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.

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College answer

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
  • 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.

Investigation for underlying cause / risk factors and treatment as appropriate.

Discussion

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

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 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.

References

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.

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.

Trialists’Collaboration, Stroke Unit. "Organised inpatient (stroke unit) care for stroke." Cochrane database of systematic reviews 4 (2013).

Foerch, C., et al. "Survival and quality of life outcome after mechanical ventilation in elderly stroke patients." Journal of Neurology, Neurosurgery & Psychiatry 75.7 (2004): 988-993.

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Jansen, Olav, et al. "Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study." Cerebrovascular Diseases 36.3 (2013): 218-225.

Mayer, Stephan A., et al. "Cost and outcome of mechanical ventilation for life-threatening stroke." Stroke 31.10 (2000): 2346-2353.

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de Courten-Myers, Gabrielle M., et al. "Hemorrhagic infarct conversion in experimental stroke." Annals of emergency medicine 21.2 (1992): 120-126.

Rosso, Charlotte, et al. "Intensive Versus Subcutaneous Insulin in Patients With Hyperacute Stroke Results From the Randomized INSULINFARCT Trial."Stroke 43.9 (2012): 2343-2349.

Gilmore, Rachel M., and Latha G. Stedd. "The role of hyperglycemia in acute ischemic stroke." Neurocritical care 5.2 (2006): 153-158.

Wrotek, Sylwia E., et al. "Treatment of fever after stroke: conflicting evidence."Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy31.11 (2011): 1085-1091.

Poca, Maria Antonia, et al. "Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? Clinical article." Journal of neurosurgery 112.3 (2010): 648-657.

Llinas, Rafael H. "Ischemic stroke and ICU care." Seminars in neurology. Vol. 28. No. 5. 2008.

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

Wang, Xia, et al. "Magnitude of Blood Pressure Reduction and Clinical Outcomes in Acute Intracerebral Hemorrhage Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial Study." Hypertension (2015): HYPERTENSIONAHA-114.

Arima, Hisatomi, et al. "Optimal achieved blood pressure in acute intracerebral hemorrhage INTERACT2." Neurology 84.5 (2015): 464-471.