Acute CVA Answers

1. An 86 y/o male PMH CAD, DM presents with new left sided weakness, and slurred speech. Stroke team has evaluated pt and reports he is not a candidate for tPa. Which of the following is true? *

The patient should be made NPO until a swallow evaluation.

The patient should be given 325mg ASA PO stat.

The patient should be placed on treatment dose of heparin.

Permissive hyperglycemia is important to prevent further damage from the acute CVA.

None of the above.

Discussion: This is an error that clinicians often make: write NPO yet then write for ASA PO stat! Any CVA patient who reports any difficulty with speech or has any facial weakness must be made strictly NPO until after their swallow evaluation. This includes ASA! Remember, ASA in the right main stem bronchus does not do anyone any good!
The above case is a common occurrence. For a variety of reasons a patient is unable to receive tpa from our outstanding stroke team. Remember though that the guidelines for who get treatment changes often and our stroke team is often part of very large trials, so always call the stroke team for any acute stroke! Do not rule out intervention on your own! Discuss the case with the stroke team, and let them decide if they should come in to see the patient to evaluate further or not. This should be done ASAP. Do not finish your H&P and then call.
Unfortunately, even with the outstanding stroke team here in cincinnati, many of our patients are not eligible for treatment. These patient should be given ASA stat (Per rectum if NPO), and admitted. Heparin is NEVER indicated for acute CVA, even when a cardio-emoblic event is suspected. When you look at the data, the risk of bleeding into the acute cva outweighs the risk of recurrent CVA (Acute CVA with Atrial Fibrillaton).
Hyperglycemia has actually been shown to worsen outcomes in an acute CVA (Acute CVA Review Article). It has not been shown that tight control is helpful, but it is assumed based upon data that out of control hyperglycemia is bad. Make sure the nursing staff has been communicated with and understands that despite the pt being NPO, they should be given their insulin. One general guideline is to give 5 units of Lantus SC for every 1 Liter of D5 a patient will receive in the next 24 hours. This is a starting point, but be careful with frail, thin elderly who may need much less. Hypoglycemia is also bad!

2. You have finished up most of your orders and are reviewing them. Which of the following orders should be changed? *

Fragmin 5000 units sc daily.

Out of bed to chair tid.

NPO except meds.

Post void residual x 1. Call if over 200ml.

None of the above. All of these are great!

Discussion: Following an acute CVA, our job is to prevent complications while also preventing progression of the CVA. DVTs, aspiration, delirium, urinary retention, pneumonias, skin breakdown, and increasing size of CVA are all important to prevent. While treatment dose of heparin is contraindicated, all patients with a CVA must be on DVT prophylaxis. Fragmin (or lovenox) is the drug of choice, but sc heparin would also be acceptable if LMWH is contraindicated. With only a few exceptions, no patients should be admitted to the hospital with bed rest. It is vital to get post-cva patients out of bed and moving. This helps prevent de conditioning, aid in the recovery, and prevent skin breakdown.
Following a CVA, patients can develop urinary retention. If the patient is elderly, their method of relaying that they have urinary retention may simply be that they get delirious! Most patients with a cva should have a post-residual checked.

3. The above patient passes his swallow evaluation. On reviewing his medications, it is found he is on lisinopril, metoprolol, and asa. Which of the following is true? *

The patient should be started on clopidogrel in addition to the asa.

The patient's blood pressure medications should be held unless his bp goes over 220/110.

The patient should be continued on asa.

Aggrenox (asa with dipyridamole) has been proven to be superior to clopidogrel.

None of the above.

Discussion: Secondary prevention for CVA is very important, even in the inpatient setting. Secondary prevention consist of anti-platelet medications such as asa, clopidogrel, or aggrenox, along with blood pressure and statin modification. The question of which anti-platelet agent is best has still not been answered.
Here is what we know:
1. ASA works very well.
2. Aggrenox (asa and dipyridamold) and clopidogrel probably work better than ASA (ESPS-2 and ESPRIT; CAPRIE Trial).
3. Clopidogrel is not inferior to Aggrenox (Aspirin and Extended-Release Dipyridamole vs Clopidogrel)
That is what we know. Take home points for someone with a CVA: If someone is not on ASA and has a CVA, start ASA (325 acutely, then 81mg daily). If they are already on ASA, stop asa and start clopidogrel. Careful with aggrenox due to side effect of HA, which is common, contraindication of CAD, and the cost. Now to the answer!
What about the combination of ASA and clopidogrel? While it does appear that the combination does prevent more ischemic events, it causes an equal number of hemorrhagic events (MATCH-ASA and clopidogrel.pdf)! For this reason, ASA and clopidogrel (plavix) should not be given together unless for drug eluting stents.
Acutely after a stroke, it appears that pts do worse if they are hypotensive. While the brain is beginning to heel, it is recommended to practice permissive hypertension. For the first 3 days, the recommendation is to hold BP medications unless the BP goes over 220/110. We actually individualize this recommendation a bit. We want the pt’s BP to run higher than their baseline. If they are typically in the 120’s, then I don’t let it go over 180’s. If they are typically in the 160-170’s, then I follow this guideline. After 3 days, the BP medications can slowly be re-introduced. It is very important to let the pt and family know that we want the BP higher acutely, along with the nursing staff.

4. Shortly after the admission, the above patient goes into Atrial Fibrillation. After 20 minutes he goes back into sinus. The patient reports palpitations with the a. fib and states he has been having this for several weeks. Which of the following is true? *

The patient should be started on fragmin 100units/kg sc q12 hour.

The patient should be started on weight based heparin.

The patient should have a TEE. If a thrombus is shown, heparin should be started.

Long term, this patient should be on warfarin and asa.

None of the above.

Discussion: As written above, even when the etiology for a CVA is felt to be cardioembolic, treatment dose heparin or LMWH is contraindicated acutely (Acute CVA with Atrial Fibrillaton). The risk of bleed outweighs the potential repeat CVA. What is not known is how long to hold anticoagulation. Generally, the goal is to hold it while the vessels in the area of the CVA are healing. For small strokes, this can be for a few days. For a large, massive CVA, then perhaps 7-10 days. Again, this question has not been answered.
Despite ASA working very differently than warfarin, the combination does not add any benefit in preventing CVAs or AMIs. ASA in addition to warfarin only adds increased risk (Using Warfarin with Aspirin) of bleed. This is surprising due to the differences in mechanism along with different mechanisms for CVA/CAD vs embolic events. There are exceptions we do make: drug eluting stents (DES) with the need for anticoagulation. The risk for thrombosis for DES without anti platelet medication is too high.

5. A 87 y/o female with PMH of DM, CAD, HTN presents with new onset left sided weakness. She unfortunately is not a candidate for tPa. A non-contrast CT scan is negative and she is admitted to the hospital for an acute CVA. Which of the following should be ordered? *

Transthoracic echo (TTE) without bubble, carotid dopplers, and MRA of head and neck.

TTE with bubble, carotid dopplers, and MRI of head.

TTE without bubble, MRA of neck, and MRI of head.

Carotid dopplers and MRI of head.

TTE without buble, MRI of head, and carotid doppler

Discussion: The work-up following an acute cva should be focused on identifying the reversible causes. These include carotid artery stenosis and embolic disease. Traditionally, echos have been ordered on everyone who presents with an acute CVA. The question must be asked, what are we looking for?
If the answer to this question is a thrombus, then a transthoracic echo is not sufficient, and either TEE or a CT of the chest is necessary. If the answer is a patent foramen ovale, then again, a TTE is not sufficient. So, if we want to answer this question we can’t stop at just a TTE, but must proceed to a TEE. Clearly, we do not wish to do that on everyone. So, we need to risk stratify whether the pt likely has an embolic source for their CVA. Please note though, we do start with a TTE, because if positive it would save a TEE. The take home message is that if you are going to go look, you can not stop until you have gotten a TEE.
Young patients (<50) and patients without any other risk for atherosclerosis would fall in this category. A 45 y/o who has DM, HTN, and already CAD with a new CVA likely just has atherosclerosis. There would not be any reason to search for an embolic cause, therefore no need for an echo. In the same way, a 55 y/o very healthy individual who does not have any family history maybe a different situation, especially if the MRI shows multiple scattered CVAs. Who gets an echo: those who we need to r/o an embolic source on. If we are to get an echo, we must be prepared to go all the way to a TEE.
What about evaluating for carotid artery stenosis? The most cost effective method is obtaining a carotid duplex. Lastly, what about a MRI of the head? This is a topic that can be debated. The recommendations are to obtain a MRI, and it will be expected from the patient. The reality is that it is very unlikely to change your management. In an elderly patient with a new CVA, rarely would I recommend a MRI. In a younger patient, absolutely because if it shows atherosclerotic disease then it will save the patient a TEE. You are not wrong getting a MRI for every stroke patient, although you maybe overusing resources.
The best answer in this case is "Carotid dopplers and MRI of the head". An echo is not necessary in this case because we are not suspicious for a paradoxical stroke or thrombus. This patient has multiple risk factors and is also elderly. The patient does need evaluations of her carotid arteries, with the most cost effective method being the duplex. It could be argued that this patient does not need a MRI, but it is also not wrong to order a MRI.