By: Seethal Sara Thomas, FNP-BC
Stroke care has evolved over the past few decades with advanced research and technology to improve patient outcomes and determine best practices. The World Stroke Organization released the “Global Stroke Fact Sheet 2022” reasserting the most recent Global Burden of Disease from 2019 stating stroke as the second leading cause of death and the third leading cause of death and disability globally with an estimated cost of over $891 billion. Strokes can be categorized as hemorrhagic strokes or ischemic strokes. The World Stroke Organization estimates there are 12.2 million new strokes per year (Feigin VL, Brainin M, Norrving B, et al., 2022). Every 40 seconds, someone in the United States has a stroke and approximately 87% of all strokes are ischemic (CDC, 2023).
Ischemic stroke is either a thrombotic (issue with the blood vessel) or embolic (travelling clot from elsewhere in the body that blocks cerebral blood flow) event that causes a decrease of blood in the brain (Hui C, Tadi P, Patti L., 2022). Large vessel occlusions (LVOs) are considered one of the most devastating strokes in terms of morbidity and mortality. LVOs include occlusions in the internal cerebral artery, middle cerebral artery, anterior cerebral artery, and posterior cerebral artery. To improve patient outcomes, certified stroke centers need to abide by certain standardized evidence-based protocols (Waldman A, Tadi P, Khan Suheb MZ, et al., 2023). Due to the costly and quickly damaging effects of a stroke, the mantra now expressed with acute stroke response is “time is brain”. To put this into perspective, a 15-minute delay in thrombolytic therapy initiation is associated with decline in the likelihood of functional independence, surviving till discharge, accessing rehabilitation care, and avoiding symptomatic intracranial bleeding and the odds of the above outcomes decrease by 3-4% for every 15-minute delay. Each additional hour of delay in mechanical reperfusion is associated with reduced functional independence, increased morbidity, and diminished quality of life (Mathur, S., Fassbender, K., 2020).
The public is educated to detect the signs and symptoms of a stroke with the mnemonic FAST, or more recently, BEFAST. This stands for: F (facial dropping), A (arm weakness), S (speech changes), T (time to call 911!). The recent additions are B (Balance) and E (Eyes). High suspicion of stroke should be had when presentation is acute, sudden, focal neurologic deficit. (Hogge et al., 2023). The most common type of stroke is a middle cerebral artery (MCA) stroke. Stroke diagnosis is confirmed by magnetic resonance imaging, but to initiate life saving treatment, the treatment should be started based on appropriate, fast imaging modalities and exam.
Imaging gives information regarding the type of stroke, location, timing, and size/damage, and helps guide treatment and recovery. There are levels of stroke care capabilities across institutions. Thrombectomy Capable Stroke Centers and Comprehensive Stroke Centers can offer both thrombolytic therapy and mechanical thrombectomy if the patient is an appropriate candidate for those treatments. The two commonly accepted ways to transfer a patient to appropriate care are the “mothership” paradigm and the “drip and ship” pathway (Mathur, S., Fassbender, K., 2020). It is important to familiarize yourself with what stroke care is available in your area and what the institutional policy regarding this is. Different institutions have different policies on what imaging to obtain and when, but the most common imaging study initially obtained when a patient comes in with stroke symptoms is a non-contrast computer tomography (CT) of the head. Usually, a computer tomography angiogram of the head and neck follows. If the emergency services are trained, it is helpful for the hospital to get prenotification and well as a fingerstick and emergency stroke assessment in the field. As the patient is preparing to be sent to obtain imaging, the patient should be stabilized, labs should be drawn including another fingerstick at the facility, pertinent history should be assessed, and patient should also rapidly be assessed with a stroke scale. Pertinent history should always include the patient’s last seen well, whether the patient has taken any anticoagulant medication including last dose, baseline functional status, as well as any contradictions to thrombolytic therapy if the patient is within the treatment window. Ischemic stroke can present in specific syndromes and correlating the exam findings to the imaging studies allows for more accurate diagnosis and treatment plan. This is a simple but concise introduction to MCA symptoms. The MCA is the large terminal branch internal carotid artery (ICA) and divides into 4 surgical segments: M1, M2, M3, M4. The MCA supplies the lateral surface of the brain, most of the basal ganglia, and the posterior and anterior internal capsule. Since the MCA vessels supply a large portion of the brain, there can be a multitude of symptoms so when assessing stroke and it is imperative that the provider describe what is seen, not just what is expected to be seen. Classic MCA stroke presentation involves contralateral hemiparesis, contralateral facial paralysis, contralateral sensory loss where the contralateral lower extremity might exhibit some weakness and sensory loss, but the contralateral upper extremity and facial areas are more involved. Other symptoms include dysarthria, neglect, and aphasia where neglect and aphasia are two cardinal signs of stroke (Hui C, Tadi P, Patti L., 2022). Aphasia will be present if the language center while is on the opposite side of the dominant hand is affected. The other cardinal sign is vision, which can be seen in MCA strokes as gaze deviation and sometimes field cut, especially if the posterior circulation is affected. Some patients might present with confusion and inattention during an MCA stroke so although it’s important to describe what is seen, it’s also important to know what you are looking for, especially when conducting the rapid exam, and correlate exam findings to imaging (Hui C, Tadi P, Patti L., 2022).
MCA territory infarcts are the most common type of occlusion seen and it is important to act quickly to help the patient get potential treatment to decrease stroke burden. The goal of acute stroke treatment is revascularization. The goal of stroke work-up is to determine stroke etiology and uncover and manage risk factors to minimize likelihood of recurrent stroke. After discharge, based on symptoms, patients have stroke recovery including but not limited to physical therapy, occupational therapy, mental health management, speech therapy, and vision therapy. Stroke rehabilitation can be a long process with some days better than others. Quick intervention during the acute stroke phase is key to better outcomes.
References:
Centers for Disease Control and Prevention. (2023). Stroke facts. https://www.cdc.gov/stroke/facts.htm
Feigin VL, Brainin M, Norrving B, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. International Journal of Stroke. 2022;17(1):18-29. doi:10.1177/17474930211065917. https://journals.sagepub.com/doi/10.1177/17474930211065917
Hogge, C., Aroor, S., & Goldstein, L. (2023, March 11). Abstract number ‐ 65: US Comprehensive Stroke Center utilization of ... Stroke: Vascular and Interventional Neurology. https://www.ahajournals.org/doi/10.1161/SVIN.03.suppl_1.065
Hui C, Tadi P, Patti L. Ischemic Stroke. [Updated 2022 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499997/
Mathur, S., Fassbender, K. (2020). Time is Brain: The Prehospital Phase and the Mobile Stroke Unit. In: Peplow, P.V., Martinez, B., Dambinova, S.A. (eds) Stroke Biomarkers. Neuromethods, vol 147. Humana, New York, NY. https://doi.org/10.1007/978-1-4939-9682-7_18. https://link.springer.com/protocol/10.1007/978-1-4939-9682-7_18
Waldman A, Tadi P, Khan Suheb MZ, et al. Stroke Center Certification. [Updated 2023 Oct 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535392/ Assessed and Endorsed by the MedReport Medical Review Board