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Ep3: Stroke 101 (Ischemic vs Hemorrhagic Stroke)

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This podcast covers Ischemic vs Hemorrhagic Stroke and discusses some of the current treatments and difference between these two types of stroke.

PODCAST TRANSCRIPT:

Welcome to the NRSNG Podcast number two, Stroke 101. As always, this podcast is meant for educational purposes. It shouldn’t be used in a clinical decision making.

 

So I just want to briefly discuss the basics behind stroke and some of the current practices and everything behind stroke. So what is stroke? So stroke essentially is a lack of oxygen delivery to the tissues, basically meaning that blood flow is interrupted or altered to the brain.

 

There are two classifications of stroke. There’s ischemic stroke and hemorrhagic stroke. Within those different classifications, I mean there are multiple types of hemorrhagic stroke. You can have a bleed in many different areas of your brain. You can have subarachnoid hemorrhage and intracranial hemorrhage. You can have bleeding within different regions inside the brain that will affect different aspects as a person begins to recover.

 

So for example, you can have a bleeding in the pons area, bleeding in the basal ganglia and I’m just – basically an area in the brain can bleed and the mortality and the effects that that person will experience will vary depending on where their bleed is. That’s a discussion for another time.

 

There’s ischemic stroke. Ischemic stroke is basically a clot or blood flow is impeded to a specific area of the brain. The most common location for ischemic stroke is the MCA and that’s the middle cerebral artery and that happens to be the place that is most commonly occluded with ischemic strokes.

 

So the majority of people that experience stroke actually have an ischemic stroke. Ischemic strokes make up about 80 to 85 percent of all strokes that people experience every year, with hemorrhagic strokes being only about 15 percent.

 

Now there are a few things that will exclude someone from being diagnosed as a stroke. We call those the three Ts. That’s trauma, tumor, and table.

 

So basically that means if the bleeding within their brain is caused or the occlusion within their brain is caused by trauma, the falling off a ladder or something that – if the bleeding occurs due to that, that’s trauma and that excludes them from having the stroke diagnosis.

 

Table, that refers to surgery. If bleeding occurs within their brain or as a result of surgery, then we call that table and that excludes them from a stroke diagnosis.

 

The last one is tumor. If it’s a tumor that creates the oxygen delivery alteration within their brain, then that’s going to also exclude them. So trauma, tumor, table, those are the three Ts that exclude people from actually being diagnosed as a stroke.

 

  1. So you have someone that is an ischemic stroke. They come in. What are some things that are currently being done for those patients? If you think about it, within the brain, you have to have your blood flow to the brain. An ischemic stroke is an occlusion of artery.

 

So there are basically two things that can be done. You’re going to need to take out that occlusion or you can bust that occlusion up. So the things that are done are called embolectomies or you administer TPA.

 

Now embolectomy is actually a guide wire inserted through the groin all the way up into the cerebral arteries, to the location of the clot, and a little cage or wire mesh net is passed over the clot and it actually retrieves that clot and pulls it out.

 

The goal with that – and that’s done in interventional radiology and the goal with that is to regain perfusion to the brain once that clot is actually removed.

 

The other option is TPA and that is administered to individuals. It’s called Tissue Plasminogen Activator and it’s given to people to break down blood clots.

 

So if someone comes into the hospital and they are exhibiting symptoms of an ischemic stroke, they can be a candidate for TPA administration. Now TPA, it’s a very potent medication. So it’s not appropriate for everyone and there’s actually about a 4.5-hour window of last known normal is what it’s called that TPA can be administered.

 

So from the last moment of the person was essentially normal, you really have only about 4.5 hours to administer that medication. Our biggest risk with TPA is going to be bleeding. As you break up that clot, of course TPA isn’t specific to just that one area and the brain that is occluded is going to – it’s going to be active throughout the entire body. So we really have to be careful as we administer that medication.

 

So there are a couple of things. We really want to administer it to people under the age of 80. We want to – so when someone comes in, they’re exhibiting signs of an ischemic stroke, weakness, hemiparesis, slurred speech. All those are signs of stroke.

 

The first thing they’re going to do is they’re going to send them over to CAT scan and the reason they send them to CAT scan is a bleeding within the brain will show up very rapidly on the CAT scan.

 

So once a person comes in with those signs of stroke, we try to determine if it’s ischemic or hemorrhagic. So we send them over to CAT scan, get a CT and if there is no bleeding within the brain, we begin to assume that it’s possibly an ischemic stroke. Now ischemic strokes do not actually show up on CT scan right away.

 

So we don’t really have that definitive diagnosis that it is a stroke. We just say that OK, they’re exhibiting stroke-like symptoms. We see no bleeding within the brain. Let’s continue on that line.

 

Another thing that you want to verify is that the person does not have low blood sugars, the confusion that somnolence and everything can be a sign of low blood sugar. So we check their blood sugar. Make sure it’s within appropriate range. We check the CT scan and the symptoms are still being exhibited. We continue to assume that it is a – it is due to the ischemic stroke.

 

So continue on down that pathway. Now prior to administering TPA, we check platelet count. We make sure it’s within appropriate range. We make sure the person hasn’t recently had a surgery or head trauma. Make sure they haven’t had a lumbar puncture and we just kind of make sure that we aren’t going to cause an additional problem by administering the TPA.

 

So a patient comes in. They’re ischemic stroke. We check their blood pressure. It’s 220 over 115. Now the reason for that is of course that the occlusion within the brain is requiring that the heart beat at a higher systolic pressure in order to perfuse the brain.

 

So prior to administering TPA, we generally keep patients’ blood pressure a little bit higher, over 200, 210, 220, systolically. Once TPA is administered, of course like I said earlier, we’re concerned about the risk of bleeding. So our goal with the systolic pressure is going to come down to about 185 just to prevent any further risk of bleeding. We just kind of lower that goal systolic pressure down a little bit.

 

We can do that with different medications to make sure that it stays below that level. But you really don’t want to take an ischemic stroke patient’s pressure down too low, because they do have that clot. We want to make sure that we continue to perfuse the brain.

 

So we administer the TPA. They’re taken up to the neuro ICU. We monitor them very closely. Vital signs are taken every 15 minutes. We perform our NIH which is basically a stroke scale to determine the severity of the stroke and we perform that every two – we perform that two hours after TPA administration and then we perform it every 12 hours for 48 hours and then on discharge.

 

It really is amazing to watch patients improve as the TPA – as the time passes, post-TPA. Now as I mentioned earlier, the biggest risk with TPA administration and ischemic stroke patients is going to be – is bleeding. Patients can actually have kind of a refractory hemorrhagic bleeding after the TPA. So we will administer the TPA. We will get repeat CT scans and within about 48 hours, 24, 48 hours, if we don’t see any signs of hemorrhagic stroke …

 

Podcast Transcription

Welcome to the NSRNG podcast, number 2: Stroke 101. And as always you know this

podcast is meant for educational purposes and shouldn’t be used in clinical decision

making.

I just want to briefly discuss the basics behind stroke and some of the current practices

and everything behind stroke.

So, what is stroke?

Stroke essentially is a lack of oxygen to the tissues basically meaning that blood flow is

interrupted or altered to the brain. There are two classifications of stroke: there's an

ischemic stroke and hemorrhagic stroke and within those different classifications there

are multiple types of hemorrhagic stroke. You can have a bleed in many different areas

of your brain; you can have a subarachnoid hemorrhage, an intracranial hemorrhage,

you can have bleeding within different regions inside the brain that will affect different

aspects as a person begins to recover.

For example, you can have bleeding in the pons area, bleeding in the basal ganglia, and

basically, any area in the brain can bleed, and the mortality and the effects that that

person will experience will vary depending on where there bleed is, and that’s a

discussion for another time.

There’s ischemic stroke. Ischemic stroke is basically a clot, or blood flow is impeded to a

specific area of the brain. The most common location for ischemic stroke is the MCA –

that’s the middle cerebral artery. That happens to be the place that is most commonly

occluded with ischemic strokes. The majority of the people that experience stroke

actually have an ischemic stroke. Ischemic strokes make up about 80% – 85% of all

strokes that people experience every year. With hemorrhagic strokes only being about

15%.

Then there’s a few things that will exclude someone from being diagnosed as a stroke,

and we call those the three Ts: trauma, tumor, and table. Basically, that means if the

bleeding within their brain or the occlusion within their brain is caused by trauma (falling

off a ladder or something of that), the bleeding occurs because of that, that’s trauma and

that excludes them from having a stroke diagnosis. Table – that refers to surgery if

bleeding occurs in their brain, or as a result of surgery, then we call that table and that

excludes them from a stroke diagnosis. And the last one is tumor. If it’s a tumor that

creates the oxygen delivery alteration within their brain, then that’s also going to exclude

them. So trauma, tumor, table – those are the three T’s that exclude people from actually

being diagnosed as a stroke.

Okay, so you have someone that has an ischemic stroke, they come in, what are some

things that are currently being done for those patients?

If you think about it, within the brain you have to have blood flow to the brain. Ischemic

stroke is an occlusion of an artery and so there’s basically two things that can be done.

You can either take out that occlusion or you can bust that occlusion up and so things

that are done are called embolectomy or you administer TPA.

An embolectomy is actually a guide wire inserted through the groin all the way into the

cerebral arteries, to the location of the clot and a little cage or wire-mesh net is passed

over the clot and it retrieves that clot and pulls it out. That’s done in interventional

radiology and the goal with that is to regain perfusion to the brain once that clot is

actually removed.

The other option is TPA. It’s called tissue plasminogen activator and it’s given to people

to break down blood clots. If someone comes into the hospital and they are exhibiting

symptoms of an ischemic stroke, they can be a candidate for TPA administration. TPA is

a very potent medication, so it’s not appropriate for everyone. There’s about a 4 ½

window of ‘last known normal’ is what it’s called, that TPA can be administered. So from

the last moment that the person was essentially normally, you really only have about 4 ½

hours to administer that medication. Our biggest risk with TPA is going to be bleeding.

As you break up that clot, of course, TPA isn’t specific to just that one area in the brain

that is occluded. It’s going to be active throughout the entire body, so we really have to

be careful as we administer that medication.

There’s a couple things: we really want to administer it to people under the age of 80. So

when someone comes in and they’re exhibiting the signs of an ischemic stroke –

weakness, hemiparesis, slurred speech, all those signs of stroke, the first thing they’re

going to do is they’re going to send them over to CAT Scan. The reason we send them

over to CAT scan is that bleeding within the brain is going to show up very rapidly on a

CAT scan. So once a person comes in with the signs of stroke, we try to determine if it’s

ischemic or hemorrhagic. So we send them over to CAT scan, get a CT and if there is no

bleeding within the brain, we begin to assume that it’s possibly an ischemic stroke.

Ischemic strokes do not actually appear on CT scan right away so we don’t really have

that definitive diagnosis that it is a stroke. We just say that okay, they’re exhibiting

stroke-like symptoms, we see no bleeding in the brain, let’s continue on that line.

Another thing you want to verify is that the person does not have low blood sugars.

Confusion, somnolence, and everything can be a sign of low blood sugar. So we check

their blood sugar to make sure it’s within an appropriate range. Check the CT scan and

the symptom are still being exhibited; we continue to assume that it is due to an

ischemic stroke, so we continue down that pathway.

Prior to administering TPA, we check platelet counts, we make sure it’s within

appropriate range, we make sure the person hasn’t recently had a surgery or head

trauma, make sure they haven’t had lumbar puncture, and we make sure that we aren’t

going to cause an additional problem by administering the TPA.

A patient comes in, they’re ischemic stroke, check their blood pressure, it’s 220/115. The

reason for that is, of course, the occlusion within the brain is requiring that the heart beat

at a higher systolic pressure in order for it to perfuse the brain. Prior to administering

TPA, we generally keep patients’ blood pressure a little bit higher, over 200, 210, 220

systolically. Once TPA is administered of course, like I said earlier we’re concerned

about the risk of bleeding. So our goal systolic pressure comes down to about 185 just to

prevent any further risk of bleeding. We just kind of lower that goal systolic pressure

down a little bit and we can do that with different medications to make sure that it stays

below that level. But you really don’t want to take an ischemic stroke patients’ pressure

down too low because they do have that clot. We want to make sure that we continue to

perfuse the brain.

So we administer the TPA, they’re taken up to the neural ICU, we monitor them very

closely – vital signs are taken every 15 minutes, we perform our NIH which is basically a

stroke scale to determine the severity of the stroke and we perform that 2 hours after

TPA administration and then we perform it every 12 hours for 48 hours and then on

discharge. It really is amazing to watch patients improve as the time passes post-TPA.

As I mentioned earlier, the biggest risk with TPA administration in ischemic stroke

patients is going to be bleeding. Patients can actually have a refractory hemorrhagic

bleeding after the TPA. So we’ll administer the TPA, we’ll get repeat CT scans, and

within about 24 – 48 hours we don’t see any signs of hemorrhagic stroke bedside,

generally an MRI will be done to get a view of that ischemic stroke and things in the area

that we’re looking for. It’s called the penumbra and that’s kind of dead, dying tissue

within the brain and as time passes after a stroke, we’ll begin to see area that’s actually

affected. That’s kind of what we do with ischemic strokes.

If you go and do the embolectomy in interventional radiology, you’re going to want to

monitor the site where they insert into the groin. You’re going to want to monitor that for

hematoma because they do use a little bit of blood, they’re puncturing through a large

vein, so you’re going to want to make sure that there is no bleeding underneath the

tissue there. You’re also going to want to monitor distal pulses – make sure there are no

clots forming within the distal portions to that insertion site.

With hemorrhagic stroke, there’s a couple different options. You’re going to want to

obviously maintain the pressure just a bit lower because you have that active bleeding

occurring within the brain. If the patient comes in with an actual aneurysm, there’s two

options that we’ll discuss.

You have an aneurysm that is within the brain – it may be leaking. So there’s a couple

things you can do. One is interventional radiology again. Another, surgical. If they have

an aneurysm, you can go in the same puncture site that you would with TPA, however,

you’ll go in with what’s called coils. You actually feed the coil a little thin wire directly up

to the aneurysm site and the interventional neuroradiologist or the interventional

radiologist will insert tiny little coins within that aneurysm up into it. And depending on

the size will help them know how much coil to feed in there, and you just fill the entire

aneurysm outpouching there with these coils. And with time, that vein or artery will

actually heal and you’ll stop the bleeding there. Another option is to actually go in

surgically and clip the neck of the aneurysm, waiting for the vessel to heal again. So

those are kind of the two options with aneurysms.

For someone that has a coiling or clipping, we are going to be concerned about vasal

spasming. Basal spasming can occur due to low blood volume. You have blood loss,

now we’re concerned about low blood volume, so we will do something that’s called

triple H therapy. And what triple H does is an attempt to prevent the vasal spasming. So

what triple H therapy really does is what we do is we kind of take care of that aneurysm,

then post clipping or post coiling, we do this triple H therapy. That involves hypertension,

hypervolemia, and hemodilution.

You’ll see that all three of those are essentially aimed at the same thing, which is blood

volume and maintaining that blood volume a bit higher, to ensure that we have perfusion

through the area of the aneurysm repair.

Hypertension were going to actually – again, this is all post coiling or post clipping of

those aneurysms. After we do that, we’re going to actually look for a little bit higher blood

pressure. So we’re going to force blood through the cerebral arteries and make sure that

we’re getting that perfusion that we need.

Hypervolemia, we’re going to give them fluids, give them a little bit more blood volume

and ensure that there is ample volume within the arteries to perfuse.

Hemodilution we’re going to thin the blood out, help it flow very easily through the brain.

Those are the three things that are done post-clipping or post-coiling of an aneurysm.

Hypertension, hypervolemia, hemodilution. That is termed ‘triple H therapy’.

Now, these patients will be given a specific calcium channel blocker called nimotop or

nimodipine. What this calcium channel blocker does is it’s more specific to the cerebral

arteries and the goal is to prevent vasal spassiming. A lot of times you’ll see doctors

order this drug for 21 days, queue 4 hours. You just really want to make sure (it’s a PO

medication), so you want to make sure it’s not delivered through an IV. If your patient is

on OG or NG2 you want to make sure it’s delivered that way rather than through an IV.

This is generally a 21-day course of medication. This is usually what doctors will do in

this case and just to make sure we prevent any of that vasal spassiming. These patients

again will have repeat CT scans to ensure that bleeding hasn’t increased or picked up.

Those are really kind of the two types of strokes that we’re going to see in our neuro

patients and some of the therapies that can be done.

Really for ischemic stroke, which is generally about 85% of the stroke population, you’re

going to see embolectomies, or you’re going to see TPA administration. Of course,

there’s a lot of things to consider with this – how severe is the stroke, what’s the location,

what’s the condition of the patient. So with ischemic strokes, we’re talking about blood

clots or occluded arteries and the most common site is the middle cerebral artery and

we’re looking at either going in and pulling the clot out physically via interventional

radiology or administering TPA to actually break up that clot.

And then with hemorrhagic strokes which make up about 15% of the population or so,

we are looking at clipping or coiling that aneurysm, and that’s generally with our

subarachnoid hemorrhages and things like that, that are going to have these aneurysms,

that are going to be bleeding in there and so we’re going to go on and either coil that

aneurysm then interventional radiology or we are going to clip the neck of that aneurysm

and get rid of it. What happens is as that blood is getting into the cerebral space, it can

cause adjacent vessels to spasm, that’s called vasal spasming, and we really want to

prevent that after hemorrhagic stroke. So we are going to give a practice as triple H

therapy. And in a lot of cases which is hemodilution, hypertension and hypervolemia and

the goal of that is to prevent that vasal spasming – make sure the arteries are perfused

and everything. This is the goal of these procedures with ischemic and hemorrhagic

strokes.

Eventually, we’ll go into further detail about the types of hemorrhagic strokes, locations

and types of ischemic strokes and locations and what deficits we’re going to be looking

for and we’ll go further into the NIH stroke scale and different things like that. This is just

an overview, stroke 101, the very basics with what’s happening with stroke and some of

the treatment and care that you may expect to see within your patients.

Date Published - Oct 24, 2014
Date Modified - Jul 21, 2016

Jon Haws RN

Written by Jon Haws RN

Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.