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Page Large Vessel Occlusion

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Large Vessel Occlusion

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Large Vessel Occlusion

  • Limited data available: >80 years of age, mRS ≥2, no core-penumbra mismatch, ASPECTS 0-2, from LKW

    All patients presenting with concern for stroke should undergo the following imaging:

    • Non-contrast CT head
    • MRI wake-up protocol when indicated ASPECTS measurement on CT or DWI-MRI
    • CTA head and neck
    • MRI wake-up protocol when indicated
    • CTP when indicated
    • ASPECTS measurement on CT or DWI-MRI
  • Endovascular thrombectomy (EVT) for acute ischemic stroke with anterior circulation large vessel occlusion (LVO) is one of the most effective interventions in medicine with a number needed to treat (NNT) of 4 for functional independence at 90 days. Historically, large-core infarcts determined on both non-contrast computed tomography (CT) and CT perfusion have been excluded from EVT treatment based on concerns about futility, risk for ICH, and death. Recent studies (ANGEL-ASPECTS, RESCUE-Japan LIMIT, SELECT2, TENSION, TESLA, and LASTE) have demonstrated that patients with large ischemic core on basic imaging should not be excluded from this effective treatment. Patients with large core infarct have improved functional outcomes at 90 days with EVT, and do not have statistically significant increased risk for symptomatic ICH or death compared to medical management alone.
    1. ASPECTS 6-10
      1. Should receive EVT when presenTIng <24 hours from LKW
    2. ASPECTS 3-5
      1. Do not exclude from treatment with EVT when presenting <12 hours from LKW
      2. CTP if presenting >12 hours from LKW
        1. Should receive EVT if core infarct volume ≤125mL
        2. May be reasonable to proceed with EVT following discussion with family for core infarct >125mL
    3. ASPECTS 0-2
      1. Do not exclude from treatment with EVT when presen ng <6 hours from LKW
      2. CTP if presenting >6 hours from LKW
        1. Should receive EVT if core infarct volume ≤125mL
        2. May be reasonable to proceed with EVTfollowing discussion with family for core volume >125mL

  • Bendszus M, Fiehler J, Sub l F, et al. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet. 2023;402(10414):1753-1763. doi:10.1016/S0140-6736(23)02032-9 (TENSION)

    Costalat V, Jovin TG, Albucher JF, et al. Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size. N Engl J Med. 2024;390(18):1677-1689. doi:10.1056/NEJMoa2314063 (LASTE)

    Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med. 2023;388(14):1272-1283. doi:10.1056/NEJMoa2213379 (ANGEL-ASPECTS)

    Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published correc on appears in N Engl J Med. 2024 Jan 25;390(4):388]. N Engl J Med. 2023;388(14):1259-1271. doi:10.1056/NEJMoa2214403 (SELECT-2)

    Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191 (RESCUE-Japan LIMIT)

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Acute Ischemic Stroke

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Thrombolytic Treatment - AIS

    • Patients of any age with suspected ischemic stroke within 4.5 hours of last known well.
    • Selected patients beyond 4.5 hours from last known well, with unwitnessed time of onset.
    • See more details regarding eligibility criteria below (GWTG Goal Times).
  • Within 4.5 hrs:
    • No upper age limit
    • SBP <185 or DBP <110 (see pretreatment recommendations below)
    Exclusions:
    • CT brain imaging exhibits extensive regions of clear hypoattenuation
    • Ischemic stroke within 3 months
    • Severe head trauma within 3 months
    • Intracranial/intraspinal surgery within 3 months
    • History of intracranial hemorrhage
    • Suspected subarachnoid hemorrhage
    • GI malignancy or recent GI bleed
    • Platelets <100 000/mm3, INR >1.7, aPTT >40 s, or PT >15 s
    • LMWH within 24 hours
    • DOAC within 48 hours
    • High suspicion of infectious endocarditis
    • Suspected aortic dissection
    • Suspected intra-axial intracranial neoplasm
    Beyond 4.5 hours from last known well (based on published WAKE UP trial: https://www.nejm.org/doi/full/10.1056/NEJMoa1804355)
    • Unwitnessed event (recognized symptoms upon awakening or unable to report timing of onset due to, for example, confusion or aphasia)
    • MRI suggestive of more recent onset of event (Based on MRI-DWI positivity and FLAIR negativity
    • Note that acute MRI may be challenging to obtain in some practice environments and this may limit eligibility by this criteria.
    • Age up to 80 years and functionally independent
    • No LVO; LVO patients are prioritized for EVT
    • Not severe stroke (NIHSS <=25)
    • Meets other standard IV thrombolytic eligibility other than time from last known well
    • Determine “Last Known Well” time. WITHIN 5 MIN OF ED ARRIVAL
    • Activate Stroke Team (513-584-8282) WITHIN 10 MIN OF ED ARRIVAL
    • Perform non-contrast CT scan and CTA (head/neck). WITHIN 20 MIN OF ED ARRIVAL
    • Draw bloods for lab tests (CBC, renal, coags, pregnancy, fingerstick glucose).
    • Obtain fingerstick glucose promptly to determine IV thrombolytic eligibility.
    • Do not delay thrombolytic for other lab results unless clinical suspicion of abnormality.
    • Establish two IV lines.
    • Record blood pressure.
    • Gently treat (usually labetalol 10 mg to start, assuming no clinical contraindications) if ≥185 systolic or ≥110 diastolic if potential IV thrombolytic candidate (details below).
    • Review eligibility criteria for IV thrombolytic (details below)
    • Interpret CT scan -- rule out bleed or subacute ischemia. WITHIN 35 MIN OF ARRIVAL
    • Start IV thrombolytic bolus if eligible. WITHIN 45 MIN OF ARRIVAL 
    • Tenecteplase (TNKase) - 0.25mg/kg (maximum 25mg). Administer as a bolus over 5 seconds, followed by a 10mL bolus of 0.9% sodium chloride (NS).
    • OR, if tenecteplase is not available, use alteplase (Activase) - 0.9 mg/kg dose (maximum 90 mg). Administer 10% as bolus over 1-2 minutes and the remainder as an infusion over 60 minutes.
    • Do not use the cardiac dose.
    • Do not exceed the maximum dose.
    • Use rt-PA = tenecteplase = TNKase. Do not use other thrombolytic agents. Use alteplase (Activase) only if tenecteplase is unavailable in the adult population. Note that the dose is different for each IV thrombolytic (see above).
    • Do not give aspirin, clopidogrel, heparin, warfarin or other oral anticoagulants for the first 24 hours after IV rt-PA.
    • Potential IV thrombolytic candidates should not receive antiplatelets (aspirin, clopidogrel) or anticoagulants (heparin, warfarin, or DOACs) upon arrival to ED.
    • However, patients who have taken antiplatelets prior to arrival in the Emergency Department are still considered IV thrombolytic candidates and those taking anticoagulant medications may still be candidates as well.
    • At 24 +/- 6 hours, a non-contrast CT scan or MRI should be performed (to rule out any intracranial hemorrhage) before starting an antiplatelet or anticoagulant medication.
  • Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:
    • Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
    • Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
    • Fluctuating neurological symptoms requiring specialized blood pressure management.
      Hold infusion and repeat head CT stat
    • Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.
  • Admit patient to ICU and follow post-IV thrombolytic order set, including:
    • Monitor BP and neuro status:
      Q15 min X 2 hours, q30 min X 6 hours, then q1 hour X 16 hours
    • Treat SBP≥180 or DBP ≥105 (details below)
    • Call stroke physician at 513-584-8282 if there is a decline in neuro status, new headache, nausea, or vomiting.
      Hold infusion and repeat head CT stat
    • NPO until swallowing assessed
    • DVT prophylaxis with intermittent stocking compression devices (SCDs) but no anticoagulants
    Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:
    • Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
    • Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
    • Fluctuating neurological symptoms requiring specialized blood pressure management.
      Hold infusion and repeat head CT stat
    • Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.
  • For IV thrombolytic candidates: BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.
    • BP MANAGEMENT PRIOR TO IV THROMBOLYTIC ADMINISTRATION
      • Up to two of the following agents may be used for nonaggressive treatment:
        • Labetalol 10 to 20 mg IV over 1-2 minutes, may repeat X 1 (max dose 40 mg)
        • Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5-15-minute intervals (up to max dose 15 mg/h; when desired BP attained, reduce to 3 mg/h)
        • Enalaprilat 0.625 to 1.25 mg IV (up to max dose of 1.25 mg)
        • Hydralazine 10 mg IV over 1-2 minutes, may repeat X1 (max dose 20 mg)
        • Nitropaste 1 to 2 inches (up to max dose of 2 inches)
    • If IV thrombolytic not planned, then permissive HTN up to 220/120 may be reasonable
  • During/after treatment with thrombolytic or other acute reperfusion intervention, BP must be aggressively maintained at SBP <180 or DBP <105 BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.
    • Monitor BP every 15 minutes for first 2 hours, then every 30 minutes for next 6 hours, then every hour for the next 16 hours.
    • Monitor blood pressure every 15 minutes during the antihypertensive therapy. Observe for hypotension.

      BLOOD PRESSURE MANAGEMENT DURING/AFTER ADMINISTERING IV thrombolytic
      If systolic BP ≥180–230 mm Hg or diastolic BP ≥105–120 mm Hg:
      • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
      • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h
      If BP not controlled or diastolic BP >140 mm Hg:
      • Consider IV sodium nitroprusside
    • If an sICH is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
    • Suspect sICH if there is any acute neurological deterioration (new headache, acute hypertension, seizure, or nausea and vomiting) or acute increase in BP.
    • If hemorrhage is suspected, then do the following:



      Management of sICH after thrombolysis is the same with tenecteplase as it is with alteplase.
    • If angioedema is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
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