Notice! Confluence will be undergoing system maintenance on Mondays from 5pm to 7pm. During this time the system may be unavailable.

Child pages
  • Michigan Medicine Service Document for Stroke.
Skip to end of metadata
Go to start of metadata


The purpose of this document is to address common practical issues that arise in the day-to-day management of stroke patients at our institution. It is not all-inclusive and is intended to complement but in no way replace the stroke handbook.

 

  1. Members on the Acute Stroke Pager
  2. Finding a Bed
  • Important Stroke Activation Info
  1. Staffing
  2. Important Inpatient Orders and Documentation
  3. Additional Protocols
    1. Modified CHANCE/POINT (“CHOINT”)
    2. Pediatric acute stroke
    3. Acute monocular blindness protocol
  • Stroke Follow-Up at Discharge
  • Intracranial Bleeding




  1. Members on the BIG pager


  • Neurology residents
  • BIG team (fellows and attendings)
  • Inpatient and ED CT techs
  • ED pharmacy (note: not inpatient pharmacy)
  • 4A charge nurse
  • NICU charge
  • Some NICU attendings (Jacobs, Rajajee)
  • One NIR attending (Chaudhary)
  • Study coordinators potentially
  • Medical students



  1. Finding a bed

Let the 4A charge (pager 8761) know as soon as possible that we have a stroke admission needing a 4AS bed

 

What do I do if there is no 4AS bed?

  • Bump the bumpables
  • Admit to the ICU (especially if large infarct or post-IV tPA)
  • Low risk TIAs can go to the floor on telemetry


  • Important Stroke Activation Info

Visitors and Outpatients

  • If you receive a stroke page for a visitor or an outpatient, please ask the person paging to send the individual to the ED via the MOVE team.
  • This will call for security and transport (provided by SWAT nurses)

                   

  1. Staffing

 

BIG Attending Presence Policy

  • All stroke activation patients must be discussed in real time with stroke fellow or attending
  • Stroke attending may or may not choose to come in and physically evaluate the patient and help in-person with acute stroke process
  • If resident on-call is uncomfortable with anything associated with the exam, workup, or treatment, he or she should call the stroke attending/fellow with a request to come in and physically evaluate the patient at any time, 24/7
  • Stroke attending is available to help with verbal consent of IV tPA treatment by phone or in person if the resident would like assistance


Staffing Stroke Activations

  • Brief ED and inpatient deactivation notes can go to the BIG attending on call. The case must be discussed with the stroke attending or fellow.
  • Assume you are staffing the case with the consult attending or overnight attending unless the BIG attending asks you to send the H&P to him/her (feel free to ask the BIG attending if you should send it to him/her)
  • For stroke patients being admitted to Team A, you do not need to call the Team A attending to repeat the story you’ve already told to the consult attending (unless you want to)


What to do if the BIG attending is not calling me back?

  • First page out to the BIG pager repeatedly asking for a call back, making it clear that the stroke attending has not called back
  • Second page the telestroke attending (90189) and see if he/she can help
  • Last resort: Start calling other stroke physicians
    • Mollie 802-238-4057
    • Cemal 734-323-3743
    • Jimmy 734-800-6259
    • Sadhana 210-363-9644
    • Joe 734-277-5999

 

Outside Facility Pages

  • Stroke attending on-call will respond to these pages and arrange for any necessary transfers
  • Residents are not responsible for returning these outside hospital pages
  • Please only respond to pages sent with a U-M callback number


 

  1. Important inpatient orders and documentation

 

  • Non-IV tPA patients need DVT prophylaxis and aspirin ordered on admission
  • IV tPA patients need DVT prophylaxis and aspirin to start 24 hours after receipt of IV tPA (unless documented contraindications)
  • Patients who have received IV tPA or mechanical thrombectomy need a Day 2 NIHSS
    • Use the Day 2 Assessment tab in the Stroke Navigator
  • Order PT/OT on admission unless the patient has returned to normal, and then document “PT/OT not indicated given no relevant deficits”

 

 

  1. Additional protocols

 

  1. Modified CHANCE/POINT

 

The POINT and CHANCE trials both assessed short term dual antiplatelets after TIA or minor stroke. The two trials had slightly different eligibility criteria and treatment regimen.  Our stroke team has agreed on the following protocol that combines elements of CHANCE and POINT. 

  • has presented with stroke/TIA and is not an IV tPA candidate
  • has NIHSS score ≤ 3 if symptomatic or ABCD2 score ≥4 if TIA
  • is able to start medications within 24 hours of last known well
  • does not have isolated numbness, isolated visual changes, or isolated vertigo/dizziness
  • does not have a planned need for anticoagulation
  • does not have an undue bleeding risk on dual antiplatelets
  • has passed a swallow screen or has been cleared for oral medications by SLP


Then would treat with:

  • Day 1: Clopidogrel 300mg x 1 and Aspirin 325mg x 1
  • Day 2-30: Clopidogrel 75mg daily and aspirin 81mg daily
  • Day 31-onward: Aspirin 81mg daily

 

  1. Pediatric
  • Pediatric neurology team will respond to any pediatric stroke activations
  • Patient should be staffed with the on-call pediatric neurology attending
  • Pediatric neurology attending can contact adult stroke attending if any further questions
  • Note: There are no definitive RCT data for acute management for patients < 18 years

 

  1. Acute monocular blindness protocol

 

This protocol is designed for ED patients with a single (non-recurrent) episode of transient monocular blindness (TMB), central or branch retinal artery occlusion (CRAO or BRAO), or non-arteritic ischemic optic neuropathy (NAION). Patients with one of these conditions may be discharged from the ED without observation or inpatient admission if all of the following criteria are met:


TMB/CRAO/BRAO

  1. Neurology is able to see the patient and leave recommendations in an expedited fashion
  2. Hemoglobin A1C and lipid panel are collected. (A non-fasting lipid panel is acceptable)
  3. Ipsilateral carotid < 50% stenosis by doppler, CTA, or MRA
  4. TTE (bubble study not necessary) without concerning valvular abnormality or EF < 30%
    1. May order TTE as “TIA protocol” to expedite completion and read
  5. Reassuring ESR/CRP
  6. Aspirin and a statin initiated on discharge and documented
  7. Documentation that patient has no PT/OT needs and there is a safe discharge plan in light of any new visual field deficits
  8. Stroke education provided and documented
  9. Follow-up requested within two weeks with Dr. Deb Levine in Cerebrovascular Disorders Clinic
  10. Absence of a condition that puts the patient at high risk of recurrent stroke (e.g. moyamoya, mechanical heart valve, atrial fibrillation with subtherapeutic anticoagulation, etc.)


NAION

  1. Hemoglobin A1c and lipid panel collected
  2. Aspirin and a statin initiated on discharge
  3. Follow-up requested with either PCP or Dr. Deb Levine in Cerebrovascular Disorders Clinic


 

  • Stroke Follow-up at Discharge

 

  • Straight-forward post-stroke patients à F/u with stroke NP, Jessie Roberts
  • Follow up BP, ACT results, lipid control
  • Patients with imaging to review or higher-level decisions à follow up with stroke attending/fellow
  • Stroke Bridge Clinic
    • Deb Levine is an internist who has a post-stroke medicine clinic to address uncontrolled diabetes, hypertension, cardiac disease prior to stroke clinic f/u
      • She is not able to serve as the long-term PCP, but can provide short term care until the patient is seen by their PCP



  • Management of Intracranial Bleeding
    1. Primary ICH (SAH, SDH, IPH)
      1. Discuss with neurosurgery
    2. Asymptomatic hemorrhagic transformation of an infarct
      1. Discuss with your attending (and a stroke attending if desired)
      2. Do not consult Neurosurgery.
    3. Symptomatic hemorrhagic transformation of an infarct
      1. Discuss with the NICU attending on call (and a stroke attending if desired)
      2. Depending on the severity of the hemorrhage, reversal agents may be indicated
  • Do not consult Neurosurgery.
  • No labels