How is stroke care changing for patients with ischemic stroke?
Why is Stroke Care Changing?
After years of following the same routine medical care, recent developments in scientific research surrounding stroke clients provide an alternative.
We have to follow the newest evidence surrounding stroke care to give patients the best possible outcome. Safe medical care is guided by using quality evidence-based research, and stroke care is no different!
What are the important definitions for stroke?
Ischemic stroke occurs when the blood flow to the brain is blocked by something, usually a clot.
Hemorrhagic stroke is when a weakened blood vessel ruptures in the brain.
Computed tomography (CT) is the radioactive imaging studies that evaluate the extent of the bleeding.
Tissue plasminogen activator (tPA) is an IV medication known as a clot buster. It will destroy any clots occluding blood flow to the brain. It is given to patients who have confirmed ischemic stroke by a CT.
What is current stroke care?
If an ischemic stroke is suspected, a CT is done to ensure that it is not a hemorrhagic stroke.
A patient with a diagnosed ischemic stroke is given tPA through their IV.
Routine computed tomography (CT) imaging traditionally occurs 24 hours later to evaluate the bleeding.
Recently, scientists are wondering how necessary it is to perform a repeat 24-hour CT in stroke patients. Routine repeat imaging in patients rarely changes the plan of care for those who are stable.
The Study: Routine Neuroimaging After Stroke
The benefits of routine CT scan in ischemic stroke patients who received tPA was examined.1 The results showed that stroke patients whose National Institute of Health Stroke Scale (NIHSS) score has a baseline of less than ten and remains stable are unlikely to have any effects by routine imaging.
The purpose of the repeat CT scan is to evaluate stroke patients for overall risk of cerebral hemorrhage. No patient with an NIHSS score of less than ten experienced a brain hematoma on the routine repeat imaging without first becoming unstable.1
This study of post-acute ischemic stroke patients who received tPA determined that routine repeat neuroimaging is not necessary for clinically stable patients. This will decrease excessive radiation exposure and minimize medical costs.
The Details: Neuroimaging After Stroke
This study analyzed patients who were admitted to Tulane Medical Center and seen by the Neurology Department between 2008 and 2011. In order to be included in the study, patients had to have a documented 24-hour NIHSS score and tPA therapy.1 The repeat CT scans were reviewed by a specialist.
Patients were divided into two groups:
- those whose 24-hour NIHSS score remained the same from baseline
- those that worsened after admission.
What does the study show?
The study promotes nursing independence, minimize radiation exposure to patients, and decrease medical costs.
What does this mean?
- Nursing staff is able to identify clinically unstable stroke patients at the risk of a cerebral hemorrhage.
- By minimizing the exposure of the client to radiation, the medical staff is encouraging optimal health for patients who do not need an MRI.
- Finally, eliminating unnecessary and expensive imaging studies significantly decreases a client’s medical expenses.
What are the drawbacks of this study?
The weakness of this study is that it did not show how this new protocol impacts nurses. This study did not directly evaluate nursing staff and their reflection on this new data.
Nurse buy-in is SO important.
If staffing won't allow close observation of the patient to catch signs of stroke, this entire protocol will fail.
A client with an acute ischemic stroke diagnosis who had been given tPA has several options regarding neuroimaging.
Currently, data shows that routine and repeat 24-hour CT imaging to evaluate for a brain hemorrhage may not be needed as long as nurses are vigilant while watching over their clients.
In the case of a client becoming clinically unstable or their NIHSS score worsens, it is imperative that the nurse reports the situation to the appropriate provider.
George, A. J., Boehme, A. K., Dunn, C. R., Beasley, T., Siegler, J. E., Albright, K. C…Martin-Schild, S. (2015). Trimming the fat in acute ischemic stroke: An assessment of 24-h CT scans in tPA patients. International Journal of Stroke, 10(1), 37-41. doi: 10.1111/ijs.12293.
© 2018 Caitlin Goodwin