STROKE: The Brain Matters Module I

1. STROKE: The Brain MattersModule I K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD1 (rev. 01.18.08)

2. Prevalence and incidence: • From 1970s to early 1990s, non-institutionalized stroke survivors increased from 1.5 million to 2.4 million • On average, every 45 seconds someone in the U.S. has a stroke • Each year 700,000 people experience a new or recurrent stroke • Blacks have almost twice the risk of first-ever stroke compared with whites

3. Impact of stroke • Stroke accounted for about one of every 15 deaths in the U.S. in 2003 • Stroke ranks No. 3 among all causes of death • 8-12% of ischemic strokes and 37-38% of hemorrhagic strokes result in death within 30 days • Top cause of disability

4. 160 142.5 140 120 100 Billions of Dollars 63.5 80 57.9 60 29.6 40 20 0 Stroke Heart Failure Hypertensive Disease Coronary Heart Disease Estimated Direct and Indirect Costs of Major Cardiovascular Diseases and Stroke United States: 2006 Source: Heart Disease and Stroke Statistics – 2006 Update

5. What is Stroke? • BRAIN ATTACK • Clinical diagnosis supported by testing • Abrupt onset of neurologic deficit attributable to a focal vascular cause • Sudden loss of blood, with subsequent loss of nutrients and oxygen to a part of the brain, causing cell death • Ischemic vs. Hemorrhagic

6. Ischemic strokes: 80% of all strokes • Ischemic strokes occur if blood flow is blocked locally in an artery supplying the brain or if the entire circulation fails so that all organs, including the brain, are inadequately perfused • What might block a brain artery?1. Pathology such as atherosclerotic plaque in the vessel's wall that narrows or even obliterates its lumen or produces complete collapse of the wall 2. A "plug" in its lumen formed by material carried in the blood 3. Abnormally high pressure in brain tissue surrounding the vessel that compresses its wall to the point of squeezing shut its lumen

7. Ischemic stroke • Cerebral thrombosis most common and occurs in arteries narrowed by cholesterol plaque • Cerebral embolism occurs when a wandering clot or other particle forms away from the brain (usually the heart or aorta) and this clot occludes an artery leading to the brain

8. Hemorrhagic stroke: 20% of all strokes • Half involve rupture of either aneurysms which initially bleed into the subarachnoid space or of arteriovenous malformations which are often located within the brain and therefore tend to bleed into the brain itself.  Both of these pathologies are thought to be the consequence of developmental abnormalities and are characterized by thinned vascular walls

9. Intracerebral Hemorrhage • Caused by rupture of the walls of small penetrating arteries serving deep structures, with bleeding directly into the brain and its ventricles • These vessels are at particular risk because of their thin muscular walls and narrow lumens.  It is thought that the cumulative effects of untreated hypertension and atherosclerosis or other kinds of pathologic changes weaken their walls and put them at special risk for rupture

10. Lobar hemorrhages • Small arteries supplying the superficial regions of the cerebral hemispheres may develop deposits of an abnormal protein called amyloid in the extremely elderly • In some cases, this material can weaken the walls of these vessels to the extent that they rupture and cause hemorrhages in the superficial regions of the hemispheres  • Unlike the intracerebral hemorrhages involving midline penetrating vessels, superficial lobar hemorrhages can occur in individuals who have had normal blood pressure throughout

11. Transient Ischemic Attack (TIA) • Symptoms and causes similar to stroke • Important RISK FACTOR; about 15% of all strokes are heralded by a TIA • TIAs are produced by transient blockage of the cerebral or retinal circulation. Typical duration of symptoms is 5-15 minutes • By definition, neurologic deficits that resolve in <24 hours • Evaluation parallels that of stroke

12. Risk factors for stroke after TIA • Age over 60 years • Diabetes mellitus • Symptom duration more than 10 minutes • Residual weakness or speech disturbance N Eng J Med 4/17/03

14. Brain anatomy: www.tbts.org/assets/ images/brainmap.gif

15. Different parts of the brain: • Cerebrum ~ The cerebrum (supratentorial or front of brain) is composed of the right and left hemispheres. Functions of the cerebrum include: initiation of movement, coordination of movement, temperature, touch, vision, hearing, judgment, reasoning, problem solving, emotions, and learning. • Brainstem ~ The brainstem (midline or middle of brain) includes the midbrain, the pons, and the medulla. Functions of this area include: movement of the eyes and mouth, relaying sensory messages (hot, pain, loud, etc.), hunger, respirations, consciousness, cardiac function, body temperature, involuntary muscle movements, sneezing, coughing, vomiting, and swallowing. • Cerebellum ~ The cerebellum (infratentorial or back of brain) is located at the back of the head. Its function is to coordinate voluntary muscle movements and to maintain posture, balance, and equilibrium.

16. More specific areas of the brain: • Pons ~ A deep part of the brain, located in the brainstem, the pons contains many of the control areas for eye and face movements. • Medulla ~ The lowest part of the brainstem, the medulla is the most vital part of the entire brain and contains important control centers for the heart and lungs. • Frontal lobe ~ The largest section of the brain located in the front of the head, the frontal lobe is involved in personality characteristics and movement. • Parietal lobe ~ The middle part of the brain, the parietal lobe helps a person to identify objects and understand spatial relationships (where one's body is compared to objects around the person). The parietal lobe is also involved in interpreting pain and touch in the body. • Occipital lobe ~ The occipital lobe is the back part of the brain that is involved with vision. • Temporal lobe ~ The sides of the brain, these temporal lobes are involved in memory, speech, and sense of smell.

17. Cerebrovascular circulation

18. Stroke Symptoms • Sudden numbness or weakness of face, arm or leg  especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordination • Sudden severe headache with no known cause

19. Neurologic symptoms of occluded vessels will vary depending on location

20. Middle cerebral artery Vertebrobasilar artery Anterior cerebral artery Posterior cerebral artery Carotid artery Aphasia, visual field defects, hemi paresis, hemiplegia, hemi sensory loss, inattention, apraxia. Diplopia, dysarthria, ataxia, poor motor coordination, vertigo, nausea/vomiting. Personality changes, confusion, weakness usually> distally, hemiplegia. Cortical blindness, dyslexia, visual field defects if occipital. Altered level of consciousness, weakness, numbness. Vessels typically effected and an overview of possible symptoms

21. American Heart Association’s 7 “D’s” of Stroke Care • Detection, early recognition of the signs and symptoms and determination of onset time. If the patient awakened with signs and symptoms of a stroke, the onset time is considered the last time he was seen awake without them. • Dispatch, rapidly getting the patient emergency medical care. • Delivery, transporting him to the nearest stroke center or a hospital capable of following the latest stroke guidelines. • Door, rapid triage in the ED. • Data, documenting or collecting information about the patient's history, lab work, imaging studies, examinations, physical assessments, and time of onset of signs and symptoms. Needs to undergo a noncontrast computed tomography (CT) scan of the brain within 25 minutes of arrival at the ED, and it must be interpreted within 45 minutes of arrival to determine if an acute ischemic stroke occurred. • Decision, answering the inclusion and exclusion criteria for t-PA therapy and reviewing treatment options with the patient and family. • Drug, starting t-PA treatment within 3 hours of onset of symptoms if all conditions are met; Nursing care at the door.

22. Diagnostics • Lab work: Complete blood cell count, glucose and electrolyte levels, renal and liver function studies, prothrombin and partial thromboplastin times, and cardiac biomarkers • 12-lead electrocardiogram • CT of brain (w/angiography IF indicated and does not delay administration of t-PA) • CT of brain with angiography

23. Timing is critical!! Three (3) hour window of time to receive acute treatment for ischemic stroke. ED Ischemic stroke pathway:

25. t-PA (Tissue Plasminogen Activator) Inclusion / Exclusion Criteria Inclusion Criteria: • Clinical diagnosis of stroke • Age 18 or older • Time of stroke onset (i.e. last time pt witnessed to be well) < 3 hours • BP Systolic <= 185, diastolic <= 110 (can receive 1-3 doses of BP agent for control) • Pro time <= 15 seconds or INR <= 1.7 • Platelet count >= 100,000 • Blood Glucose => 50 and <= 400 mg/dl Exclusion Criteria: • Minor stroke or rapidly resolving stroke • Seizure at onset of stroke • Heparin treatment during the past 48 hours with an elevated PTT • Evidence of acute myocardial infarction Exclusion Criteria (Relative Contraindications): • History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm • Major surgical procedures within 14 days • Stroke or serious head injury within 3 months • Gastrointestinal or urinary bleeding within last 21 days • Lactation or Pregnancy within 30 days Modified from NINDS criteria

26. t-PA dose and administration Tissue Plasminogen Activator (t-PA) Alteplase (Activase®) Drug class = Fibrinolytic used to treat acute ischemic stroke. Clot-specific binding to fibrin-bound plasminogen allowing conversion to plasmin, which digests the fibrin. Onset of action occurs in 60-90 minutes. LOADING dose = 0.09 mg/kg IV push over 1 minute (dose not to exceed 9 mg) Followed by: INFUSION dose = 0.81 mg/kg IV infusion over 1 hour (dose not to exceed 81 mg)

27. Order sets used by the ED: Link: ??

28. Post-thrombolytic order set • Key issues: ASA, heparin, Coumadin contraindicated up to 24 hrs. after t-PA administered • NPO until swallow evaluated • Assess for changes in neuro status that may indicate post t-PA complication of bleeding • Assess any other abnormal bleeding

29. Other ED pathways: TIA and Hemorrhagic

30. Stroke Patient Placement • Patient placement is planned with use of designated stroke unit beds unless other factors determine otherwise • After t-PA, patients are monitored in CICU 18-24 hrs (or SCU). If stable, they are then transferred to P3CD (R4, if tele needed)

31. Stroke Bed Aggregation:

32. Act F.A.S.T. If you think someone may be having a stroke, act F.A.S.T. and do this simple test: • FACE    Ask the person to smile.Does one side of the face droop? • ARMS    Ask the person to raise both arms.Does one arm drift downward? • SPEECH  Ask the person to repeat a simple sentence.Are the words slurred?  Can he/she repeat the sentence correctly? • TIME    If the person shows any of these symptoms, time is important. Call 911 or get to the hospital fast. Brain cells are dying. TIME LOST IS BRAIN LOST! NINDS