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Nicholas J. Okon,D.O. Medical Director St. Vincent Healthcare, Billings For the Montana Stroke Initiative

Nicholas J. Okon,D.O. Medical Director St. Vincent Healthcare, Billings For the Montana Stroke Initiative. http://montanastroke.org. Stroke Stats. 1 stroke very 53 seconds 1 death from stroke every 3.3 minutes (436/day) 750,000 new and recurrent strokes each year in US Mortality

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Nicholas J. Okon,D.O. Medical Director St. Vincent Healthcare, Billings For the Montana Stroke Initiative

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  1. Nicholas J. Okon,D.O. Medical Director St. Vincent Healthcare, Billings For the Montana Stroke Initiative http://montanastroke.org

  2. Stroke Stats • 1 stroke very 53 seconds • 1 death from stroke every 3.3 minutes (436/day) • 750,000 new and recurrent strokes each year in US • Mortality • 7.6% 30d • 16-23% 3 months • Yellowstone County • 310 strokes expected

  3. Stroke is a treatable condition. • IV tPA is approved for use within 3 hours (NINDS) • Intra-arterial therapy has proven to be safe and effective within 6 hours (PROACT II) • Combined IV/IA may be more effective than IV t-PA (Interventional Management of Stroke -IMS) • Mechanical and laser catheter technologies are showing great promise (Angio-Jet)

  4. Stroke: The Challenge • Only 1-3% of all stroke victims receive treatment with tPA in the US • 25% of Acute MI patients receive treatment (lytics or PTCA) in the US • Mean time to presentation • AMI: 3hrs • Acute Stroke: 4-10hrs • 24-59% patients present within 3 hours • 40-76% patients present within 6 hours

  5. Reasons for lack of treatment: • Patient’s inability to recognize stroke symptoms • 40% of stroke patients can’t name a single sign or symptom of stroke or stroke risk factor. • 75% of stroke patients misinterpret their symptoms • 86% of patients believe that their symptoms aren’t serious enough to seek urgent care • Physician’s lack of experience with stroke treatment and therefore reluctance to “risk” treatment • Lack of organized delivery of care in many medical centers throughout the country.

  6. What is a stroke or TIA? • Stroke- • Sudden onset of focal neurologic deficits fitting a vascular distribution • TIA • Stroke-like symptoms lasting <1 hr and completely resolve • Most TIAs last 15-30 minutes

  7. Symptoms of stroke • Sudden numbness or weakness of the 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

  8. Types of Stroke 85% Ischemic 15 % hemorrhagic

  9. Left MCA Syndrome • Language loss (aphasia) • Right hemiparesis • Right hemisensory loss • Right visual field cut • Left gaze preference

  10. Right MCA Syndrome • Left hemi-neglect • visual,spatial, • Left hemiparesis • Left hemisensory loss • Left visual field cut • Neglect of deficits • “anasgnosia”

  11. Stroke is due to sudden vascular occlusion ACA MCA

  12. Vascular occlusion causes stroke symptoms • 50-70% of all stroke is due to embolism (cardiogenic and artery-to-artery) • 80 % of acute strokes are due to MCA territory ischemia • Arterial occlusion is seen in 80-90% within 6-24° of symptom onset • Spontaneous recanalization seen in ~ 20% within 6 ° of symptoms

  13. Many Causes of Stroke

  14. Hypoglycemia Hyperglycemia Seizure Subdural Hematoma Stroke Mimics

  15. Hypoglycemia Hyperglycemia Seizure Subdural Stroke Mimics Altered consciousness Hemiparesis Glucose <50 or Glucose >300

  16. Hypoglycemia Hyperglycemia Seizure Subdural Stroke Mimics • Altered consciousness • Hemiparesis • (Todd’s paralysis) • History of seizures • Seizure medications

  17. Hypoglycemia Hyperglycemia Seizure Subdural Stroke Mimics Altered consciousness Hemiparesis Signs of trauma

  18. Field Assessment • “Load and GO !!!” • ABC’s • Vitals • Rhythm • Glucose • Bring witness/Meds

  19. Time dependent treatment • IV t-PA must be given within 3 hours from onset of symptoms or from “time last seen normal” • Intra-arterial (IA) therapy must be given within 3 hours 6 hours

  20. Establishing time of onset • Symptom onset or time last seen normal • Correlate times (alarms, work, drive time TV) • Corroborate time with witness • Bring witness to ER or at least obtain phone number where they can be reached

  21. Details of Facial Droop

  22. Details of Arm Drift

  23. Acute Management: Vitals A B C • Airway - secure? • Breathing - O2 Sat, CHF? • Circulation - BP too high or too low? A-Fib?

  24. Acute Management: History • Symptom onset or time last seen normal • Correlate times (alarms, work, drive time TV) • Corroborate with witness • Prodromal or previous symptoms/TIAs • Exclude stroke mimics (seizure,migraine hypoglycemia, orthostasis)

  25. Is the patient a thrombolytic candidate? • Onset < 6 hrs • CT negative for hemorrhage • Not anticoagulated (INR <1.5) NO YES  Keep BP < 220/120  ASA 325mg chewed  DVT prophylaxis -Heparin 5000 SQ BID •  Keep BP <185/110 •  < 3 hrs • -IV tPA •  3-6 hrs • -Intra-arterial t-PA

  26. Blood Pressure Management in Acute Ischemic Stroke No thrombolytics Thrombolytics BP >220/120 MAP>130 requires Labetalol 10-30 mg IV q 10-15min Enalapril 0.625-1.25 mg IV q 6-8hrs prn Nitroprusside 0.5-1.0 µg/kg/min cont. IV Nicardipine 2.5-15 mg/hr continuous IV DBP> 140 Nitroprusside 0.5-1.0 µg/kg/min cont. IV Nicardipine 2.5-15 mg/hr continuous IV BP > 185/110 Nitropaste 1-2 inches Labetalol 10-30 mg IV q 10-15min Enalapril 0.625-1.25 mg IV q 6-8hrs (watch for angioedema)

  27. Heparin ISNOT an acute treatment for stroke • There are no large randomized placebo controlled studies using IV heparin in acute ischemic stroke. • Prospective case series have had mixed results • Our best guide is from the International Stroke Trial (IST)

  28. International Stroke Trial (IST)Lancet 1997;349:1569-1581 19,435 (AIS < 48˚) Heparin (9717) No Heparin (9718) 12,500 IU*(4856) 5000 IU*(4860) ASA(2430) No ASA(2426) ASA(2432) No ASA(2429) ASA(4858) No ASA(4860) *Heparin 12,500 and 5000 Sub-Q BID; ASA 300 mg

  29. International Stroke Trial (IST)Lancet 1997;349:1569-1581

  30. International Stroke Trial (IST)Lancet 1997;349:1569-1581 • Net effect is zero • Increased rate of bleeding in the heparin group off-sets any benefit

  31. Aspirin IS a treatment for acute ischemic stroke • International Stroke Trial (IST) and Chinese Acute Stroke Trial (CAST) • ASA allocated patients (n= 40,000) had significantly fewer recurrent stroke at 14 days • ASA benefit was not off-set by an increase in hemorrhagic strokes • Significant reduction in death or any non-fatal stroke • ASA did contribute to significantly more transfused or fatal extracranial bleeds

  32. Aspirin IS a treatment for acute ischemic stroke Give ASA 160-325mg for acute stroke

  33. Stroke Therapy Pre t-PA

  34. Stroke Therapy: Thrombolytic Era

  35. “Time is Brain” • Treatment of stroke is a salvage procedure • Permanent deficits are dependent on: • Regional cerebral blood flow • Duration of ischemia • Experimental evidence demonstrates that significant volumes of neuronal tissue can be salvaged by reperfusion within the first 4 - 6 hours

  36. Thrombolytic Therapy for Acute Ischemic Stroke Onset of Symptoms Therapy < 3 hours IV t-PA 3-6 hours IA t-PA

  37. Fibrinolytic Therapy: Yes/No Checklist Inclusion Criteria (all “Yes” boxes must be checked before fibrinolytics are given) Yes  Age 18 years or older  Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit  Time of symptom onset well established to be <180 minutes before treatment would begin

  38. Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (all “No” boxes must be checked before fibrinolytics are given): No  Evidence of intracranial hemorrhage on noncontrast head CT  Only minor or rapidly improving stroke symptoms  High suspicion of subarachnoid hemorrhage even if CT is normal  Active internal bleeding (eg, gastrointestinal bleeding or urinary bleeding within last 21 days)  Known bleeding diathesis, including but not limited to — Platelet count <100 000 mm3 — Patients who received heparin in last 48 hours; have elevated PTT — Recent anticoagulant use (eg, coumadin); have elevated PT

  39. Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (cont’d) (all “No” boxes must be checked before fibrinolytics are given): No  <3 mo ago: intracranial surgery, head trauma, previous stroke  <14 days ago: major surgery or serious trauma  <7 days ago: lumbar puncture  Recent arterial puncture at noncompressible site  History of intracranial hemorrhage, AV malformation, or aneurysm  Witnessed seizure at start of stroke  Recent acute myocardial infarction  SBP >185 mm Hg/DBP >110 mm Hg; confirmed several times  BP must be treated aggressively to bring within these limits

  40. Montana Stroke Initiative http://montanastroke.org

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