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Stroke CRASH: Critical Reviews and Skills Enhancement

Stroke CRASH: Critical Reviews and Skills Enhancement. J. Stephan Stapczynski, MD Chair, Department of Emergency Medicine University of Arizona College of Medicine – Phoenix Maricopa Medical Center. Objectives. Appropriate assess patients with acute cerebrovascular syndrome

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Stroke CRASH: Critical Reviews and Skills Enhancement

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  1. StrokeCRASH: Critical Reviews and Skills Enhancement J. Stephan Stapczynski, MD Chair, Department of Emergency Medicine University of Arizona College of Medicine – Phoenix Maricopa Medical Center

  2. Objectives • Appropriate assess patients with acute cerebrovascular syndrome • Distinguish TIA from CVA • Be aware of the various types of CVA including location • Develop appropriate treatment plan for CVA patients

  3. Assessment • Prehospital and Triage screening • FAST: Face Arm Speech Test • MASS: Melbourne Acute Stroke Scale • ED assessment • ROSIER: Recognition of Stroke in the Emergency Room • NIHSS: NIH Stroke Scale

  4. Face-Arm-Speech-Time • Face • Ask patient to smile or show teeth • Look for NEW lack of symmetry, unequal smile, or grimace • Arm • Lift the patient's arms together to 90° if sitting, 45° if supine and ask them to hold the position for 5 seconds then let go • Does one arm drift down or fall rapidly? • Speech • Look for NEW disturbance of speech • Slurred speech, word-finding difficulties • Time

  5. Recognition of Stroke in the ER Score  +1 = sensitivity of 93% and specificity of 83% for acute ischemic stroke LR+ = 5.4 and LR- = .08

  6. NIH Stroke Scale • Structured neurological exam: 11 elements, total ranges 0 to 42 • Validated tool for detection of significant deficits •  22 to 25 → large stroke •  4 → small stroke • Value as an educational tool • Thrombolytic screening tool • http://www.nihstrokescale.org/docs/NIH_Stroke_Scale.pdf

  7. NIH Stroke Scale

  8. Not typical of acute cerebrovascular disease if in isolation • Confusion: important to exclude dysphasia • Impaired consciousness • Amnesia • Dizziness or lightheadedness • Generalized weakness – simultaneous bilateral weakness • Sensory symptoms – pain, tingling, paresthesias • Fainting or syncope • Incontinence: bladder or bowel • Bilateral blurred vision • Evolution of symptoms – spread from one body part to another, or gradual change in character of symptoms

  9. Stroke Mimics • Hypoglycemia • CNS mass lesions • Seizures and postictal state • Complicated migraine • Encephalopathies and toxic-metabolic conditions • Decreased LOC and normal eye movements increase the odds of a stroke mimic being present

  10. Stroke – Initial Stabilization • Airway and Breathing • Protect from aspiration and hypoxemia • Vitals / O2 (if SaO2 < 95%) • IV access (isotonic fluids only) • Labs • Glucose, electrolytes, CBC • Consider cardiac markers, tox screen, coagulation tests • EKG • Order Non-Contrast Head CT • Neurological Assessment First 10 Minutes!

  11. Stroke – History and Examination • Onset and scenario • Significant comorbidities and medications • Review contraindication list for thrombolytics • General PE • NIH Stroke Scale or Canadian Neurologic Scale • Start CT ! Within 25 Minutes!

  12. TIA • 2009 AHA definition of a TIA • Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction. • TIME ELEMENT REMOVED • Three pathophysiologic subtypes: • Large artery TIA-low flow: carotid stenosis or other proximal stenosis • Embolic TIA: artery to artery, cardioembolic, or unknown source • Lacunar or small vessel TIA

  13. TIA - Duration • “Most” 5-10 min • “Majority” resolve within 1 h  60% • If duration > 1 h and patient seeks medical attention • Stroke: NINDS 1995 study - if not rapidly improving over 3 h, less than 2% will resolve within 24 h → 98% have stroke • Stroke: Cornell 1988 study - about 14% resolve within 24 h → 86% have stoke • Large artery or embolic stoke ~ 6:1

  14. TIA - Examination • History • Duration: <10min, 10‐60min, >60 min • Evidence to suggest non‐vascular cause • Vascular risk factors • Exam: Neurologic deficits? • Carotid bruits: note limitations • Cardiac abnormalities: arrhythmia, murmur • Symptoms reproducible with maneuvers • ECG, Monitor • Labs: CBC, glucose, chemistries, PT

  15. Stroke Risk after TIA • Rate of stroke after TIA • ~12% in 90 days after TIA • ~ 5% in first 2 days • Averages, risk higher with • Large artery stenosis – arterioembolism • Atrial fibrillation – cardioembolic source • Age > 60 • Diabetes • Duration > 10 min • Dysphasia or motor deficit

  16. TIA Stroke Risk Assessment: ABCD2 score

  17. Stroke Risk According to ABCD2 Score

  18. TIA - Disposition Decisions • Discharge for outpatient work up – can this be accomplished within 2 days? • Continue work up in the ED – competition with other ED patients for care • Admit or observe – the benefits of hospitalization are unknown (SC Johnson – NEJM 2002)

  19. TIA - Management • Manage comorbidities aggressively • BP <130/85 • LDL <100 • FBS < 126 • Discontinue Tobacco, excessive EtOH • Physical activity (30-60min 3-4 x wk) • Discontinue HRT • Utilize antithrombotic agents

  20. TIA - Post-ED Care and Assessment • Serial Neuro Exams • To detect developing stroke • Unit staff physician and a neurology consult • Cardiac monitoring • To detect paroxysmal atrial fibrillation • Carotid Doppler's • To detect 50-70% stenosis • 2-D Echocardiogram • Detect PFO, valvular heart disease, mural thrombus, aortic arch disease • When no cause identified by other means

  21. TIA - Antithrombotic Therapy • Cardioembolic source (Atrial Fibrillation) • Warfarin: INR goal 2.5 (2 to 3) • Initiate with bridging therapy using UFH or LMWH • Atherothrombotic source(Class IIa, Level A) • ASA 50-325 mg daily • Extended Release Dipyridamole (200 mg) + ASA (25 mg) bid (best outcomes in studies thus far) • Clopidogrel 75 mg daily

  22. TIA Treatment

  23. Aspirin for TIA • Standard treatment • Acute protection • 30% relative risk reduction in stroke (0.7% absolute risk reduction) • 25% relative risk increase in ICH (0.2% absolute risk increase) • Long-term protection • 22% relative risk reduction in stroke, MI and vascular death

  24. Clopidogrel for TIA • Clopidogrel alone • Long-term: 9% relative risk reduction in stroke, MI and vascular death • Aspirin + Clopidogrel • Long-term: 34% relative risk reduction in stroke, recurrent TIA, ACS and death compared to aspirin alone

  25. Cerebral Circulation

  26. Major Vascular Territories

  27. CVA Location • Carotid circulation • Contralateral weakness • Ipsilateral blindness • Dominant hemisphere: dysphasia, aphasia, or speech apraxia • Posterior circulation • Vertigo • Dysphagia, dysarthria • Diplopia • Blindness • Truncal or limb ataxia • Impaired consciousness

  28. Hemorrhagic Ischemic CT Read – within 45 min

  29. Cause: 15% of all stroke Primary (70-90%): Hypertension, amyloid angiopathy Secondary (10-30%): Vascular malformation (aneurysm, AVM), Tumor, Thrombolytic agents, Manifestation Rupture of blood vessel with surrounding tissue damage symptoms of increased ICP: severe headache, nausea/vomiting, altered mental status/coma KEY POINTS - Non-contrast CT positive for bleed - 50% mortality (80% of survivors with permanent disability) - ICP monitoring - Neurosurgical intervention Hemorrhagic Stroke

  30. Hemorrhagic Stroke • Neurosurgery consult • Manage ICP • Mannitol: transient benefit • Surgical decompression • Blood Pressure • 90% have acutely elevated BP (usually >160/90) • Goal of MAP <130 • Safe to reduce by 20% in controlled fashion • Labetalol, esmolol, nitroprusside • ICU • Manage comorbidities

  31. Cause: 85% of all strokes Thrombotic: atherosclerosis Embolic: Atrial fibrillation, prosthetic valve Vasoconstriction: eclampsia Manifestation Occlusion of artery to specific area of brain causes specific neurologic syndrome middle cerebral artery: contralateral hemiplegia, hemianesthesia, homonymous hemianopia KEY POINTS Evaluate appropriateness of fibrinolytic therapy - 3 hour window - Non-contrast CT negative for bleed - No contraindications Ischemic Stroke

  32. Fibrinolytic Indications • New symptomatic ischemic stroke with clearly defined onset AND • Onset of symptoms to tPA < 3.0 hours (3 to 4.5 hours with warnings ) AND • Non-contrast CT showing no intracranial hemorrhage or well-established acute infarct (>1/3 MCA territory) AND • No contraindications

  33. Fibrinolytic Contraindications • Age < 18 • CT scan findings (intracranial hemorrhage, or major acute infarct signs) • Suspicion of subarachnoid hemorrhage (even if head CT is negative ) • Recent (within 3 months) major surgery or trauma • History of intracranial hemorrhage , brain aneurysm, vascular malformation, or brain tumor • Known bleeding diathesis OR • Current use of oral anticoagulants with INR > 1.7 or PT > 15 seconds • Use of heparin within 48 hours AND prolonged aPTT • Platelets <100,000 • Internal hemorrhage (GI hemorrhage, urinary tract hemorrhage) < 3 weeks • Dabigatran use in the past 48 hours • Low molecular weight heparin use (i.e.- enoxaparin) in the past 24 hours. • Persistent systolic BP >185 mm Hg or diastolic BP >110 mm Hg despite treatment.

  34. Alteplase (tPA) only FDA approved agent for ischemic stroke Consent patient Risk ICH rate of 6% (up to 15% if guidelines not followed) Benefit Improved 24 hour recovery: mean 8 vs 12 on NIHSS Improved 3 month recovery: 30% improvement Reduced 3 month death/severe disability: 4% Increase in patients with excellent 3 month outcomes: 11-13% Meets Fibrinolytic Criteria

  35. Alteplase (tPA) Therapy • 0.9mg/kg tPA IV 10% bolus & rest over 60 min • Monitor for ICH • No anticoagulants or antiplatelets agents for 24 hours • Blood Pressure • Pretreatment goal: SBP<185 and DBP<110 • Labetalol, esmolol, Nitro paste, Nicardipine infusion, Nitroprusside • During/Post-treatment: maintain at or below goal in controlled fashion

  36. Expanded fibrinolytic window • Additional contraindications for patients treated with alteplase between 3 to 4.5 hours • Age > 80 • History of prior stroke AND diabetes • Any anticoagulant use prior to admission (even if INR <1.7) • NIHSS >25 • Risk: 8% ICH rate (ECASS-3) • Benefits: Improved 3-month outcome – 7% absolute increase in percent of patients modified Rankin Scale score of 0 to 1 (45% to 52% in ECASS-3)

  37. Acute Ischemic Stroke – Supportive Care • Supplemental oxygen only if SaO2 drops below 95% • Maintain a blood glucose concentration between 4 and 11 mmol/l • Antihypertensive treatment only if there is a hypertensive emergency • Benign neglect up to 220/120 • If greater 220/120 • 10-15% reduction • Labetalol, esmolol, nitroprusside, nicardipine • Screen for swallowing difficulties before giving any oral food, fluid, or medication • Continue prior statin therapy: statin withdrawal associated with a 4.7-fold increase in the risk of death or dependency at 3 months

  38. Questions?

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