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Stroke Management

Stroke Management. Chemeketa Community College Peggy Andrews. The "Golden Hour" of Acute Ischemic Stroke. > A Look at Current Stroke Treatment. What's Changed in 2000?

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Stroke Management

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  1. Stroke Management Chemeketa Community College Peggy Andrews

  2. The "Golden Hour" of Acute Ischemic Stroke • > A Look at Current Stroke Treatment What's Changed in 2000? “EMS systems should implement a prehospital stroke protocol to evaluate and rapidly identify patients who may benefit from fibrinolytic therapy, similar to the protocol for chest pain patients” (Class IIb). “Patients who may be candidates for fibrinolytic therapy should be transported to hospitals identified as capable of providing acute stroke care, including 24-hours availability of CT scan and interpretation.” (Class IIb). “Stroke presenting with 3 hours should be triaged on an emergent basis with urgency similar to acute ST-elevation myocardial infarction.”

  3. Acute Stroke Where are we today? • Public poorly informed • Response time too slow • Presentation too late • Hospitals ill prepared

  4. Models for the "Golden Hour" Trauma • Times studied/defined • Centralized trauma center system • Mortality Low AMI • Similar door-drug/groin benchmarks for reperfusion • Decentralized system • Treatment data strongly supports

  5. AMI - example The paradigm has shifted • Chest pain - patients know to call 911 • Rapid access to EMS • Early recognition • ECG • S/S • Rapid Transport • Team, protocols, drugs in the ED • “Door to Drug” in 30 Minutes

  6. Why Care? Impact of Stroke • 3rd leading cause of death in U.S. • Leading cause of adult disability • 750,000 new cases/year in U.S. • 150,000 deaths/year • 1/3 Under age 65

  7. Forces of Change • Public expectations • Aware of “Draino for the Braino” • Medical - legal pressures • Managed care cost concerns - Long term vs Short Term • New/better treatments • Physicians‘ willing/able to treat - Evidenced based medicine

  8. Organized Stroke Care Saves Lives • 21% reduction in early mortality • 18% reduction in 12 month mortality • Decreased length of hospital stay • Decreased need for institutional care Source: Jorgenson, Stroke, 1994

  9. What are we talking about here? • Ischemic Stroke (84%) • Hemorrhagic Stroke (16%) • These have very different needs • Philosophy in treatment takes a different direction • Traumatic Brain Injury (TBI) • Not talking about today – PHTLS

  10. Ischemic Stroke • HYPOperfusion • Embolic (20% had a-fib) • Thromboembolic • GOAL of Treatment • 1. Restore Circulation • 2. Stop Ischemia

  11. What is this rt-PA • Recombinant Tissue Plasminogen Activator • Review of clotting cascade • Collagen Exposed • Vessel injury • Damage • Long term wear • Embolus • Clotting factors aggregate • Fibrin Repair (Bond-O) • FIBRINOLYSIS

  12. Intra-venous fibrinolysis for acute ISCHEMIC stroke • Class IIV  - t-PA within 3 hours of onset • Class IndeterminateIV - t-PA between 3 and 6 hours of onset

  13. Intra-arterial thrombolysis • TPA, Urokinase, Anti-platelet • All experimental in the 3-6 hour window • Lower doses, delivered right to clot • Snare devices • Reach in and grab it • Vessels sometimes too small to get into • Mechanical devices • Angiojet – rotating blade • Ultrasound • Lasers

  14. With rt-PA, considering 1,000 eligible patients: • Hospitalization costs  = $1.7 million more • Rehabilitation costs  = $1.4 million less • Nursing home costs  = $4.8 million less • 564 quality-adjusted life-years saved Source:Fagan, Neurology 1998

  15. NIH National Symposium Recommendations • Door-to-MD:>10 minutes • Door-to-Neurologic Expertise:>15 minutes • Door-to-CT scan:>25 minutes • Door-to-CT Interpretation:>45 minutes • Door-to-Drug:(80% compliance)>60 minutes • Door-to-Admission:>3 hours

  16. Stroke Chain of Survival & Recovery • Detection: Early recognition • Dispatch: Early EMSactivation • Delivery: Transport &management • Door: ED triage • Data: ED evaluation &management • Decision: Specific therapies • Drug: Thrombolytic &future agents

  17. Dispatch & Delivery: Transport & Management • ABC’s • Stroke recognition • Establish time of onset • Perform neurological evaluation • Check glucose • Early hospital notification • Rapid transport

  18. Cincinnati Pre-Hospital Stroke Scale Facial Droop • Normal:Both sides of face move equally • Abnormal: One side of face does not move at all

  19. Cincinnati Pre-Hospital Stroke Scale Arm Drift • Normal:Both arms move equally or not at all • Abnormal:One arm drifts compared to the other

  20. Cincinnati Pre-Hospital Stroke Scale Speech • Normal: Patient uses correct words without slurring • Abnormal:Slurred or inappropriate words or mute

  21. NIH Stroke Scale

  22. I smell II vision III pupil constriction, eye movement IV downward gaze V facial sensation VI lateral eye movement VII taste, frown, smile VIII hearing, balance IX taste, gag, swallowing X voice XI shoulder shrug XII tongue movement 12 cranial nerves check

  23. Preparation Know your stroke team before you need them • Check glucose • Two large IV lines • Oxygen as needed • Cardiac monitor • Continuous pulse-ox • Stat non-contrast CT scan • ECG • CXR • Get rt-PA> Prepare to mix> Have pharmacy alerted • Discuss options with patient and family • Contact  primary care provider

  24. American Heart Association Recommendations Oxygen • Use to correct hypoxia • Suggestion that supernormal levels may hurt> one year survival 69% 3L NC vs 73% control Glucose • Maintain euglycemia • Treat glucose > 300 mg/dl with insulin Source:Rønning, Stroke 1999

  25. True Time of Onset How normal were they? • What are they like at baseline? • Who saw them last? • Clearly no symptoms? Times of reference • Television • The time the basketball game started

  26. Modifiable risk factors High blood pressure Cigarette smoking Transient ischemic attacks Heart disease Diabetes mellitus Hypercoagulopathy Carotid stenosis Bruits Other Non-modifiable risk factors Age Gender Race Prior stroke Heredity Stroke Risk Factors

  27. Differential Diagnosis • Intracerebral hemorrhage • Hypoglycemia / Hyperglycemia • Seizure • Migraine headache • Hypertensive crisis • Epidural / Subdural • Meningitis / Encephalitis / Brain abscess • Tumor

  28. What are the Options? No thrombolytics • Nothing • Aspirin • Heparin Intravenous rt-PA Other • Intra-arterial thrombolytics • Investigative procedure

  29. Bleeding concerns Stroke/head trauma in 3 mos Major surgery<14 days Hx of intracranial hemorrhage Seizures at the onset of stroke SBP > 185 mm Hg DBP > 110 mm Hg Symptoms suggestive of hemorrhage GI hemorrhage within 21 days Urinary tract hemorrhage within 21 days Arterial puncture at non-compressible site < 7 days Rx anticoagulants Possibly not indicated or wrong diagnosis Rapidly improving or minor symptoms Glucose < 50 or > 400 mg/dl Possible Setup for DIC/other metabolic disorders Heparin within 48 hours PTT High PT High INR High Platelet count low Exclusions to Thrombolytics

  30. Let’s talk about blood pressure • MAP – Mean Arterial Pressure (70-90 Normal) • ICP – Intracranial Pressure • Normally about 0-15mmHg • >20 = Bad • CPP – Cerebral Perfusion Pressure • CPP=MAP-ICP • CPP must be above 70mmHg for cerebral perfusion • You do the math

  31. IF CPP=MAP-ICP • And we know that the body autoregulates pressures to preserve itself • 80-90% of ischemic strokes present with elevated BP • ICP may have risen because of Edema

  32. Studied: • Multicenter Study – 372 patients • Compared Neuro outcome vs BP changes in first 24 hours • If Diastolic BP decreased by >25% (even once) • Poorer outcomes regardless of baseline diastolic BP levels, Stroke location or use of HTN agents • NO EVIDENCE THAT LOWERING BP HELPS • Remember we’re still talking about ischemic strokes • FAIR Evidence that it harms

  33. BP Treated in extreme cases “Gentle” management if thrombolytic candidate: • SBP > 180 mm Hg • DBP > 110 mm Hg Choices: • Labetalol • Enalapril • Nitropaste

  34. Treatment Considerations: Who will benefit from rt-PA? • Patient age • Co-morbid factors • Medical history • Risks of treatment • Odds of Presenting • Benefits of Treatment • Odds of surviving

  35. Treatment considerations (cont’d) • Time from onset (Remember 3 hours) • Stroke severity • Stroke subtype • Data driven here too • CT findings • Assymetry = Bad • Density image – Tissue/fluid ratio • Charcoal=Normal • Dark = Higher density (more tissue than fluid) • Ischemia • Light = Lower density (More fluid than tissue) • Hemorrhage • Tumor

  36. Which one is which?

  37. Factors Associated with Increased Risk of ICH • Treatment initiated > 3 hours • Increased thrombolytic dose • Elevated blood pressure • NIHSS > 20 * • Acute hypodensity or mass effect **Even though increased r/o ICH, still with benefit vs. placebo

  38. Stroke Treatment – Aspirin • Two important trials:>International Stroke Trial>Chinese Acute Stroke Trial • Combined analysis (n=40,090) • Death / nonfatal strokes reduced 11% • Don’t forget to check swallowing • Local protocol driven

  39. Stroke Treatment – Heparinoids • Decreased recurrent ischemic strokes • Increased hemorrhagic events • No net stroke benefit

  40. The "Golden Hour" of Acute Ischemic Stroke > Case Study • History: • A 61 year old male, with acute aphasia, right facial droop, and right sided weakness.

  41. 12:30 Sudden onset while working in yard. 12:45 Family calls 911. 13:05 Advanced squad evaluates neurologic deficits and glucose. 13:15 Squad notifies receiving hospital of possible stroke patient 13:30 ED arrival.  Initial evaluation by E.D. physician. 13:45 Stroke Team arrives.  NIHSS 18. 14:00 CT scan performed. 14:15 Discuss with family and PMD. 14:20 Labs back: gluc 97.  BP remains 150/70’s. 14:20 CT reading back. No hemorrhage or early signs of ischemia

  42. 14:25 Checklist done. No exclusion criteria met. 14:30 Decision time. 14:35 IV rt-PA given. 0.9 mg/kg total>10% bolus- 9 mg>90% over 1 hr - 81 mg 15:45 Patient goes to ICU.  Report personally given to ICU staff. 15:50 Pathway actions begin (HOB, BP parameters, aspiration precautions).

  43. 24 Hour Follow-up • A 61 year old male, with acute stroke, treated with rt-PA. • Repeat NIHSS = 3: • VF intact • No gaze palsy • Mild facial palsy • Mild right arm drift • Mild dysarthria

  44. Hemorrhagic Stroke • Treatment Goals – (Different) • 1. Reduce the risk of re-bleed • 2. Reduce risk of continued bleeding

  45. Hemorrhagic Stroke (16%) • Bleeding into or surrounding the brain • Intracerebral Hemorrhage (ICH) • HTN • Tumor/Lesions • Venous sinus thrombosis • Drains from the dura mater • Amyloid angiopathy • Starch-like deposits on vessel walls- precursor

  46. Hemorrhagic Stroke (16%) • Bleeding into or surrounding the brain • Sub-arachnoid hemorrhage (SAH) • Blood in arachnoid space, basal cisterns & often intraventricular • Aneurysm rupture • Trauma • Arteriovenous malformation (AVM)

  47. Some Skull Ground Rules • Monroe-Kellie Hypothesis • Intracranial space/volume constant • Three components = ICP • CSF – 100mL • Production/absorption is pressure driven • Blood – 150mL • Here lies the problem • Brain – 1250mL (or grams) • Relatively constant (IS H2O minimally displaceable)

  48. Head Bleeds • Still assuming a closed system (non-trauma) • ICP will rise • BP will rise • Remember autoregulation (compensatory) • If SBP>230 & DBP > 120 • Sodium Nitroprusside 0.5mcg/kg/min • If SBP>180 & DBP >105 • Labetolol 10mg/1-2min – Double q10 to 300mg • If Hypertensive, but not extremely high • LEAVE IT ALONE

  49. Benefits of playing with BP • Decrease Edema • Limit size of damaged area • Limit further vascular damage • Might actually need a fluid bolus • 1 Hypotensive episode-mortality 30+ %

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