Stroke and Neurodegenerative Disorders Stroke and Neurodegenerative Disorders: 1. Stroke Management in the Acute Care Setting Cara Camiolo Reddy, MD, Alex Moroz, MD, Steven R. Edgley, MD, Henry L. Lew, MD, PhD, John Chae, MD, Lisa A. Lombard, MD Objective: This self-directed learning module highlights management of stroke in the acute care setting. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on initial assessment and management of acute ischemic and hemorrhagic stroke, descriptions of posterior circulation and lacunar stroke, and criteria for admission to acute inpatient rehabilitation after stroke and secondary stroke prevention. The goal of this article is to improve the learner’s ability to identify, treat and manage a patient with a stroke in the acute care setting. 1.1 Clinical Activity: A 65-year-old woman presents to the local hospital’s emer- gency department with a 2-hour history of right hemiparesis. Describe the initial assessment and management of acute stroke. Identify causes of acute mortality. Management of acute stroke necessitates timely organized care from all members of the care team. Response time is critical in the initial treatment of stroke; therefore, educational campaigns directed at the lay population have focused on the awareness of stroke symptoms and the need for quick response. Despite these efforts, less than 10% of patients with acute strokes arrive at the emergency department within 1 hour after stroke and less than 25% arrive in fewer than 3 hours [1]. The designation of medical centers as specialized stroke centers has improved delivery of care; however, the specialized services these centers provide are often limited to large academic settings. For example, recombinant tissue plasminogen activator (rt-PA), a now well-established treatment of ischemic stroke more commonly known as TPA, is given more frequently to patients at academic centers than nonacademic hospitals. Telemedicine technology, developed in response to these treatment barriers, is emerging as an effective way to extend stroke care into rural areas and small, community-based hospitals [2]. Any acute change in neurologic status warrants rapid assessment of the ABCs (Airway, Breathing, Circulation) upon arrival of the medical care team. Ensuring airway protection and adequate ventilatory support is critical. Cardiac assessment should include determina- tion of cardiac rhythm, blood pressure (BP) and pulse. Vital signs are measured to assess for fever, high BP, or irregular heart rhythm. Cardiovascular physical assessment and electro- cardiogram should be performed and cardiac monitoring should be done in all stroke patients for the first 24 hours, since cardiac abnormalities can both lead to and result from stroke. Evaluation of a patient with acute onset hemiparesis begins by determining that the symptoms are not due to a different neurologic disorder. A detailed history is imperative, including specific questions regarding onset of symptoms; recent events such as myocardial infarction (MI), stroke, trauma, or surgery; presence of comorbid diseases such as hyper- tension (HT) and diabetes mellitus (DM); and the use of insulin or anticoagulants. When assessing patients for possible treatment with thrombolytics, the time the patient was last observed to be symptom-free is assumed to be the time of onset. After historical details are obtained, a physical examination should be performed. The neurologic examination is one of the best predictors of stroke severity and it should be C.C.R. Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, 3471 Fifth Ave, LKB Ste 201, Pitts- burgh, PA 15213. Address correspondence to: C.C.R.; e-mail: camioloce1@upmc.edu Disclosure: nothing to disclose A.M. NYU School of Medicine, Rusk Institute of Rehabilitation Medicine, New York, NY Disclosure: 2, IPRO S.R.E. University of Utah, Salt Lake City, UT Disclosure: 2, Northstar Neuroscience H.L.L. Harvard Medical School, VA Boston Healthcare System, Physical Medicine and Rehabilitation Service, Boston, MA Disclosure: nothing to disclose J.C. Case Western Reserve University, Metro- Health Medical Center, Department of Physical Medicine and Rehabilitation, Cleveland, OH Disclosure: nothing to disclose L.A.L. Santa Clara Valley Medical Center, De- partment of Physical Medicine and Rehabili- tation, San Jose, CA Disclosure: nothing to disclose Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org PM&R © 2009 by the American Academy of Physical Medicine and Rehabilitation 1934-1482/09/$36.00 Suppl. 1, S4-S12, March 2009 Printed in U.S.A. DOI: 10.1016/j.pmrj.2009.01.015 S4