Emergency Medicine Forum

A 55 y/o male presents with generalized weakness right > left, which started 15 min prior to arrival.  He has a history of CVA with mild R sided weakness (he could walk independently) from a few years ago. History is limited as patient is vomiting during evaluation, and some dysarthria is noted. No family is available. Family dropped patient off, and gave some history to triage (onset of symptoms), but now can’t be found.

PMH:  Hypertension, previous CVA. No diabetes or cardiac disease.
Meds:  BP pill
PE:  VS:  97.8F, RR=18, HR=75, BP=204/108.
HEENT: Eyes deviated to left, speech dysarthric, Complete Hemianopia is noted.
Minor facial paralysis also noted. 
Heart:  RRR
Lungs:  Normal
Abd:  Unremarkable
Ext:  Negative
Neurologic:  Alert and Oriented to person, place and time
Cranial nerves: Eyes deviated to Left
Sensation:  Some decreased perception of sensation on right is noted
Motor:  No motor deficits appreciated
Reflex:  Normal
Cerebellar Exam:  Normal
NIHSS score=8

Questions:

1. Should you lower the blood pressure?  What if the patient has a bleed?

This is an interesting question.  Clearly, the blood pressure will need to be lowered before the patient would be a TPA candidate.  And, if the CT showed a bleed, the blood pressure may need to be lower also.  Unfortunately, there is little evidence regarding the ideal target blood pressure in either ischemic or hemorrhagic stokes. 

Ischemic Strokes: 
Before TPA, the blood pressure should be 180/110 or lower. However, in ischemic strokes, if you lower the blood pressure to much, you can hypo-perfuse the ischemic area making the stroke worse.  Additionally, studies suggest the blood pressure in patients with ischemic strokes may spontaneously decrease with out treatment. (1)  The appropriate treatment of arterial hypertension in the setting of acute ischemic stroke remains controversial.  The best information available (based on consensus after review of all available data) suggests

1) Antihypertensive treatment should initially be withheld in acute ischemic stroke patients NOT candidates for TPA unless the diastolic blood pressure is >120 or systolic blood pressure is >220. (1)  Many of these patients may decrease their blood pressure spontaneously.

2) In patients who ARE candidates for TPA, the blood pressure will need to be lowered to <185/110. (1)

Reference #1 is entirely available on line, and gives great advise on numerous ischemic stroke controversies. (1)

Hemorrhagic Strokes (Intracranial Hemorrhage (ICH)):

Blood pressure management in hemorrhagic strokes is also controversial, and the target blood pressure may need to be individualized based on baseline blood pressure, cause of hemorrhage, and presence of increased intracranial pressure (ICP).  Patients with ruptured aneurysm or arteriovenous malformation have the highest risk of continued bleeding or re-bleeding.  Although conclusive information is not available, the American Heart Association suggests the following treatment guidelines for hypertension in the setting of ICH (2): 

a. If SBP is >200 mmHg or MAP>150mmHG, then CONSIDER aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure checks every 5 minutes.
b. If SBP is >180 mmHg or MAP is >130 mmHg, AND evidence or suspicion of increased ICP, then consider medications to keep cerebral perfusion pressure >60-80 mmHg.
c. If SBP is >180mm Hg or MAP is >130 AND there is NO evidence for increased ICP then consider a modest reduction of blood pressure (target of MAP of 110 or 160/90).

A great summary of current evidence and consensus suggested management of patients with hemorrhagic strokes is available on line from the American Heart Association at reference #2 link.

2. Which is worse, hemorrhagic stroke or ischemic stroke?  Which is more common?

Hemorrhagic strokes are not as common as ischemic strokes (they make up 10% of all strokes).  (4).  Hemorrhagic strokes have a higher mortality risk (1.56 ) compared to ischemic strokes, but the risk is time-dependant (risk of death in hemorrhagic stroke compared to ischemic stroke was 4 fold initially, 2.5 fold after 1 week, and after 3 months, stroke type did not correlate to mortality).(4)

3. Which locations of strokes are most common?

In one case controlled study (5), for Ischemic strokes, 47% were anterior circulation, 13% were partial anterior circulation, 23% were lacunar infarcts, and 9% were posterior infarcts.  For Hemorrhagic patients, 56% were deep hemorrhages, and 44% were lobar hemorrhages. 

Outcome:
CT revealed a pontine bleed.  Patient was given labetalol and blood pressure was controlled at 160 systolic.  (He was also given an anti-emetic which also helped lower blood pressure.)  He was admitted to the ICU overnight, and as he continued to improve, was discharged a few days later with improved neurologic status to complete outpatient rehabilitation.

References:
1. Guidelines for Early Management of Adults with Ischemic Stroke.  AHA/ASA Guideline.  Stroke, 2007; 38:1655.  Entire manuscript available at: http://stroke.ahajournals.org/cgi/content/full/38/5/1655
2. Broderick J, Connolly S, Feldmann E, Hanley D, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults:  2007 Update: A Guideline from the American Heart Association/American Stroke Association.  Stroke 2007; 38; 2001.  Available at: http://circ.ahajournals.org/cgi/content/full/116/16/e391#TBL2183689
3. Nassisi D. Stroke, Hemorrhagic. Emedicine, Dec21, 2009. Accessed at: http://emedicine.medscape.com/article/793821-overview
4. Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard P.  Hemorrhagic and Ischemic Strokes Compared. Stroke 2009; 40:2068.  Abstract available at: http://stroke.ahajournals.org/cgi/content/short/40/6/2068
5. Paolucci S, Antonucci G, Grasso MG, et al.  Functional outcome of Ischemic and Hemorrhagic Stroke Patients after Inpatient Rehabilitation.  Stroke 2003; 34; 2861.  Entire manuscript available at: http://stroke.ahajournals.org/cgi/content/full/34/12/2861