Lisa A. Shultz, MD Medical Director, Lourdes Stroke Center Chief, Division of Neurology

1. Performance Improvement: Emergency Management in Acute Cerebrovascular PatientsCurrent US Guidelines Lisa A. Shultz, MD Medical Director, Lourdes Stroke Center Chief, Division of Neurology

2. ABSOLUTE Concurrent acute MI or current Platelets < 100,000 or INR ≥ 1.4 Major surgery within past 14 days Co-morbidity that predisposes to hemorrhage ICH on Head CT or clinical suspicion of SAH Pregnant or lactating Stroke within past 3 months Lifetime history of intracranial hemorrhage Serious head trauma within past 3 months • Known AVM or Aneurysm HTN >185/110 despite 2 PRN Rx doses RELATIVE FS glucose <50 or > 400 Seizure at onset of stroke Post-MI pericarditis GI or GU hemorrhage in past 21 days Lumbar puncture in past 7 days Arterial puncture at non-compressible site in past 7 days tPA Contra-indications

3. HTN Rx in Ischemic CVA • In setting of CVA, cerebrovascular autoregulation impaired and penumbra at highest risk for ischemia due to hypoperfusion with BP changes • Non-tPA candidates: No prn Rx unless systolic>220, diastolic>120 • Pre-tPA candidates: If BP>185/110, prn Hydralazine 10-20mg IV q15min or Labetalol 10mg IV q10min -Aggressive measure, ie Rx gtt, is absolute contra-indication to tPA per Brain Attack Coalition (AAN, AANS, ACEP, ASA, NINDs) • Post-tPA patients: If BP>180/105, prn Hydralazine or Labetalol as above with initiation of Nicardipine gtt 5mg/h if BP remains elevated s/p 2 prn dosages or as first line Rx -American Stroke Association, 2003

4. HTN Rx in Hemorrhagic CVA • HTN may be present as etiology of ICH, brain’s attempt to maintain cerebral perfusion pressure, sympathetic activation but can lead to hematoma expansion • Immediate reduction of BP by 20% does not lead to neuro deterioration • Current standard is systolic<180 within 1 hour • Current trial for aggressive management of systolic<140 is ongoing but initial data indicates hematoma growth is decreased by 60% • First-line Rx options: Nicardipine or Labetalol • Nitroprusside leads to arterial and venous dilatation, which leads to elevated ICP - Considered last choice and should be accompanied by documentation why agent being used and acknowledgement of risks - American Stroke Association, 2007

5. Reversing Coagulopathy in ICH • Fresh Frozen Plasma: Immediate reversal - May require repeat of 30ML/Kg at least once in 24 hour period • Vitamin K - Sub-cutaneous is inferior to oral or IV and is not recommended - Oral: 24-48 hours for reversal - IV: 2-24 hours for reversal diluted 5-10 mg administered as slow infusion (no IV push) • Recombinant Activated Factor VII did not reduce mortality or improve functional outcome in ICH

6. GCS and NIH may not reflect early signs of deterioration – Drowsiness, slowed response time & intractable vomiting are more specific Risks for rapid deterioration Admit sys BP > 200 Pinpoint pupils Hematoma > 30mm Extension into vermis Brainstem distortion Intraventricular blood Upward herniation Hydrocephalus Posterior Fossa ICH