can make a decision on endovascular therapy for large vessel occlusion or looking at a diffusion perfusion mismatch, which is an MR based protocol where the diffusion tells you how much of the stroke has already occurred
00:38:13
Speaker
And the perfusion gives you the area that's still at risk.
00:38:15
Speaker
And if there's a mismatch, you can go in and open up those vessels as well.
00:38:21
Speaker
Excellent.
00:38:21
Speaker
And in terms of a care post-endovascular therapy, is there a difference in patients who don't get TPA versus those that only get endovascular or those who get both?
00:38:35
Speaker
A difference in care post-treatment?
00:38:39
Speaker
Is that your question?
00:38:40
Speaker
Yeah, and the things that you would do in the ICU.
00:38:45
Speaker
It comes down to the size of the stroke.
00:38:49
Speaker
And even if they have opened the vessel up, if it is a large stroke in evolution, then their risk for cerebral edema and their risk for hemorrhagic transformation is much higher.
00:39:02
Speaker
And that is what we would be monitoring for closely.
00:39:04
Speaker
So it's really important to know what that baseline was and what kind of treatment they've undergone.
00:39:13
Speaker
Okay.
00:39:13
Speaker
So again, I think, again, very important for us to be able to monitor objectively if there's any changes.
00:39:19
Speaker
And that's where I think for the non-neurologist, having familiarity with NIH score can be a great way of transmitting that information to the endovascular team, neurosurgical team, neurocritical care team as well.
00:39:32
Speaker
We're helping them with those patients.
00:39:35
Speaker
Correct.
Edema Management Techniques
00:39:36
Speaker
So you mentioned cerebral edema, which is obviously the other big complication we worry about.
00:39:41
Speaker
We did talk about hemorrhagic conversions, but why don't we talk a little bit about cerebral edema, Sayona, and just maybe give us an overview of what are some of the general interventions that you can do in terms of trying to give good critical care hygiene to these patients to prevent edema or minimize it, and then as they develop edema, what are the more aggressive interventions, both pharmacologically and maybe surgically,
00:40:06
Speaker
that you might implement and when?
00:40:08
Speaker
Sure.
00:40:09
Speaker
So patients coming in with large hemispheric infarctions, and that means they have taken out a significant portion of their MCA distribution, or in the case of posterior circulation, that would be the pica or the posterior inferior cerebellar artery or the superior cerebellar artery strokes.
00:40:29
Speaker
These are the patients that are at the highest risk for developing secondary cerebral edema and herniation syndromes.
00:40:36
Speaker
So up front, when you look at the imaging, or as a non-neurologist case, when you're looking or reading the reports on CT scans, you usually know who are the patients that have had big strokes.
00:40:51
Speaker
And if more than 50% of a vascular distribution in the case of MCA is involved, then their risk for secondary cerebral edema and deterioration is pretty high.
00:41:03
Speaker
So
00:41:04
Speaker
These are patients that you would probably have to do serial CT scans on.
00:41:09
Speaker
We usually do them perhaps every 24 hours or so unless something changes in between and they start to become really drowsy, in which case that in itself would be an indication to send them for some sort of more definitive treatment, surgical treatment.
00:41:26
Speaker
We're always working in conjunction with our neurosurgeons.
00:41:29
Speaker
So any patient that we are concerned is at high risk for deterioration
00:41:33
Speaker
our neurosurgeons are following them along with us.
00:41:37
Speaker
The hemicraniectomy trials have all shown that if you're going to do a hemicraniectomy, you want to do it within 48 hours.
00:41:46
Speaker
That's generally most places.
00:41:48
Speaker
That's the guidelines that most practices maintain.
00:41:51
Speaker
And if the patient deteriorates, as in have, not be that awake, should I say,
00:41:58
Speaker
then that would be an indication to go ahead and decompress these patients.
00:42:03
Speaker
Now, when I say decompression, what it means is a portion of the skull is taken out and it has to be large enough that the brain can be allowed to swell outward as opposed to inward.
00:42:12
Speaker
They also have to do a dura, to remove the dura, should I say, so that the brain is allowed to swell outward because just removing the bone alone is not going to help the patient.
00:42:25
Speaker
The same goes for cerebellar strokes.
00:42:28
Speaker
They are at a high risk for causing compression of the brainstem.
00:42:32
Speaker
And the bone is taken out, it's a suboccipital decompression, and again, permitting the brain to herniate outward as opposed to inward.
00:42:41
Speaker
So Sayona, I know that a lot of the studies that have evaluated a decompression via surgery, hemocrilectomy, have found a big difference in terms of age, in terms of outcomes.
00:42:54
Speaker
And most of the studies that I have read, I mean, have a cutoff of 60 years.
00:42:59
Speaker
Now, could you talk a little bit about the decision process and what are the risks of doing a hemicronectomy in somebody who's maybe older or might have a worse outcome?
00:43:10
Speaker
Yes.
00:43:10
Speaker
So, there's a significant increase in favorable outcomes for patients younger than 60 who undergo a decompressive hemicraniectomy.
00:43:19
Speaker
The
00:43:22
Speaker
What the studies have not been able to show is improved functional outcomes.
00:43:27
Speaker
And this gets worse if you're older than the age of 60.
00:43:31
Speaker
So generally, anyone older than 60 doing decompression on them is controversial.
00:43:36
Speaker
Because what it really comes down to is it improves mortality, but these patients are usually left with severe disability.
00:43:44
Speaker
So in these patients, the risk is survival with no potential for ever recovering neurologically, correct?
00:43:50
Speaker
That is correct.
00:43:52
Speaker
So these are discussions that we have with families and of course any surgical indication for ischemic stroke has to take the whole patient into consideration.
00:44:04
Speaker
What else do they have going on?
00:44:06
Speaker
If their mortality or their risk for mortality in six months is high because they have metastatic cancer,
00:44:15
Speaker
or they have a poor cardiac function or multiple factors that are going into the making of the ischemic stroke.
00:44:22
Speaker
The ischemic stroke at the end of the day is just the end result of everything else that's going on with them.
00:44:27
Speaker
So if in combination they make poor medical candidates for surgery, then truly even the mortality benefit is a very short-term mortality benefit.
00:44:39
Speaker
So these are discussions that have to be had with the family about
00:44:46
Speaker
what to expect at the end of the surgery.
00:44:49
Speaker
Excellent.
00:44:50
Speaker
And obviously the surgical option or hemocrinectomy is a more definitive and aggressive type of therapy that you said, I mean, the right patient when done within the first four hours can really make a difference and it's something that I think should be considered and offered.
00:45:05
Speaker
But could you share with us your pharmacological approach to managing edema or increases in intracranial pressure?
00:45:12
Speaker
with the mannitol or hypertonic saline, how do you use them when you use one versus the other and how you follow it?
00:45:19
Speaker
Absolutely.
00:45:20
Speaker
So with regards to treatment of cerebral edema, the practice is not really any different for ischemic stroke versus any other increased intracranial reason for increased intracranial pressure in the ICU.
00:45:36
Speaker
We pull either mannitol or we pull hypertonic saline.
00:45:41
Speaker
Generally, it's easier to get to the mannitol than it is to the hypertonic saline because if you're using 23.4%, which is what we use generally as a bolus dose for hypertonic saline, you do need a central line in order to administer it.
00:45:55
Speaker
It cannot be given peripherally just because of how costic it is to the vein.
00:45:59
Speaker
So it's just easier to pull mannitol.
00:46:02
Speaker
But if you're using mannitol, a couple of things that have to be kept in mind.
00:46:07
Speaker
You want to dose it appropriately.
00:46:10
Speaker
So at a minimum, the dose has to be one gram per kilogram.
00:46:13
Speaker
And along with dosing it at that rate, you are going to run into a massive loss of volume because it is hyperosmolar, it pulls volume, and it causes you to have massive diuresis.
00:46:25
Speaker
So it's very important to keep an eye on the urine output and to make sure that you're repleting volume as you're giving the mannitol using something that is isoosmolar or hyperosmolar because you're not trying to decrease the osmolarity but rather trying to get them hyperosmolar, which the mannitol in itself will do.
00:46:45
Speaker
Now, some of the other challenges with mannitol is that if you have a patient who has poor renal function or is end-stage renal,
00:46:52
Speaker
There's a first pass effect, which is a rheologic effect, which means it kind of makes the RBC slippery and it lets perfusion occur as a result, but you're not going to get the effective diuresis that goes with it.
00:47:06
Speaker
And it just kind of stays around and causes further complications as a result of it.
00:47:12
Speaker
So you're kind of limited in your ability to use mannitol in those kinds of patients.
00:47:17
Speaker
Now, hypertonic saline, of course, there are different types
00:47:21
Speaker
what is the word that I'm looking for?
00:47:23
Speaker
Different concentrations of it.
00:47:27
Speaker
It comes anywhere from 2% to 23.4, 23.4 being the most concentrated of it.
00:47:33
Speaker
And that's what we're pulling in the setting of somebody who is deteriorating as a result of cerebral edema.
00:47:38
Speaker
And as I said, it has to be given using a central line and it's 30 cc's, which is kind of slowly pushed over 10 minutes.
00:47:46
Speaker
You can even give it in five minutes.
00:47:48
Speaker
That's not a problem.
00:47:49
Speaker
But usually somebody has to stand there and administer it.
00:47:52
Speaker
And it does not come with the same level of massive diuresis that you get with mannitol.
00:47:58
Speaker
And it's very effective.
00:48:00
Speaker
The difference between the two is mannitol acts a little bit more rapidly than hypertonic saline does, 20 minutes versus 30.
00:48:08
Speaker
However, the effect of hypertonic saline lasts longer, four to six hours, as opposed to just under four hours for mannitol.
00:48:17
Speaker
So both of those would be temporizing measures, and I guess in many patients as you're bridging to a hemoclonectomy or more definitive therapy.
00:48:24
Speaker
Correct.
00:48:26
Speaker
Are there any other issues that you might consider?
00:48:28
Speaker
I mean, I have read that some neurointensivists might prefer to use subclavian or other types of lines over IJs in patients who have a very high risk of having significant edema, keeping the bed elevated.
00:48:42
Speaker
Are those things that you routinely worry about?
00:48:46
Speaker
The head of the bed being at at least 30 degrees is something that we always worry about and also keeping the head straight so that you're not obstructing your jugular venous flow.
00:48:58
Speaker
That is something we worry about.
00:49:01
Speaker
In terms of is one central line better than the other central line, in my practice at least we just go with the general critical care guidelines.
00:49:09
Speaker
I mean if we can actually put in a
00:49:11
Speaker
subclavian, we'll put in a subclavian, but if IJ is what we're quickly going to get to, or if the femoral is what we're quickly going to get to, in the interest of getting things going for the patient, then we just do what's optimal at that point.
00:49:24
Speaker
Makes sense.
Challenges of Posterior Circulation Strokes
00:49:26
Speaker
And the other thing I wanted to ask you, which is a different category, you did mention them a couple of times, but posterior circulation strokes obviously are very, very challenging.
00:49:36
Speaker
I think that for the non-neurologist,
00:49:40
Speaker
You can be fooled multiple times.
00:49:41
Speaker
I remember very precisely a case that was presented to me as a cardiac arrest and ended up being a posterior circulation stroke.
00:49:51
Speaker
So if you can maybe tell us a little bit about how to suspect these, how to think about these, and what are maybe some differences in the treatment and monitoring of patients who have a posterior or bastillary and moderate stroke.
00:50:05
Speaker
I agree with you.
00:50:06
Speaker
Basilar strokes are missed all the time because the patients can come in with very subtle findings.
00:50:12
Speaker
And you may never realize that that's what you're looking at.
00:50:15
Speaker
It may be just vertigo and vomiting.
00:50:18
Speaker
And the CT doesn't have to show you anything up front.
00:50:22
Speaker
However, many a times you can see what's known as a hyperdense basilar sign, which is the basilar looking much more prominent than it should in somebody who hasn't gotten any sort of contrast.
00:50:34
Speaker
And they will have subtle clinical signs, perhaps anhystagnosis, perhaps some ataxia.
00:50:40
Speaker
And they may look good up front and then quickly and rapidly deteriorate on you.
00:50:45
Speaker
As in your case, it ended up being a cardiac arrest because they quickly lose their airway.
00:50:49
Speaker
They quickly lose their ability to maintain their blood pressure.
00:50:52
Speaker
And here you are in the setting of a cardiac arrest.
00:50:56
Speaker
So it's very important to do the subtle nuances of a posterior circulation exam.
00:51:04
Speaker
And I understand that it's not everyone who can suspect or even see it.
00:51:12
Speaker
In case of any doubt, just get a CT angiogram and at a minimum, you will be able to see what vessel is occluded and there are treatment options available.
00:51:22
Speaker
For basilar strokes, our window for doing endovascular therapies is actually a much longer than in anterior circulation strokes.
00:51:32
Speaker
mostly because of the fact that these patients are going to do so poorly if something isn't done for them.
00:51:40
Speaker
So if there's any opportunity to establish revascularization in these patients and give them a chance to recover, at least to some extent, then we will offer it.
00:51:51
Speaker
Many institutions maintain up to 12 hours.
00:51:54
Speaker
In our institutions, we may actually
00:51:57
Speaker
go beyond that, especially if the MRI is not really showing that much in the way of stroke, but the risk is high.
00:52:04
Speaker
Yeah, and I think that's an important point because if you have a suspected or established posterior circulation stroke, no matter what the time is, you probably should get your neuro colleagues involved as soon as possible because even though you might think they're out of window, there might be options for that patient that go beyond what we usually think of.
00:52:25
Speaker
That is correct.
00:52:28
Speaker
So I wanted to ask you, Sayana, about some additional critical care considerations in these stroke patients.
Medication Protocols Post-Stroke
00:52:34
Speaker
We did talk about antiplatelet therapy.
00:52:37
Speaker
You did mention that for most patients, it's going to be aspirin and usually start at 24 hours after TPA.
00:52:43
Speaker
They got TPA.
00:52:45
Speaker
We're not going to dive into maybe the specifics or when you use dual antiplatelet therapy.
00:52:51
Speaker
But I did want to clarify something that I think a lot of people still get confused, and it's
00:52:55
Speaker
the role and place for anticoagulation with heparin or similar drugs in stroke?
00:53:01
Speaker
Yes.
00:53:03
Speaker
So the role for anticoagulation is actually very limited.
00:53:08
Speaker
And the real indication is just cardiac.
00:53:13
Speaker
If this is a patient whose, when you, the stroke workup shows that it really is the only risk factor here is atrial fibrillation,
00:53:21
Speaker
or if they have a low EF and you're perhaps seeing an LB thrombus, or they have DVTs, and this is generally in younger patients, they have a PFO, or this is somebody who's hypercoagulable as a result of some sort of an underlying disorder that's causing them to be hypercoagulable.
00:53:45
Speaker
These are the only indication for anticoagulation in patients presenting with ischemic stroke.
00:53:51
Speaker
The challenge with anticoagulation in these patients is that if they have come in with a stroke and the stroke is big, even if you did nothing, they run a risk for hemorrhagic transformation.
00:54:02
Speaker
So now putting them on an anticoagulant that definitely increases their risk for having hemorrhagic transformation, then what is the timing for that?
00:54:12
Speaker
And that comes down to, again, what is the risk factor?
00:54:16
Speaker
How high is their risk for having another stroke as a result of which?
00:54:20
Speaker
and how big is their stroke and can they safely be anticoagulated sooner rather than later?
00:54:26
Speaker
Excellent.
00:54:26
Speaker
I think that's an important point.
00:54:28
Speaker
And like you said, I mean, it's not something that is driven by the neuro presentation, but mostly by cardiac risk factors.
00:54:36
Speaker
But the timing probably is a conversation that needs to happen within a team of neuro cardiology and the critical care team caring for that patient.
00:54:45
Speaker
So I just wanted to make sure that we had that for our
Temperature and Glucose Management
00:54:47
Speaker
audience.
00:54:47
Speaker
The second aspect that I wanted to ask you about, Sayona, in this bucket was temperature management.
00:54:54
Speaker
I know that, I mean, there's been a lot of studies of hypothermia or target temperature management in neuroinjury, including strokes, but what's the current evidence or what would be the current recommendations for managing temperature in patients post acute ischemic stroke?
00:55:10
Speaker
So we know that fever is not good for the brain.
00:55:13
Speaker
And the reason it's not good for the brain is it increases the cerebral metabolism.
00:55:18
Speaker
So we want to control the fever so that the brain can start to recover and heal from whatever process is going on.
00:55:27
Speaker
So across the board, any brain injury, we treat the fever.
00:55:32
Speaker
And it isn't as much an issue with hypothermia as it is with normal thermia.
00:55:39
Speaker
So what we're looking to do is to prevent fever.
00:55:43
Speaker
while we're trying to get to the bottom of why they have fever.
00:55:46
Speaker
And as you know, many neuroinjured patients will have fever just by virtue of the brain injury and not necessarily a whole lot more than that.
00:55:54
Speaker
So our goal in these patients is to try to keep them normal thermic.
00:56:01
Speaker
And we will utilize things like round-the-clock Tylenol or cooling devices, including both external as well as internal cooling, though
00:56:12
Speaker
The cooling catheters are, generally speaking, preferred for hypothermia as opposed to normothermia, though it depends on the institution.
00:56:20
Speaker
The goal is to keep them euthermic as much as possible and do whatever you need to while the brain is recovering.
00:56:30
Speaker
Excellent.
00:56:31
Speaker
And what about glucose control?
00:56:33
Speaker
Where do you stand these days?
00:56:34
Speaker
I know this has been kind of like a swinging pendulum in the ICU.
00:56:38
Speaker
from very intensive glucose control to a little bit more lax to making sure we don't cause hypoglycemia.
00:56:44
Speaker
But clearly, I mean, hyperglycemia has also been associated with brain injury.
Encouraging Early Mobility in Stroke Recovery
00:56:49
Speaker
Correct.
00:56:50
Speaker
So hyperglycemia and hypoglycemia needs to be avoided.
00:56:55
Speaker
hypoglycemia that you're seeing in systemically actually has a bigger impact on the brain because if you if for those studies that have looked at brain glucose the brain glucose is actually much lower than the systemic glucose in the setting of hypoglycemia so if I were to shuffle between which one is worse I would say the hypoglycemia is worse
00:57:20
Speaker
So a recent trial just got published, the SHINE trial, and they really looked at the effect of hyper and hypoglycemia in patients presenting with brain injury, ischemic strokes, and both were found to be equally bad.
00:57:35
Speaker
So the goal then is, at least in our ICU, what we do is we consider up to 180 to be normal, but we treat with, again, titratable agents, so we actually have
00:57:49
Speaker
IV glucose as opposed to subcutaneous glucose, sorry, should I say insulin, not glucose, to manage hyperglycemia.
00:57:57
Speaker
And we do manage it tightly between 120 and 180 with much less tolerance to the blood glucose dropping below 120, you know, blood glucose of 200 or 220.
00:58:10
Speaker
We can manage that.
00:58:14
Speaker
And the last question I had in terms of just general ICU considerations,
00:58:19
Speaker
relates to early mobility, Sanoya?
00:58:21
Speaker
I know that in the ICU with the A to F bundles, there's been a big push for early mobility, getting people up and walking even on ventilators.
00:58:31
Speaker
I did find or I recall reading one paper that maybe showed that in stroke, there might be some limits of how early you want to go.
00:58:40
Speaker
Any comments in terms of what's the current practice and what the research is pointing out in that direction?
00:58:46
Speaker
So we were the only neuro unit to participate in the ABCDF trial.
00:58:51
Speaker
And we also very strongly believe in early mobility.
00:58:56
Speaker
So the way we have it written in our protocol is as long as they're out of the TPA window, if they have received TPA and they're out of that risk, or if they have not received TPA or any sort of therapy, then within six hours, we try to mobilize our patients.
00:59:11
Speaker
So early mobility in that regard is good for these patients.
00:59:16
Speaker
to get them going and also to get a true sense for what their deficits are.
00:59:22
Speaker
So I think that's important.
00:59:23
Speaker
So just the only patients that you wouldn't maybe push is those who are post-TPA window.
00:59:28
Speaker
You would watch 24 hours, let them get out of that window, and then you would continue doing the things that you would do for everybody else.
00:59:34
Speaker
But otherwise, you do believe, I mean, that early mobility, like all ICU patients, probably has benefits for these patients as well.
00:59:40
Speaker
That is correct.
00:59:42
Speaker
Excellent.
00:59:43
Speaker
Well, we could...
00:59:43
Speaker
continue, I mean, talking about many of these topics, but I also want to be very respectful for your time.
00:59:49
Speaker
And I did want to end with a couple of questions that are unrelated to the topic, if that's okay?
00:59:55
Speaker
Yes, absolutely.
00:59:57
Speaker
So the first question relates to books.
Recommended Reading and Reflections
01:00:00
Speaker
And I would like to know, I mean, if there's one book or series of books that you have gifted most to others or that has influenced you the most?
01:00:10
Speaker
So the book that has influenced me the most is something that I read rather recently, and it's The Hundred Days of Abraham Lincoln's Presidency.
01:00:20
Speaker
I was asked to read it as part of a leadership training program that I was in, and I truly did not expect to enjoy reading this book because I'm not into history.
01:00:31
Speaker
But this was perhaps the most amazing book I have read.
01:00:35
Speaker
It truly...
01:00:38
Speaker
talked about a person that had no real leadership skills and used his own intellect to understand how to manage a situation as the president.
01:00:54
Speaker
And I would highly recommend this book to anyone who's interested in reading.
01:00:59
Speaker
So I have not read it, but I'm already intrigued.
01:01:01
Speaker
And the first thing that comes to mind, which is very interesting, is when you think of Abraham Lincoln, you obviously think of
01:01:08
Speaker
the tremendous impact that he's had on our country and on many, many, many things.
01:01:15
Speaker
But I never thought that that was done in only 100 days.
01:01:19
Speaker
Yes, he did.
01:01:19
Speaker
That's the first thing that strikes me.
01:01:23
Speaker
That is correct.
01:01:25
Speaker
Wow.
01:01:26
Speaker
So I definitely will link that book, and it sounds like a fascinating read.
01:01:30
Speaker
I do think that I have definitely seen stories or case studies of Abraham Lincoln
01:01:37
Speaker
in terms of leadership, in terms of also what people call like a balanced approach, focus on what's important, not what's urgent.
01:01:47
Speaker
And clearly, I think that this sounds like a book that a lot of our listeners will enjoy, and I will put it there.
01:01:53
Speaker
Thanks for sharing that with us.
01:01:55
Speaker
Absolutely.
01:01:56
Speaker
The second question relates to something you believe to be true that many other people don't believe to be true or don't act like it's true, either in medicine
Art and Science of Medicine
01:02:06
Speaker
or in life.
01:02:08
Speaker
So I'm going to sound a bit cliched.
01:02:12
Speaker
And I don't know if people believe it or not, but I think medicine is actually an art that takes science into account.
01:02:23
Speaker
Because I take care of patients with the same disease process just about every day.
01:02:30
Speaker
And I have come to realize that just because they have the same disease process that these two patients are not the same.
01:02:39
Speaker
And how do you then individualize care for these patients?
01:02:45
Speaker
And it really comes down to taking the science and converting it into that specific medicine for that specific patient.
01:02:56
Speaker
And I think that's a great point.
01:02:58
Speaker
And we have discussed similar points to this with other guests.
01:03:02
Speaker
And I think it also applies to this drive for protocolized care, which I think has a lot of benefits.
01:03:08
Speaker
but protocols may help us eliminate unwanted or unneeded variation.
01:03:14
Speaker
But like you said, there are variations that patients require because of their unique aspect that we as clinicians, and maybe that's the art of it, have to identify and provide to them.
01:03:25
Speaker
Correct.
01:03:27
Speaker
So the last question or the closing question would be just, what would you want every intensivist and listener listening to us today to know?
01:03:38
Speaker
So I'm not going to give you a popular answer, but I'm a neurologist.
01:03:43
Speaker
And I think everybody needs to know how to do a neuro exam.
01:03:48
Speaker
It is heavily underrated and definitely not well taught.
01:03:56
Speaker
The ability to do a quick, and it doesn't have to take more than two minutes, neuro exam is critical in the care of any patient anywhere.
01:04:07
Speaker
And that's what I would want every intensivist to know.
01:04:10
Speaker
And I think that's a great recommendation and something for people to work on because, like you said, I mean, it can make a real difference in identifying issues and making diagnoses.
01:04:23
Speaker
And I think that, especially in the ICU, we tend to listen to the heart, listen to the lungs, but we're also monitoring those in so many ways.
01:04:32
Speaker
And I think that the two areas that I have over the years
01:04:36
Speaker
seen neglected are a good abdominal exam in somebody who's intubated and sedated and a good neuro exam in somebody who's in the ICU.
01:04:43
Speaker
So clearly I think it's a great thing for our audience to work on.
01:04:48
Speaker
Absolutely.
01:04:50
Speaker
So Joana, it was really a pleasure to talk with you.
01:04:53
Speaker
Thank you so much for sharing your expertise with us and giving us your time in such a generous way.
01:04:58
Speaker
I hope that I can have you back soon and maybe talk about other aspects of neuro critical care and brain injury.
01:05:05
Speaker
But again, thank you so much for your time.
01:05:07
Speaker
Thank you so much for having me and I look forward to doing more sessions with you.
01:05:13
Speaker
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01:05:17
Speaker
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01:05:23
Speaker
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01:05:28
Speaker
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