Acute Stroke Management :
Mnemonic Approach
Internal medicineNervous system
Last modified: Aug 28, 2019
Mnemonic: BRAIN ATTACK
a. Blood pressure:
Antihypertensives are
recommended only in following
conditions:
1. SBP >220 mmHg, DBP >120
mmHg or MAP >130 mmHg
(Target SBP reduction by 15% in
1st 24 hours)
2. End organ damage: Acute MI,
Aortic dissection, Hypertensive
encephalopathy, Severe left
ventricular failure
3. Candidates for thrombolysis:
SBP >185 mmHg and DBP >110
mmHg (Target: SBP ≤185 mm Hg
and DBP ≤110 mm Hg)
4. For patients with SAH:
Prehemorrhage blood pressure
or a MAP <140 mm Hg if the
baseline blood pressure is
unknown.
Drugs and dosing:
If parenteral agents are used,
labetalol or nicardipine is favored
because of ease of titration and
limited effect on cerebral blood
vessels. Sublingual nifedipine or
sublingual nitroglycerin is not
recommended because either
agent can produce a precipitous
drop in BP.
1. Labetalol 10-20 mg IV over 1-
2 minutes (may repeat 1 time)
2. Nicardipine infusion 5 mg/hr
titrated to maximum of 15 mg/hr
and when desired BP is reached,
reduced to 3 mg/hr
b. Respiration:
Supplemental oxygen: Only if
SaO2 <95% (Target SaO2 >94%)
c. Airway:
Airway management
If GCS <9: Intubate
d. Imaging:
Target door to CT scan
completion: 20 minutes
Target door to CT scan reading:
45 minutes
Emergent non-contrast CT head:
To detect Hemorrhages
(hyperdense in acute, isodense
in subacute) and Stroke mimics
The ABC/2 technique is a
quick and accurate method of
measuring ICH volume at the
bedside
Early ischemic changes
(within 3 hours): Hyperdense
artery sign (acute thrombus in
a vessle), sulcal effacement,
loss of insular ribbon, loss of
grey-white interface, mass
effect, acute hypodensity
Gross signs of infarction (6-12
hours): Hypodensity
MRI:
Can visualize ischemic infarcts
earlier and identify acute
posterior circulation strokes
more accurately
As effective as CT in
identifying ICH
e. Normoglycemia:
Glucose target: 140-180 mg/dl
If glucose >200 mg/dl: Use
sliding scale insulin or GKI
f. Antiplatelets or Aspirin:
TIA: Aspirin 75 to 325 mg PO
daily, Clopidoogrel 75mg PO
daily
Acute ischemic stroke: Aspirin
325 mg within 24 to 48 hours
1st 24 hours after rtPA: NO
ANTIPLATELETS
g. Temperature:
Target: 37.0°C±0.5°C (For
fareneheit – 32 + celsius X 18)
h. Thrombolysis (rtPA) for
ISCHEMIC STROKE:
Onset to rtPA: within 3 to 4.5
hours
Dose: 0.9 mg/kg (maximum 90
mg)
Bolus: 10%
Remaining: 90% over 60
minutes
Monitoring: Vital signs and GCS
need to be monitored every 15
minutes for two hours using
manual BP cuff; every 30
minutes for the next six hours;
hourly for the next six hours;
and four-hourly for up to two
days post-treatment.
Contraindications:
<1 week: Lumbar puncture,
Arterial puncture,
Anticoagulant use
<2 week: Major surgery or
serious trauma
<3 week: Active internal
bleeding (GI or GU hemorrhage)
<3 month: Intracranial
surgery, serious head trauma,
previous stroke, MI
>1/3rd: stroke size >1/3 of
cerebral hemispheres
SBP >185 mmHg and DBP
>110 mmHg
Platelets: <1,00,000/ml
Glucose: <50 mg/dl or >400
mg/dl
PT: >15 seconds
Seizure
Pregnancy
Hemorrhage in CT scan
For SAH: Nimodipine 60 mg PO 4
hourly and ICP reduction
techniques
i. Assess swallow, nutrition and
hydration:
Perform a bedside swallow
screen
If swallow screen failed
(drowsy/unsafe swallow), refer
to the speech and language
therapist
If the patient is nil by mouth,
prescribe intravenous 0.9%
sodium depending on the
patient’s state of hydration.
Avoid dextrose in the first 48
hours unless hypoglycemic
Consider modified diet or
nasogastric feeding at 24 hours
and refer the patient to a
dietician
j. Continence:
Indwelling catheters should be
avoided post-stroke because of
the risk of complications and
should only be used when other
options have failed
k. Keep uptodate with patient
positioning:
Head-end elevation to 30
degrees (decreases ICP, prevent
choking and aspiration)
Hypoxia inducing positions
should be avoided (left sided or
slumped in a chair)
