A 69 y/o male, previously healthy except for a history of HTN, presents with an acute episode of dysphasia and right arm and leg weakness. His family noted his slurred speech 40 minutes ago while sitting in a chair, and when he went to stand up, he was unable to bear weight on his right side. His NIHSS (National Institute of Health Stroke Scale) score is 15. BP is 150/80, pulse of 85, and RR 18. He is afebrile.
1. How is the NIH stroke scale score calculated? What does the number mean?
At our hospital we have a copy of the scale with a description of the scoring system attached to our stroke pathway so it is easy to calculate. It is also available in most hand held computers. For a detailed explanation, see the first link below. The first few times you attempt to calculate this, you may feel like you are stumbling through it, but the more you use it, the easier it becomes. It’s important to calculate the NIHSS, and document and time this in the ED record. Significant and rapid improvements in this score are a relative contraindication to TPA. Additionally, TPA is not given in very low (3 or less) as the risk of bleeding may outweigh the benefit (patient doesn’t have that significant of a deficit). Many consider a very high score also a contra-indication (> 22 score). This is because the risk of bleeding is increased in patients with higher scores (it is a larger volume stroke).
2. Should you give Aspirin?
No Aspirin is given in the first 24 hours if the patient receives TPA. If the patient is not a candidate for TPA, and there is no bleeding (or other contraindication), Aspirin is indicated. The International Stroke Trial (IST) found that Aspirin produces a reduction of 10 deaths or recurrent strokes per 1000 patients in the first few weeks after a stroke (see first link). The second link below has all the contra-indications to TPA. The third link is a nice review of emergency management of stroke (including blood pressure recommendations).
3. If this patient receives TPA, and then suddenly deteriorates neurologically, what do you do?
If you suspect an intracranial bleed, the NINDS (National Institute of Neurological Disorders and Stroke) recommends the patient have immediate PT, PTT, platelet count, type and screen, and fibrinogen levels done. While awaiting for the stat CT, the NIINDS also recommends thawing 6-8 units of cryoprecipitate (containing factor VIII) and prepare 6-8 units of platelets for administration, depending on the results of the lab work. An emergent neurosurgical consultation, and hematology consultation is also recommended. (See link below for algorithm).