The Stroke Unit & Stroke Investigations

1. The Stroke Unit &Stroke Investigations Diane Ames Imperial College, St Mary’s Campus April 2008

2. Format Stroke …. • Current drivers and background for change • Thrombolysis • London stroke services in future • Stroke investigations • How we manage our patients

3. The drivers!

4. “Faster access to better stroke care”NAO report 2005 Concluded • Treatment was a post-code lottery • Stroke - very expensive and very common • Key - rapid access to specialised services • Delays lead to  deaths/disability • Recognised the “abandonment” on discharge • Recognised need for higher priority

5. “Emergency response is generally lacking” • NAO 2005recommendations tPA ICH Better coordination LAS / Stroke teams ESD More acute treatments & early scans Increased Awareness Better Community supports

6. RCP 2006 Audit • Only 54% patients > 50% stay in SU • Too few stroke beds • Delays in transfers (into,through & out) • Few direct admissions (12%) • Delays in CT brain scans (42% only within 24 hours) • Patients managed on a Stroke unit had better results for all the key indicators

7. Key indicators RCP 2006n=13,625 • Screened for swallow disorder < 24 hours • Brain scan < 24 hours • Aspirin within 48hours • PT within 72 hours; OT within 7 days • Weighed, mood assessed • Anti-thrombotics ( AF) • Rehab goals documented • OT home visit (removed this round- 2008)

8. Delays: Stroke Onset to hospital(days) National Sentinel Stroke Audit 2006 0.9% patients took > 10days to be admitted

9. More significantly….. Stroke Onset to hospital admission (hours) RCP 2006 National Sentinel Audit

10. The main driver for all current developments December 2007 Treatment delays can result in 1.9 million neurons lost /minute

11. Awareness Prevention Carer involvement Acting on warnings Stroke- a medical emergency Stroke Unit quality Rehabilitation Community Supports Workforce issues Service networks National Strategy for Stroke2007 10 point action plan focussing on:

12. Hyper-acute treatments

13. Emergency stroke pathway • Suspect a stroke, ring 999 • LAS use pre-assessment tool (FAST) • Pre-alert “hyperacute” receiving hospital • “24/7 thrombolysis service available” • Stroke team available • Immediate scan / decision to treat • Transfer to SU • Stroke networks emerging to channel patients to receiving centres

14. LAS Validated tool • Use to triage to centre • Public awareness campaign

15. Ischaemic penumbra Penumbra Poorly perfused Core of infarction DEAD tissue Thrombus or embolism Ischaemic /poorly perfused brain cells may be saved from infarction by prompt treatment

16. Thrombolysis • rt PA i/v - on licence in Europe since 2002 • Patients meeting inclusion criteria are able to receive treatment < 3 hours of onset of event • ( 6 hours IST-3 – on trial 9-5) • 24/7 stroke service at Imperial ( SMH & CXH sites) • Highly effective (only 10 people need to be treated to prevent 1 becoming dead or disabled) • Risk of intracerebral / other haemorrhage

17. Evidence 1. NINDS rt-PA study (NEJM 1995;333(24);1581-7) • Showed improved outcomes but  risk of ICH 2. 2 major reviews a) Cochrane (18 trials, 5727 patients, 4 drugs: rtPA, SK, UK, rpUK) b) rt-PA pooled data(NINDS, ECASS , ATLANTIS) • Cochrane 2003 • Significant  in death & dependency O.R. 0.8 (95% CI 0.69%-0.93%) • Non Significant excess of deaths O.R 1.13 (0.86-1.48) • ‘The data…may justify the use of thrombolytic therapy’

19. ICH in SITS-MOST register • Obligatory register n= 6482 treated with rtPA • 3/12 mortality 11.3%(cf 17.3 % in RCTs) • ‘Symptomatic ICH’ = 1.7%(type 2 bleed, ↓NIHSS ≥ 4) • ‘Fatal ICH’ @ 24 hr = 0.3%(type 2 bleed → death @ 24 hr) • ‘Fatal ICH’ @ 7 days = 2.2%(any bleed → death @ 7 days) WahlgrenN et al Lancet 2007; 369: 275–282

20. SITS-MOST register • “Mortality rates in first 3 months were lower in SITS-MOST (11.3%) cf RCTs (17.3%)” • “Functional independence at 3 months was higher in SITS-MOST (54.8%) cf RCTs(50.1%)” • Concluded “The results of SITS-MOST confirm that routine use of alteplase within 3 hours of ischaemic stroke has a safety profile at least as good as that seen in RCTs”

21. NICE, June 2007 • ‘Alteplase is recommended for the treatment of acute ischaemic stroke’ • ‘within 3 hours of the onset of stroke symptoms’ • ‘Clinically and cost effective’ • ‘Healthcare organisations should ensure they conform to NICE technology appraisals’

22. Urgent CT Brain Scan when… • If GCS is reduced • If thrombolysis considered • If on aspirin,other anti-platelet agent • If on warfarin • If history of falls, especially H.I. & alcohol • Fever, meningism, fluctuating conscious level • If uncertain and ?other pathology • Otherwise all scanned <24 hours

23. CT brain scan • Will exclude haemorrhage - Acute infarcts are often NOT seen early - “normal” scan early does not exclude CI • The diagnosis of stroke is clinical…. • Evidence exists for early anti-platelet Rx • Occasionally will identify structural lesions

25. St Mary’s Risk Factor profile n=1112 patients Vulnerable population!

26. General stroke management-all • Full clinical assessment • Monitor coma scale,T, P, BP ,O2, BM • Rehydrate i/v (or po) after swallow screen • Catheter not routine • Thrombo-prophylaxis (TEDS) • Ideally direct admission • Feed early ( po or n/g) • Pressure relief

27. Medical • All assessed by Stroke SpR • Scan & Dopplers Day1 • Secondary prevention early • Daily Consultant Neurologist or Stroke Physician review • Further Investigations - to clarify deficit/diagnosis - to identify underlying aetiology - to manage the comorbidity - Unusual not to identify a cause

28. Cerebral Infarction Investigations • Atherothrombotic 50-60% RFs : DM,  BP,  lipids, PVD, smoker • Cardioembolic 20% AF, PAF, carotid disease,prosthetic valves,DCM, poor LV,aortic arch, PFO, atrial myxoma • Non-atherothrombotic 10% Vasculitides,infective incl HIV, syphilitic, recreational drugs • Haematological 5-10% HbS, thrombophilias,Anti-Phospholipids,LAC, OC pill,HRT

29. Imaging • Multi-modal CT • CT perfusion/diffusion imaging - delineate the penumbra • Multi-modal MRI • MRI with DWI - diagnostic tool • MRI - posterior circulation lesions • MRA - looking at vessels , intra/extracranial - After intracerebral haemorrhage ? Aneurysm,AVM, structural lesion • Carotid Dopplers -if symptomatic stenosis – CTA/MRA arch

30. MRI

31. CTA

32. MRA extra or intra- cerebral and carotid dopplers

33. Cardiovascular Ix • ECG - AF important & common - Troponins when ECG changes • Echocardiogram - especially when suspect cardioembolic source • Bubble echo – young/ unexplained • Holter monitor - PAF, arrthymias common - PPM insertion not unusual

34. Bloods • Routine FBC, Chemistry, Glucose,TFTs, CK • Clotting • Lipids, vasculitic screen,Treponemal serology • Consider - Troponins, ABGs Young Strokes- search very hard • Thrombophilia screen incl LAC, Anti phospholipids Homocysteine • Consider • LP, HIV

35. Secondary preventionanti-platelets / anti-coagulate • Only after CT scan excludes haemorrhage • Add aspirin 300mg & Dipyridamole 25mg tds • Event on aspirin - add dipyridamole • Event on A&D - start clopidogrel • Aspirin intolerant - clopidogrel RCP 2004; Esprit; IST; • Usually anti-coagulate for AF @ 2-4 weeks

36. Longer term BP management • Usually do not treat aggressively for~ 2 weeks • Good control > important than agent used • Beta -blockers – good for IHD, less beneficial in stroke • Diabetic patients targets lower • Usually use perindopril, indapamide, CCBs 60-70% patients are hypertensive

37. Lipids • Simvastatin 40mg ( unless CK raised) - caution in renal failure, some drugs • If known IHD & on atorvastatin - up-titrate to 40mg • Concurrent ACS & Stroke - atorvastatin • No stroke evidence yet for ezetimibe

38. Diabetes • ~20% stroke patients diabetic nationally • Frequently identify new • Insulin by consensus if Blood Glucose > 15 • If on metformin- stop few days • Problems with NG feeding/ PEG feeds • HbA1C; renal function; clearance; proteinuria • Careful BP management

39. Intracerebral haemorrhageon warfarin •  risk of prolonged bleeding &  mortality • 33% continue to bleed • Bleeding correlates well with GCS • Needs rigorous reversal of INR • Intensive monitoring • Use multiple agents /haematology advice • Rescan if GCS falls Steiner S et al .ICH Associated With Anticoagulant Therapy Stroke 2006;37:256-262

40. London future stroke services • NWT Stroke clinical reference group • Developing standards, pathways In conjunction with • Cardiac and Stroke Networks • Hub(s) –offering a comprehensive service • Spokes offering acute services ~ 7am-7pm • How many comprehensive services???

41. Comprehensive Stroke CentresUS style Outcomes • Increased use of lytic agents – all routes • Improved complex stroke management • Specific interventions, surgery, ITU facilities, 24/7 availability • Improved outcomes & decreased LOS AHA recommends • clusters of primary centres closely associated with comprehensive centres

42. Chain of survival! • Detection -recognition of stroke • Dispatch -call 999 & priority LAS • Delivery -prompt transport & pre-hospital notification • Door - Immediate triage • Data - Assessment, bloods, imaging • Decision - Diagnosis & decision re therapy • Drug - Appropriate drug/other intervention Adams et al. AHA Guidelines Stroke 2007;38;1655-1711

43. Summary Stroke is a medical emergency 24/7 i/v thrombolysis routine Clot retrieval & intra-arterial Rx next Outcomes improved with rapid assessment and treatment on a stroke unit early Multi professional input is integral Stringent risk factor management is key Remember Time lost = Brain lost