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Lecture Goals

Ischemic Anterior Circulation Stroke Edward C. Jauch, MD, MS Assistant Professor Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati, OH and Greater Cincinnati/Northern Kentucky Stroke Team. Lecture Goals.

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Lecture Goals

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  1. Ischemic Anterior Circulation StrokeEdward C. Jauch, MD, MSAssistant ProfessorDepartment of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnati, OHandGreater Cincinnati/Northern Kentucky Stroke Team

  2. Lecture Goals • Review Emergency Department evaluation of acute ischemic stroke • Identify issues specific to thrombolytic therapy in acute stroke • Identify treatment options for acute ischemic stroke Introduction

  3. 61 year old male, with acute aphasia, right facial droop, and right sided weakness • 12:30 Sudden onset while working in yard • 12:45 Family calls 911 • 13:05 Advanced squad evaluates and rapidly transports • 13:15 Squad notifies receiving hospital of possible stroke patient Case

  4. 61 year old male with possible stroke arrives at Our Lady of Faint Hope • 13:30 ED triage and physician evaluation • 13:45 Stroke Team responds • 14:00 CT scan performed • 14:15 Discuss with family and PMD • 14:20 Labs back: gluc 97 BP remains 150/70’s Case

  5. Item Description Score 1a 1b 1c 2 3 4 5 6 7 8 9 10 11 12 13 Level of Consciousness LOC Questions LOC Commands Best Gaze Best Visual Facial Palsy Motor Arm Left Motor Arm Right Motor Leg Left Motor Leg Right Limb Ataxia Sensory Neglect Dysarthria Best Language 0 0 0 1 1 2 0 2 0 2 0 1 0 0 1 Neurologic ExaminationNIH Stroke Scale Case

  6. 61 yo male with possible stroke • 14:20 CT reading: No hemorrhage or early ischemia • 14:25 Checklist done: No exclusion criteria met • 14:30 Decision time Case

  7. Impact of Stroke • 3rd leading cause of death in the U.S. • A leading cause of adult disability • 600,000 new strokes per year in U.S. • 85% are ischemic Introduction

  8. Death Rates from Stroke Epidemiology (Dept Health and Human Services)

  9. Stroke Outcomes • In the 4.5 million US stroke survivors: 10% Recover almost completely 25% Recover with minor impairments 40% Experience moderate to severe impairments requiring special care 10% Require care in a nursing home or other long-term care facility 15% Die shortly after the stroke (NSA, 2001) Outcomes

  10. Stroke Outcomes • Medical morbidity associated with stroke: 30% Develop pneumonia within first month 10% Risk of recurrent stroke per year 10% Deaths post-stroke from pulmonary embolisms • Other morbidity from stroke: 23% Develop multi-infarct dementia 70%* Develop depression (27% major) 40% Depression common among care-givers Outcomes • *High end of estimates

  11. Modifiable risk factors High blood pressure Cigarette smoking Transient ischemic attacks Heart disease Diabetes mellitus Hypercoagulopathy Carotid stenosis Other Unmodifiable risk factors Age Gender Race Prior stroke Family History Other possible risk factors Sickle cell disease Apolipoproteins Others Stroke Risk Factors Epidemiology

  12. Influence of Initial Medical Contacton Arrival Times to the E.D. Epidemiology (Barsan, Arch Int Med, 1993)

  13. Detection • What are Signs & Symptoms? • 43% general public didn’t know any • 39% of acute stroke patients didn’t know any • What are Risk Factors? • 32% general public didn’t know any • 43% of acute stroke patients didn’t know any (Pancioli JAMA 1998; Kothari Stroke 1997)

  14. Where Are We Today? • Poorly informed • Too slow • Too late • Ill prepared • Fatalistic Epidemiology

  15. Forces of Change • Public expectations • Aware of “Draino for the Braino” • Nihilistic attitude of stroke changing • Medical - legal pressures • Managed care cost concerns • New treatments of stroke on horizon • Change in treating physicians perceptions of “risk” Epidemiology

  16. 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 (Jorgensen, Stroke 1994) Epidemiology

  17. Patient Aversion to Various Stroke Outcomes Aversion: (Solomon, Stroke 1994) Epidemiology

  18. Tissue-Plasminogen Activator inAcute Ischemic Stroke • Double-blinded, randomized • Placebo controlled • 0.9 mg / kg IVP dose • 624 patients • Treated within 3 hours • 1/2 within 90 minutes • 1/2 within 91-180 minutes Management

  19. Benefits of Thrombolyticsin the NINDS Trial For every 16 patients: No/Minimal Moderate Severe Dead

  20. Relationship of Time to Thrombolytic Treatment Odds Ratio of Favorable Outcome Time is Brain! Odds Ratio for Favorable Outcome at 3 Months Benefit for rt-PA No Benefit for rt-PA Minutes from Stroke Onset to Start of Treatment Management

  21. Symptomatic Hemorrhages by CT Findings in NINDS Trial Percent of Patients that Developed Symptomatic Hemorrhages % Edema or Mass Effect Seen on Initial CT (Broderick, Stroke 1997)

  22. Symptomatic Hemorrhages by Baseline NIHSS in the NINDS Trial Percentage of t-PA Patients with Symptomatic ICH (Broderick, Stroke 1997)

  23. Cost Effectiveness for rt-PA in Acute Ischemic Stroke rt-PA placebo p value LOS 10.9 12.4 0.02 Discharge home 48% 36% 0.002 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 (Fagan, Neurology 1998) Epidemiology

  24. STARS Study • Prospective Phase IV study mandated by FDA • Multicenter (24 academic, 33 community) • NINDS protocol used for 389 patients • Median times: Onset to treatment 2.7 hrs Arrival to treatment 1.6 hrs Less than 4% treated in under 90 mins • Median NIHSS 13 (14 mean) (Albers, JAMA 2000) Management

  25. STARS Study • Results – Outcome • Favorable outcome 35% (mR1) • Functionally independent 43% (mR2) • 30 day mortality rate 13% • Results – Complications • Symptomatic ICH* 3.3% * Within 3 days • Fatal ICH 1.8% (Albers, JAMA 2000) Management

  26. STARS Study • Predictors of favorable outcome • Baseline NIHSS < 10 • Absence of significant CT abnormalities • Age < 85 years • Lower mean arterial pressure • Predictors of lack of response • NIHSS (22% decrease in OR per 5 points) • NIHSS > 10 75% decrease in OR • Significant CT findings 87% decrease in OR • Increased mean arterial pressure 19% decrease in OR (Albers, JAMA 2000) Management

  27. Cleveland Area Experience • Historical prospective cohort study • Conducted July 1997 through June 1998 • Multicenter –29 hospitals (academic and community) • No coordination or fixed protocol (NINDS protocol assumed) • 3948 patients reviewed (Katzen, JAMA 2000) Management

  28. Cleveland Area Experience • Results – • 3984 AIS patients admitted to 29 hospitals in 1 yr • 17% admitted within 3 hours of stroke onset • 1.8% received t-PA at 16 hospitals (0 - 10.2% of stroke patients) • Of the top 4 hospitals in Cleveland, utilization ranged from 0-28% within 3 hour window (Katzen, JAMA 2000) Management

  29. Cleveland Area Experience • Results – Complications in tPA patients • Total ICH rate 22% • Symptomatic ICH* 15.7% • Fatal ICH 8.6% • Results – Mortality rate • tPA patients 15.7% • Patients in 3 hours ø tPA 7.2% • All patients ø tPA 5.1% (Katzen, JAMA 2000) Management

  30. Cleveland Area Experience • Results – Protocol violations • Total NINDS violations 50% • Antiplatelets / anticoagulants 37.1% • Beyond 3 hours 12.9% (3.15-6.25 hrs) • Risk of complications not associated with protocol violations (p=0.74) (Katzen, JAMA 2000) Management

  31. How to Evaluate and Treat Acute Ischemic Stroke in 2000 Evaluation

  32. Acute Myocardial Infarction This paradigm has shifted – • Chest pain / SOB / dysrhythmia • Rapid access to EMS • Prehospital identification and call • Prehospital ECG • Team and protocols in place in ED • “Door to Drug - 30 Minutes” • What is the mortality and morbidity? Evaluation

  33. 2000 American Stroke AssociationNew Guidelines • EMS systems should implement a stroke protocol • Potential fibrinolytic candidates should be taken to hospitals capable of providing acute stroke care • E.D. AIS triage should be similar to AMI • Intravenous fibrinolysis for AIS is Class I • Intra-arterial fibrinolysis for AIS is Class IIb (ASA, Circulation 2000) Evaluation

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

  35. Door-to-MD: 10 minutes Door-to-Stroke 15 minutes Team notification: Door-to-CT scan: 25 minutes Door-to-Drug: 60 minutes (80% compliance) Door-to-Admission: 3 hours NIH Symposium Recommendations Evaluation

  36. Detection: Stroke Public Awareness Evaluation

  37. Dispatch: Call 911Delivery: Transport & Management • Priority dispatch • ABC’s • Time of onset • Neurological evaluation / Prehospital stroke scale • Check glucose • Stroke recognition • Early hospital notification • Rapid Transport Evaluation

  38. Door: Emergent TriageData: ED Evaluation Evaluation

  39. Check glucose Two large IV lines Oxygen as needed Cardiac monitor Continuous pulse-ox Non-contrast CT scan ECG CXR Perform the NIH stroke scale Get rt-PA Prepare to mix Have pharmacy alerted Make sure family is available Contact primary care provider Preparation Evaluation

  40. Preparation • Systems and personnel need to be in place • Know your Stroke Team before you need them! Evaluation

  41. General Stroke Management • Oxygen • Use to correct hypoxia • Suggestion it may hurt one year survival 69% 3L NC vs 73% control • Glucose • Maintain euglycemia • Treat glucose < 50 with D50 • Treat glucose > 300 mg/dl with insulin (Rønning, Stroke 1999) Evaluation

  42. General Stroke Management • Cardiac monitor • Observe for ischemic changes or atrial fibrillation • Intravenous fluids  • Avoid D5W and excessive fluid administration • IV normal saline at 50 cc / hr unless otherwise required • NPO • Aspiration risk is great, avoid oral intake until swallowing assessed • Temperature • Avoid hyperthermia, PO/PR acetaminophen prn Evaluation

  43. The True Time of Onset • Multiple sources • How normal were they? • Who saw them this morning? • Clearly no symptoms? • Times of reference • The time the basketball game started Evaluation

  44. Value of the NIHSS: Correlates with size of stroke and prognosis Strokes with NIHSS < 4 do well and are not typically thrombolytic candidates Strokes with NIHSS > 20 are large with extremely poor prognosis and fair response to IV thrombolytics Item Description Score 1a 1b 1c 2 3 4 5 6 7 8 9 10 11 12 13 Level of Consciousness LOC Questions LOC Commands Best Gaze Best Visual Facial Palsy Motor Arm Left Motor Arm Right Motor Leg Left Motor Leg Right Limb Ataxia Sensory Neglect Dysarthria Best Language 0-3 0-2 0-2 0-2 0-3 0-3 0-4 0-4 0-4 0-4 0-4 0-2 0-2 0-2 0-3 Neurologic ExaminationNIH Stroke Scale Evaluation

  45. Middle Cerebral ArteryStroke Syndromes • Dominant hemisphere Contralateral hemiparesis arm, face > leg Contralateral sensory loss Contralateral homonymous hemianopia; Ipsilateral eye deviation Broca’s and Wernicke’s aphasias • Non-dominant hemisphere Contralateral hemiparesis arm, face > leg Contralateral sensory loss with extinction Contralateral homonymous hemianopia; Ipsilateral eye deviation Dysarthria without aphasia Ipsilateral hemineglect, inattention, extinction on double stimulation Evaluation

  46. Anterior and Posterior Cerebral Arteries Stroke Syndromes • Anterior Cerebral Artery Contralateral hemiparesis leg > arm, face Contralateral sensory loss Change in personality, speech perserveration Bilateral occlusions produce paraplegia, anarthria, akinetic mutism • Posterior Cerebral Artery Contralateral hemianopia (patients frequently unaware) Brain stem findings (varied) Bilateral occlusions produce cortical blindness Evaluation

  47. Loss of insular ribbon Loss of gray-white interface Loss of sulci Acute hypodensity* Mass effect* Dense MCA sign Early CT Changes in Ischemic Stroke * Relative contraindication Evaluation

  48. Considerations:Who will it and won’t it help • Factors associated with worse outcomes: • Increased patient age • History of diabetes mellitus • Increased time from onset • Increased blood pressure • Increased stroke severity • Baseline CT findings of stroke • All subgroups (age, race, gender, co-morbid illnesses, and stroke location and size) benefited from thrombolytics compared to placebo in the NINDS trial Evaluation

  49. Treatment initiated > 3 hours Increased thrombolytic dose Elevated blood pressure NIHSS > 20 Acute hypodensity or mass effect on baseline CT Factors Associated with Increased Risk of ICH Evaluation

  50. Differential Diagnosis • Intracerebral hemorrhage • Hypoglycemia / Hyperglycemia • Seizure • Migraine headache • Hypertensive crisis • Epidural / subdural • Tumor • Meningitis / Encephalitis / Abscess Evaluation

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