You are asked to admit a 76-year-old man with a past history of ischaemic heart disease and paroxysmal atrial fibrillation who has just been intubated in Accident and Emergency after collapsing from a brain stem stroke (diagnosed clinically). He had a Glasgow Coma Score of 6 before being intubated. Outline your management strategy for him for the first 24 hours.

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College Answer

Key Features

Obvious attention to ABC.                                                                            

a)     Urgency is required for the best results here.                                                                    .

b)         Investigation: CTA scan of brainstem to exclude a bleed (Although not the best investigation compared to a MRI, but quickest and easiest to arrange) and to elucidate the vascular supply.   Plus exclusion of an embolic cause ie TOE should be done.

c)         Therapy: Discussion with neurologist/interventional neuroradiologist re urgent regional thrombolysis/ angioplasty / platelet antagonists.                                                       .

d)         Discussion with family re therapy and outlook.

Discussion

This brainstem stroke question is another one of these "outline your management" questions, where one ought to go through a stereotypical pathway. Yes, you would direct your attention to the A B Cs and you would maintain airway patency, ensure normoxia and normocapnea with mechanical ventilation, etc etc. Ultimately, it is not the general supportive management which is the real question here. The college - I assume - wants to know how well you understand the management of stroke. This topic is well explored elsewhere.

In brief:

Definitive management option:

  • Intravenous thrombolysis
  • Intraarterial thrombolysis
  • Endovascular embolectomy
  • Conservative management and subsequent antiplatelet therapy

Supportive management:

  • Airway: intubation, for the protection thereof (being mindful that it may be futile)
  • Ventilation: aiming for normocapnea and normoxia
  • Circulatory support: to keep BP normal, and below 220 mmHg systolic (or 180 if thrombolysis is being explored as an option)
  • Sedation: as needed to tolerate ICU management in comfort
    • Management of raised intracranial pressure is not going to be a major issue outside of the setting of malignant MCA.
    • If the brainstem stroke is extensive or involves a large proportion of the cerebellum, decompression may still be relevant. Hydrocephalus may eventually develop and an EVD may be useful as a route of CSF egress.
  • Electrolyte and endocrine control: ensuring normoglycaemia and normothermia
  • Fluid balance management to ensure protection of renal function following contrast
  • Enteric nutrition may commence by the nasogastric route
  • Heparin is not indicated given the risk of haemorrhagic transformation
  • Family discussion so as to address the possibility of poor prognosis 

After the airway has been controlled, the ventilation managed and the circulation appropriately supported, one needs to establish whether this patient has had an embolic stroke (from his AF) or whether there has been a haemorrhage. This is best done with a non-contrast CT brain.

If a haemorrhage has developed, giving features of brainstem pathology, it must be a central one, or one which is extensive. In any case, hydrocephalus may develop, and one would get on the phone to the neurosurgeons to get an EVD in, if not to evacuate the bastard. Surely the earlier this is done the better.

If there is no haemorrhage, there is no point debating whether the stroke is embolic or ischaemic. One would give thrombolysis immediately. The evidence for this is discussed elsewhere. Suffice to say, we give people alteplase because the NINDS Study demonstrated a neurological recovery benefit without any increased bleed-related mortality. Mechanical embolectomy is an option if thrombolysis is contraindicated, but it is a poorer option, and not as well supported.

Then, the next 24 hours will be spent in anxious anticipation of a killing-blow intracranial bleed (as with thrombolysis) or recovering from neurosurgical evacuation and EVD insertion. In either case, one ought to have a word with the next of kin, so as to manage their expectations.

Though not immediately indicated, a carotid doppler and TOE should be performed to determine whether the carotid artery or the fibrillating atrium are sources of the clot.

References

References

 

Oh's Intensive Care manual

Chapter   51   (pp. 568)  Acute  cerebrovascular  complications by Bernard  Riley  and  Thearina  de  Beer.

 

The Internet Stroke Centre has an excellent summary of stroke syndromes.

 

Kammersgaard, Lars Peter, et al. "Short-and long-term prognosis for very old stroke patients. The Copenhagen Stroke Study." Age and Ageing 33.2 (2004): 149-154.

 

National Collaborating Centre for Chronic Conditions (Great Britain). "Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)." Royal College of Physicians, 2008.

 

Friedman, Howard S., W. J. Koroshetz, and N. Qureshi. "Tissue plasminogen activator for acute ischemic stroke." N Engl J Med. 1995;333(24):1581.