Latest Trends in Care of the Stroke Patient

1. Latest Trends in Care of the Stroke Patient William J. Meurer, MD Clinical Lecturer and Stroke Fellow University of Michigan Stroke Program Departments of Emergency Medicine and Neurology

2. Objectives • Review concise clinical pearls in caring for the acute stroke patient • Review results of past research that may influence your practice • Discuss recently announced acute stroke research • Provide overview of ongoing research which may influence your practice in future

3. Disclosures • My salary is provided by the University of Michigan • No other financial support • I WILL discuss some off label uses of medications

4. Overview • Review scope and disease process of stroke • Review clinical guidelines and pearls • Discuss recent advances • Discuss ongoing national and local research

6. Annual rate of first cerebral infarction by age, sex and race (Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94).Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31.

7. Smoothed County Stroke Death Rates: Adults 35 and Older, 1991-98 Source: CDC. Atlas of Stroke Mortality: Racial, Ethnic and Geographic Disparities in the United States, Jan. 2003

8. Michigan’s Stroke Belt Source : The Atlas of Stroke Mortality

10. Acute Stroke / ASA Guidelines • tPA if indicated and exclusions absent • Anti-platelet within 48 hours (do not give with tPA) • Permissive hypertension • No IV anticoagulants (i.e. heparin) – DVT prophylaxis okay (after 48 hr if tPA given) • CT remains standard acute imaging

11. ASA guidelines – ischemic stroke • If not receiving thrombolytics • Do not treat unless SBP > 220 or DBP > 120 • If receiving thrombolytics treat if • PreRx SBP > 185 DBP > 110 • PostRx SBP > 180 DBP > 105

12. Doesn’t ACEP also have a guideline? • Has practice guideline • www.acep.org – type acute stroke into search box • I recommend you read it yourselves if interested

13. Copied from ACEP website verbatim • EDs and hospitals should work with emergency medical services and the community so that all parties know what the hospital's capabilities are regarding acute stroke care. • Further studies are needed to define more clearly those patients most likely to benefit from fibrinolytic therapy in acute ischemic stroke.

14. Copied from ACEP website verbatim • Intravenous tPA may be an efficacious therapy for the management of acute ischemic stroke if properly used incorporating the guidelines established by the National Institute of Neurological Disorders and Stroke (NINDS).

15. Copied from ACEP website verbatim (bolding mine) • There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical practice when systems are not in place to ensure that the inclusion/exclusion criteria established by the NINDS guidelines for tPA use in acute stroke are followed. Therefore, the decision for an ED to use intravenous tPA for acute stroke should begin at the institutional level with commitments from hospital administration, the ED, neurology, neurosurgery, radiology, and laboratory services to ensure that the systems necessary for the safe use of fibrinolytic agents are in place.

16. tPA

21. A. Hernandez, M.I. Rochera, R. Angles, M. Farre, J. Caballero: Hemorrhagic Transformation And A New Ischemic Accident During Thrombolysis Treatment With rtPA. The Internet Journal of Emergency and Intensive Care Medicine. 2006. Volume 9 Number 1

22. Acute stroke - summary • Time is brain (notify, notify, notify) • tPA is your friend • Watch for fluctuation • Treat fever • Consider treating hyperglycemia • Use crystalloid (think perfusion) • Avoid dropping BP in ischemic stroke • Acute Stroke Protocol in place and ready to go!

23. Important advance – primary stroke centers • Acute Stroke Teams • Written Care Protocols • Emergency Medical Services • Emergency Department • Stroke Unit • Neurosurgical Services • Support of Medical Organization • Neuroimaging • Laboratory Services • Outcomes/Quality Improvement • Education Programs

24. Primary Stroke Centers (JCAHO)

25. Florida Stroke Act • Required EMS to take patients to primary stroke centers (JCAHO or state certified) • Resulted in significantly increased utilization of tPA at certified centers • Resulted in increased stroke volume at certified centers

26. Important Advance – Stroke Units • Outcomes improved (trends) • Decreased disability • Reduced discharges to nursing homes • Reduced mortality • Behavior changed • Increased use of tPA

27. Important advance – telemedicine

28. Disclaimer • Discussion from this point (other than summary) is regarding experimental therapies • Some of these may be offered to patients at centers in Michigan currently • Some may not • Some may turn out not to work…

29. Options other than tPA • Intra-arterial tPA (up to 6 hours) • MERCI retrieval (up to 6-8 hours) • Either could be considered in selected cases when systemic tPA contra-indicated or outside 3 hr window • Severity requirement Source: Imaging Economics, November 2005

30. MERCI Device Source: St. Petersburg Times, October 2003

31. Recent Negative Research • NXY-059 (SAINT II) • Neuro-protective agent • Primary outcome not reached • NovoSeven • Recombinant Factor VIIa • Hemostatic agent (ICH) • Primary Outcome Not Reached • No longer seeking FDA approval

32. Activated Factor VIIa

33. NXY-059 (SAINT-II)

34. Ongoing Acute Stroke Research at UMHS • Multi-center • CLEAR • TNK • INSTINCT • NETT

35. TNK / CLEAR • Studying alternate thrombolytic regimens to tPA • Similar inclusion • Similar outcome measures • Proposed as potentially safer agents

36. INSTINCT • Multi-center trial • Targeted educational intervention • Involves 24 hospitals in Michigan • Primary endpoint is appropriate use of tPA

37. NETT • A multi-center network to engage in acute treatment trials in Neurologic Emergencies • System of hubs and spokes • U of M is clinical coordinating center • Henry Ford and Wayne State are hubs

38. What is being studied elsewhere • Encouraging pilot / safety studies • Highlighting therapies which may have impact on acute care in future

39. IMS-2 • 2/3 of standard dose tPA given (0.6 mg/kg) • Cerebral angiogram • Additional bolus and infusion at embolism site

40. CLOTBUST

41. Therapeutic hypothermia • Recommended therapy for comatose survivors of out of hospital cardiac arrest • Feasibility study done in stroke – further work ongoing

43. Prehospital Magnesium • Novel system in LA county • IV magnesium sulfate given to patients identified in the field with severe acute ischemic stroke • www.fastmag.info

44. Summary – take home points • Time to treatment is key • Treat fever / hyperglycemia • Permissive HTN in acute ischemic stroke • There are options beyond 3 hours • A great deal of exciting research is going on in Michigan and around the world

45. The University of Michigan Comprehensive Stroke Program Neurosurgery Julian T. Hoff, MD B. Gregory Thompson, MD Cardiology Kim A. Eagle, MD Neurology Lewis B. Morgenstern, MD Director Devin L. Brown MD, MS Michael M. Wang MD PhD Kate Maddox, RN Darin Zahuranec, MD Jennifer Majersik, MD William Meurer, MD Radiology Ellen Hoeffner, MD Dheeraj Gandhi, MD Joe Gemette, MD Epidemiology Lynda D. Lisabeth PhD Mary N. Haan, PhD Emergency Medicine William G. Barsan, MD Phillip A. Scott, MD Robert Silbergleit, MD Shirley Frederiksen, MS, BSN Annette Sandretto, MSN William Meurer, MD Physical Medicine & Rehabilitation Lisa DiPonio, MD

46. University of Michigan Stroke Program • Website – www.med.umich.edu • My email – wmeurer@umich.edu • Please feel free to contact me if you would like an educational program at your site!