You are asked to admit a 46-year-old male who has just been intubated in the Emergency Department (ED) after collapsing from a brain stem stroke, two hours earlier. His Glasgow Coma Scale (GCS) prior to intubation was 6.
Outline your management strategy for him for the first 24 hours.
Resuscitation, definitive and supportive treatment. 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
- Interventional cerebral angiography if facilities and resources available or transfer to specialist centre if within acceptable time window
Note: Acceptable time window varies between centres but may be up to 12hrs or longer if CT perfusion scan shows salvageable brain.
Although recent trials have shown benefit for acute thrombectomy in acute stroke, brain stem stroke was not well represented in the study population. However, it is so potentially devastating that thrombectomy is advocated
- Some centres may combine with IA fibrinolysis (recent papers including one from RMH showing some good outcomes with IA fibrinolysis up to 24-48 hours post stroke)
- Systemic thrombolysis if specialist neuroradiological intervention not available
- Heparin infusion
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.
Investigation for underlying cause / risk factors and treatment as appropriate.
This question is virtually identical to Question 13 from the second paper of 2011, with the exception of the college this time specifying that the collapse occurred two hours ago. The answer to Question 13 is therefore reproduced below with minimal modification.
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
- 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 in a previous incarnation of this question (2011), the college suggested the use of a heparin infusion. This strategy has now fallen out of favour, given that it seems to kill people. Certainly, the 2007 AHA guidelines were not in favour of its use. In spite of this, the heparin anachronism has also been repeated in the college answer to this question.
Oh's Intensive Care manual: Chapter 51 (pp. 568) Acute cerebrovascular complications by Bernard Riley and Thearina de Beer. This chapter of Oh's has the distinction of having very few tables in it - there are only two, for an extremely long block of text.
The Internet Stroke Centre has an excellent summary of stroke syndromes.
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