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STROKE: RESIDENT – Brain Matters Module VI

STROKE: RESIDENT – Brain Matters Module VI. 1. Acute care of ischemic stroke 2. Primary prevention 3. Secondary prevention 4. Resources for adherence to ischemic stroke guidelines. Learning objectives:.

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STROKE: RESIDENT – Brain Matters Module VI

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  1. STROKE: RESIDENT – Brain MattersModule VI • 1. Acute care of ischemic stroke • 2. Primary prevention • 3. Secondary prevention • 4. Resources for adherence to ischemic stroke • guidelines K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  2. Learning objectives: • Identify recommendations for treatment of acute ischemic stroke including t-PA and primary and secondary prevention • Describe MMC Stroke Service operations, rationale for focus on stroke and tools available to help providers adhere to AHA stroke care guidelines • Identify educational resources for stroke that will provide more in depth information K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  3. Why should stroke be a clinical area of focus? • Nationally, stroke is the 3rd largest cause of death • Leading cause of permanent disability for the 700,000 Americans who suffer a stroke annually • MMC cares for 425+ inpatients with stroke annually K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  4. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  5. Primary Stroke Center criteria and certification by JCAHO • Improve awareness and availability of optimal acute stroke care • Implement secondary stroke prevention • Continuous monitoring of quality measures to improve outcomes K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  6. Timing is critical!! • The time window for treatment of patients with acute ischemic stroke is narrow • IV-Thrombolysis (t-PA) is the recommended treatment within 3 hrs after ischemic stroke onset though benefit may be present up to 4.5 hrs • Earlier therapy is associated with better outcome • IV t-PA is not recommended when the time of onset of stroke cannot be ascertained reliably • Acute intracranial vessel occlusion may be treated with intra-arterial therapy (in a 6 hr window) or Merci retrieval in selected patients K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  7. Emergency diagnostic tests • CT head to differentiate between ischemia and hemorrhage • Vascular imaging (CTA, ultrasound) for information about the vessel patency if indicated and only IF administration of t-PA will not be delayed. If CTA indication MUST BE documented. • Evaluation of physiological parameters (HR, BP, pulse oximetry) • CBC, CMP • ECG K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  8. IV t-PA • Compared with placebo, treatment with t-PA nearly doubles the odds of recovery to independent function at 3 months after stroke and beyond • ~47% of patients treated with t-PA will return to all pre-stroke physical, social and occupational functions, compared with 27% of those not treated • Rate of risk for symptomatic ICH after t-PA is 6.4% K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  9. Question #1 A 71-year-old man presents to the ED at the instruction of his PCP. This man felt well when he went to bed at midnight but awoke at 8:00 a.m. with left upper-extremity weakness and numbness. He called his physician who told him to go to the ED. He arrives at the ED at 9:00 a.m. The patient's PMHx includes hypertension and hyperlipidemia for which he takes a Thiazide diuretic and a statin. His BP is 178/92 mm Hg; P/E reveals mild left-sided neglect, a mild left central facial palsy, mild LUE and LLE weakness, and a mild left hemi sensory deficit. CBC, BMP are normal. CT scan of the brain is normal. • Which of the following is the most appropriate next step in this patient's management? • Start aspirin • Start intravenous heparin • Start clopidogrel • Start intravenous tissue Plasminogen activator • Lower blood pressure to 140/90 mm Hg MKSAP 14 K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  10. Question #1: Acute treatment Answer: A • This patient had an acute ischemic stroke in the right MCA territory. The time of onset is unknown, but he was last known to be well at midnight, and he is therefore not eligible for intravenous thrombolytic therapy, which is indicated if therapy is started within 3 hours of onset of stroke symptoms or when the patient was last known to be well. • Early administration of aspirin, 160 to 325 mg daily, results in a modest reduction in the risk of recurrent stroke in the short term, and slightly less death and disability in the long term. • Early administration of parenteral anticoagulants has no net benefit for patients with acute stroke. Clopidogrel is not beneficial as acute stroke therapy. • Early blood pressure lowering is not recommended for most patients with acute stroke unless they are being considered for thrombolytic therapy or are suffering from a concomitant myocardial infarction or aortic dissection. In such cases, some experts aim for a target mean arterial pressure of 140 mm Hg, though without definitive evidence that this is beneficial. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08) MKSAP 14

  11. t-PA inclusion 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 K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08) Modified from NINDS criteria

  12. t-PA exclusion criteria: Exclusion Criteria: • Minor stroke or rapidly resolving stroke (controversial) • Heparin treatment during the past 48 hours with an elevated PTT • Evidence of acute myocardial infarction 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 • Seizure at onset of stroke • Gastrointestinal or urinary bleeding within last 21 days • Lactation or Pregnancy within 30 days K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  13. t-PA dose and administration Tissue Plasminogen Activator (t-PA) Alteplase (Activase®) 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) tPa dose calculator and NIHS Scale are accessed through use of the ED stroke order set K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  14. The Mainstays of Acute Treatment • Treatment and stabilization of general conditions • Specific therapy, either recanalization of a vessel occlusion or prevention of mechanisms leading to neuronal death in the ischemic brain • Prophylaxis and treatment of complications • Hemorrhagic transformation, space-occupying edema • Seizures • Aspiration • Infections • pressure ulcers • deep vein thrombosis or pulmonary embolism • Early secondary prevention • Early rehabilitation K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  15. Acute treatment • Aspirin • Small but significant reduction in death and dependency and recurrence of stroke • In a combined analysis, the reduction in death and dependency during the first 2 weeks was 1% • Anticoagulation (heparin or LMWH) • Not routinely used • but selected patients may benefit K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  16. Blood Pressure Recommendations: • Immediate antihypertensive therapy for moderate HTN is recommended in case of stroke but should be applied cautiously (preservation of ischemic penumbra) • Recommended BP targets • with prior HTN: 180/100-105 mmHg • without prior HTN: 160-180/90-100mmHg • After thrombolysis: keep BP <180/105 mmHg • Recommended drugs: IV: Labetalol, sodium nitroprusside or NTG; orally: captopril • Avoid nifedipine and any drastic BP decrease • Avoid and treat hypotension particularly in unstable patients by administering adequate amount of fluids and when required, volume expander and or catecholamine K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  17. Acute treatment ~ Other considerations • 24 hour telemetry • treat fever and its cause when temp reaches 37.5◦C • Fever negatively influences neurological outcome after stroke • Experimentally, fever increases infarct size • electrolyte abnormalities: • rare after ischemic stroke but frequent after ICH and SAH • balanced electrolyte and fluid status are important to avoid: hypo/hypervolemia, plasma volume contraction and raised hematocrit • glucose • High glucose levels in acute stroke increase the size of the infarction and reduce functional outcome • Hypoglycemia worsens outcome as well K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  18. Other Recommendations: ● Continuous cardiac monitoring in the first 24 hrs. ● Oxygenation monitoring ● O2 administration in case of hypoxemia ABG or O2 sat <92% K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  19. High blood pressure Atrial fibrillation Diabetes Mellitus Carotid artery disease Myocardial infarction Hormone replacement therapy Migraine High cholesterol Hyper-homocysteinemia Smoking Heavy alcohol use Physical inactivity/obesity Primary Prevention Conditions and lifestyle factors identified as a risk for stroke: K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  20. Primary Prevention: Atrial fibrillation • Average stroke rate in a pt with AF = 5%/year • Warfarin reduces the rate by 60-70% with an INR between 2-3 (INR <2.0 is not effective) • ASA (300 mg) results in a relative risk reduction of 21% • Use CHADS score to determine need for anticoagulation • Patients with contraindications to anticoagulant therapy should be offered ASA K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  21. Primary Prevention: asymptomatic internal carotid (ICA) stenosis • Management is controversial • Performing carotid Endarterectomy (CEA) in asymptomatic carotid stenosis >60% offers an absolute RR of 5.9-12.6% over 5y • NNT = 8-17 • In order to have benefit, the surgical risk must not exceed 3% K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  22. Question #2 A 64-year-old man is evaluated because he lost vision in the lower field of his right eye for about 10 minutes yesterday. He wants a referral to see an ophthalmologist. His medical history includes hypertension and he is a former smoker. His medications are aspirin and enalapril. BP is 142/90 mm Hg. P/E is normal. Carotid ultrasonography reveals 70% to 80% stenosis of the right internal carotid artery and 80% to 90% stenosis of the left internal carotid artery. He has no known contraindications to carotid intervention. 2. Which of the following is the most appropriate next step in the management of this patient? • Right carotid Endarterectomy • Left carotid Endarterectomy • Switch aspirin to Warfarin • Add clopidogrel to aspirin • No change in therapy K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08) MKSAP 14

  23. Question #2 : Secondary Prevention Answer: A • The right internal carotid artery is stenotic and symptomatic, having caused partial transient monocular blindness (amaurosis fugax) with a typical loss of vision in either the upper or lower half of one eye. The benefit of carotid intervention is far greater for symptomatic than asymptomatic stenosis, regardless of the degree of stenosis. Carotid Endarterectomy remains the standard intervention, and is most beneficial when performed within the first few weeks after initial symptoms. Carotid angioplasty and stenting are still under investigation and are not recommended for patients who are good candidates for surgical Endarterectomy, except in the context of a randomized clinical trial. • Switching from aspirin to Warfarin has never been shown to be of benefit. • Adding clopidogrel to aspirin increases the risk of major bleeding without any additional benefit. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08) MKSAP 14

  24. Secondary Prevention • ASA :13% relative risk reduction for stroke after TIA or stroke • Incidence of GI disturbances is dose dependent • No difference in effectiveness amongst low (<160mg), medium (160-325) or high (500-1500mg) dose aspirin • Dipyridamole and ASA (Aggrenox): Yields a modest risk reduction, 1% per year • Clopidogrel (Plavix): Not more effective than ASA unless patient has multiple vascular bed (CAD, PVD) disease. Combination ASA/clopidogrel for stroke indications cannot be recommended routinely K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  25. Secondary Prevention • Blood pressure, lipid, and Diabetes mellitus control effectively reduces vascular recurrence rates in all vascular beds • Keep SBP < 140 and DBP < 90; in those with diabetes or chronic renal disease SBP <130 and DBP <80 • Keep HgbA1C <7 K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  26. LDL-primary target of therapy ° <100 °100-129 °130-159 °160-189 °≥190 Total cholesterol °<200 ° 200-239 °≥240 HDL cholesterol °<40 °≥60 Optimal ° Near/above optimal ° Borderline high ° High ° Very high ° Desirable ° Borderline high ° High ° Low ° High (ATP) Adult Treatment Panel III Classification of:(LDL) low density lipoprotein, (HDL) high density lipoprotein cholesterol, and total US Dept. of Health and Human Services National Institutes of Health National Heart, Lung and Blood Institute, 2003 K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  27. Stroke Pathways & Order Sets Use of Stroke pathways and order sets in the ED and at admission aid in: • Following specific guidelines for stroke care in relation to hypertension control, cardiac monitoring and other parameters • Use of appropriate diagnostics for workup • Streamline the process to avoid delays in t-PA administration • Simplify order entry and accuracy K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  28. CEA: Secondary Prevention • In pts with 70-99% carotid stenosis that is symptomatic (specifically defined as having contributed to a TIA or minor stroke), CEA significantly reduces the 2y risk for stroke from 26% to 9% • For pts with 50-70% stenosis, the risk for stroke over 5 years decreases from 22% to 16% with surgery • benefit is seen mostly in men, in those with recent stroke symptoms, and in those with hemispheric compared with ocular symptoms • CEA is most beneficial when performed within the first 2-4 wks after the initial cerebrovascular event • Surgical risk for perioperative stroke or death must be <6% for this benefit in symptomatic carotid stenosis • no benefit for stenosis <50%. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  29. Available Emergency Department (ED) tools that utilize AHA guidelines • ED Ischemic Stroke Pathway • ED Hemorrhagic Stroke (ICH/SAH) Pathway • ED Transient Ischemic Attack Pathway (TIA) The pathways are posted in trauma and CT rooms and work stations • ED Stroke Order Set K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  30. ED Pathways Can be accessed on MMC intranet Stroke Service Program K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  31. Can be accessed on MMC intranet Stroke Service Program K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  32. Admission Order Sets • Stroke Ischemic Adult • Stroke Post Thrombolysis • Stroke-Hemorrhagic ICH / SAH • Stroke mini–Order (add on to other admission order sets) • TIA These order sets incorporate AHA guidelines and quality measures, thus use is strongly encouraged to assist in the decision making process yet allowing for provider judgment. Use of order sets improves quality outcomes and streamlines the admission orders process. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  33. Access to order sets for stroke: K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  34. Example of Order Set: K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  35. Joint Commission  Quality Measures(all are being monitored for compliance) K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  36. Stroke Patient Placement: • Patient placement is planned with use of designated stroke unit beds unless other factors determine otherwise • Treatment in a stroke unit has been shown to reduce death, dependence and need for long term institutional care in comparison to a general unit • Care is multidisciplinary K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  37. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  38. Available resources to provide Evidence-based Care • American Heart Association (AHA) Statements and Practice Guidelines for TIA, Ischemic and Hemorrhagic stroke, Atrial fibrillation • These can be found on the MMC intranet in Department section under Stroke Service Program https://my.mmc.org/C19/C5/American%20Stroke%20Association%20Ed/default.aspx https://my.mmc.org/C0/C6/Maine%20Medical%20Center%20-%20In%20Hous/default.aspx K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  39. Intranet access: K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  40. Maine Medical Center Stroke Program - Operations Group K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  41. Stroke Service Contacts: • Medical Director: John Belden, MD  207-883-1414 Extension 361 • jbelden@maineneurology.com • Nurse Practitioner: Georgann Dickey, RN, ANP  207-662-2069 dickeg1@mmc.org • Program Manager: Darcy Evans BA, BS  207-662-3406 evansd1@mmc.org We encourage input to improve stroke practice and the tools used to facilitate care. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  42. Intranet Stroke Education Resources: • E-learns • MMC library including E-books, clinical resources and research assistance • Stroke Self-study for residents:http://www.umassmed.edu/strokestop • PowerPoint presentations: Medical Grand Rounds: Stroke Dysphagia Intracranial Hemorrhage Stroke Secondary Prevention K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  43. Post-test question(s): • Patient inclusion criteria for fibrinolytic therapy for acute ischemic stroke include age 18 or older, onset of symptoms less than 180 minutes before treatment would start, and • Stroke within previous month • INR< 1.7 • Serum glucose > 400 • Blood pressure >210/120 Ans. b K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  44. Post-test question(s): • Which ONE of the following factors puts a 40 year old man at the GREATEST risk of having a stroke? • Blood pressure of 160/95 on repeated measurement • Body mass index of 28 • Consumption of 1 or 2 cans of beer after dinner most nights • Prior history of cigarette smoking while a teenager Ans. a K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  45. Post-test question(s): 3. To reduce the risk of pneumonia in Mrs. WO, a stroke patient who has facial droop and dysarthria, the following is recommended: • Keep her N.P.O. until a swallowing evaluation has been completed by either physician or speech therapy • Order elevation of the head of her bed 20 degrees when providing feeding assistance • Discourage performing mouth care as this can make her gag • Recommend keeping her supine to decrease episodes of coughing  K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  46. Post-test question(s): • The Stroke service program at MMC encourages which of the following to promote optimal stroke care? • Use of specific stroke order sets • Requesting smoking cessation counseling and/or medications for tobacco users • Consider rehabilitation for all stroke patients • All of the above Ans. d K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

  47. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD RESIDENTS (rev. 01.18.08)

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