The purpose of this critical care post is to serve as an education tool for both healthcare workers and the general public. The information provided here is based on both best-practice, evidenced based medicine and the years of experience I have spent taking care of the critically ill. Critical Care is not “black and white”, there are many different ways to achieve the desired outcomes, and some treatments discussed here may or may not be appropriate for certain patients. The recommendations, tests, and treatments provided here do not supersede the recommendations of your individual healthcare team that is directly caring for you. My hope is that this post helps others understand more about certain diseases and inspires new healthcare workers to pursue the specialty of Critical Care Medicine.
Stroke remains one of the leading causes of morbidity and mortality worldwide, necessitating rapid intervention and intensive critical care management. In this blog post, we will explore the essential aspects of stroke treatment, stroke management, and stroke recovery in the critical care setting, focusing on ischemic stroke and hemorrhagic stroke.
Immediate Assessment and Diagnosis of Stroke
The key to optimizing stroke outcomes lies in early recognition and prompt intervention. The primary assessment follows the ABCs (Airway, Breathing, Circulation) with an immediate focus on stabilizing vital signs.
Initial Evaluation and Stroke Imaging
- Neurological Assessment: Conduct a rapid assessment using the National Institutes of Health Stroke Scale (NIHSS).
- Brain Imaging for Stroke: A non-contrast CT scan is the first-line imaging modality to differentiate ischemic stroke vs. hemorrhagic stroke.
- CT Angiography (CTA) or Magnetic Resonance Angiography (MRA): Essential for identifying large vessel occlusions or vascular abnormalities.
Acute Ischemic Stroke Management
The goal in ischemic stroke treatment is to restore cerebral perfusion as quickly as possible.
Intravenous Thrombolysis (IV tPA) for Stroke
- Alteplase (tPA): Administered within 4.5 hours of symptom onset unless contraindications exist.
- Tenecteplase: An alternative to alteplase that may have similar or superior efficacy in some cases.
Endovascular Thrombectomy (EVT) for Stroke
- Recommended for patients with large vessel occlusions (LVOs) within 6 hours of symptom onset.
- Select cases with favorable imaging profiles may benefit up to 24 hours post-stroke.
Blood Pressure Control in Stroke
- If IV tPA is given, maintain BP < 185/110 mmHg before administration and < 180/105 mmHg afterward.
- In non-thrombolysis candidates, permissive hypertension (BP < 220/120 mmHg) is generally allowed to maintain cerebral perfusion.
Neuroprotection & Supportive Care for Stroke Patients
- Maintain Oxygen Levels: Keep SpO2 > 94%.
- Blood Sugar Management in Stroke: Target glucose levels between 140-180 mg/dL.
- Prevent Hyperthermia: Fever is associated with worse outcomes.
- Early Stroke Rehabilitation: Initiate physical, occupational, and speech therapy after stroke as soon as clinically feasible.
Hemorrhagic Stroke Management
For hemorrhagic stroke treatment, the emphasis is on controlling bleeding, reducing intracranial pressure, and preventing secondary complications.
Intracerebral Hemorrhage (ICH) Treatment
- Blood Pressure Control: Maintain SBP < 140 mmHg (some guidelines suggest 130-150 mmHg as a target).
- Reversal of Anticoagulation:
- Vitamin K and prothrombin complex concentrate (PCC) for warfarin reversal.
- Andexanet alfa for direct oral anticoagulants (DOACs).
- Surgical Stroke Treatment:
- Decompressive craniectomy or hematoma evacuation for large hemorrhages with mass effect.
Subarachnoid Hemorrhage (SAH) Management
- Aneurysm Treatment for SAH: Endovascular coiling or surgical clipping.
- Preventing Vasospasm in Stroke: Initiate nimodipine (60 mg every 4 hours for 21 days).
- Intracranial Pressure (ICP) Control:
- Elevate the head of bed to 30 degrees.
- Consider external ventricular drainage (EVD) if hydrocephalus is present.
Neurocritical Care & Long-Term Stroke Recovery
Preventing Secondary Brain Injury Post-Stroke
- Seizure Prevention in Stroke: Routine use in ICH/SAH is controversial but may be considered in high-risk patients.
- DVT Prevention in Stroke: Use low-dose heparin or intermittent pneumatic compression.
- Stroke Nutrition & Hydration: Enteral nutrition is preferred over parenteral.
Multidisciplinary Stroke Recovery Approach
- Stroke Rehabilitation Therapy: Early physical, occupational, and speech therapy improves functional outcomes.
- Cognitive & Psychological Support Post-Stroke: Post-stroke depression and cognitive impairment are common and require intervention.
Conclusion
Stroke management in the critical care setting requires a multidisciplinary approach, integrating rapid stroke diagnostics, targeted stroke therapies, and meticulous stroke supportive care. Advances in thrombolysis, endovascular therapy, and neurocritical care have significantly improved stroke survival rates, but timely stroke intervention remains the most critical determinant of stroke recovery.
By understanding and implementing the latest stroke treatment guidelines, healthcare professionals can improve stroke outcomes and reduce stroke mortality rates for both ischemic and hemorrhagic stroke patients.
Sources
- American Heart Association/American Stroke Association. “2023 Guidelines for the Early Management of Patients with Acute Ischemic Stroke.”
- Centers for Disease Control and Prevention (CDC). “Stroke Facts and Statistics.”
- National Institutes of Health Stroke Scale (NIHSS) – Training and Certification Resources.
- Mayo Clinic. “Stroke: Symptoms and Causes.”
- World Stroke Organization. “Global Stroke Guidelines and Action Plan.”
