You are asked to admit a 46-year-old man who has just been intubated in the Emergency Department after collapsing from what appears clinically to be a brain stem stroke. His Glasgow Coma Score prior to intubation was 6.
Outline your management strategy for him for the first 24 hours.

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College Answer

Activate the stroke team if available in this hospital as urgent intervention is needed for the best
potential outcome – involves neurologist and interventional neuroradiologist.


Attention to ABC (confirm tube position, adequacy of ventilation, control hypertension and treat
hypotension to ensure adequate CPP)

Investigations / Interventions
• CT scan to exclude bleed and confirm diagnosis – can miss post fossa and brainstem lesions
in the early stages so MRA may be indicated
• Interventional cerebral angiography and thrombectomy if within time window and facilities and
resources available.
• Thrombolysis with tPA within 4.5 hours of event if intervention unavailable or unsuccessful
• Heparin infusion
• Aspirin

Physiological monitoring and maintenance of normal parameters (BP, Na, BSL etc)

Role of EVD if hydrocephalus is present

Ongoing neurological assessment – at risk of progressing to locked in syndrome

Supportive care of the intubated ventilated critically ill patient

Discussion with family re therapy and outlook plus risk factors for poor outcome

 

Discussion

This question does not seem to stem from any specific guidelines.The college is asking what one might do with a brainstem stroke; in order to pass the candidate needs to

  • demonstrate that they understand the importance of early thrombolysis
  • know about the role of interventional neuroradiology in stroke
  • appreciate the need to exclude intracranial haemorrhage, and the limitations of CT in posterior fossa lesions
  • know how to manage stroke if neither thrombolysis nor clot retrieval is possible
  • appreciate the possibility of hydrocephalus developing with posterior fossa strokes
  • appreciate the prognosis of such a stroke, and the need to manage family expectations.

A detailed discussion of the definitive management options in acute stroke is available elsewhere.

Supportive management of acute stroke is also covered in a summary article.

If one were to summarise in brief the approach to management here, it would resemble this:

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
  • Circulatory support: to keep BP normal, and below 220 mmHg systolic
  • Sedation: as needed to tolerate ICU management in comfort
  • 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*
  • Antibiotic therapy if contaminated aspiration is suspected

* It should be pointed out that though the college (writing in 2011) suggest the use of a heparin infusion, this strategy has already fallen out of favour by this stage, given that it seems to kill people. Certainly, the 2007 AHA guidelines were not in favour of its use.

References

Regarding early thrombolysis:

Wardlaw JM, Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev. 2003;(3):CD000213.

The Stroke Foundation guidelines for management of acute stroke

 

Regarding early cerebral angiography and thrombectomy:

The Stroke Foundation guidelines dont actually recommend mechanical clot retrieval ("insufficient evidence", they say) but they do recommend intra-arterial thrombolysis, and the reference they give is the 2009 update of the Wardlaw meta-analysis mentioned above.

 

Regarding the need to exclude intracranial haemorrhage:

The need itself does not require references - it is common sense. CT or MRI? Here is a Cochrane review; diffusion-weighted imaging seems to be more sensitive in detecting ischaemic stroke.

Brazzelli M, Sandercock PA, Chappell FM, Celani MG, Righetti E, Arestis N, Wardlaw JM, Deeks JJ. Magnetic resonance imaging versus computed tomography for detection of acute vascular lesions in patients presenting with stroke symptoms. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007424. doi: 10.1002/14651858.CD007424.pub2.

 

Regarding antiplatelet agents and anticoagulation:

Again, the Stroke Foundation guidelines for management of acute stroke recommend aspirin and hemaprin in patients who definitely have no haemorrhage.

 

Regarding the possibility of hydrocephalus

I have not found any literature about the actual risk of this happening with undifferentiated posterior fossa lesions, but cerebellar infarction stands out as the leading culprit:

Hornig CR, Rust DS, Busse O, Jauss M, Laun A. Space-occupying cerebellar infarction. Clinical course and prognosis. Stroke. 1994 Feb;25(2):372-4.

 

Regarding the prognosis of brainstem stroke:

There is a good (though dated) article regarding the prognosis of stoke in the ICU. Sensibly, it seems older patients and those in a coma on admission have the poorest prognosis.

Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W.Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997 Apr;28(4):711-5.

 

Regarding the danger of heparin infusion:

Adams, Harold P., et al. "Guidelines for the Early Management of Adults With Ischemic Stroke " Circulation 115.20 (2007): e478-e534.