2013.stroke areyouready
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DURING A STROKE…
YOU LOSE TWO MILLION BRAIN CELLS PER MINUTE!
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Stroke… Are You Ready?2013
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Saint Luke’s Neuroscience Institute
StrokeBrain Tumor
EpilepsyMinimally Invasive Spine
Movement DisorderRehabilitation Brain Fitness
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Regional Networking
Treats > 1000 people ischemic and hemorrhagic
stroke annually
Come by helicopter or ambulance from more than
80 regional hospitals
Acute Treatment Rate Over 30%
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SLNI Acute Stroke Intervention2002 – 2012 (preliminary-rev. 1/22/13)
8.9%5.9%
8.2% 7.4%9.4% 8.9% 9.8%
15.9%18.6% 18.9%
16.5%
3.8%
1.8%
2.9%1.6%
1.4% 1.5%2.6%
2.5%
2.0% 1.5%
0.6%9.5%
4.7%
5.1%
3.6%1.8% 2.7%
5.3%
2.8%
3.6%1.6%
0.4%
1.2%
2.3%
1.8%
1.3%3.4% 2.0%
3.2%
3.0%
4.7%4.7%
5.0%
1.8%
9.6%
10.1%
9.6% 7.0%6.0%
8.5%5.6%
7.3%7.2%
2.9%
0.0170.0176991150442478
0.019
0.0150.023598820058997
0.028
A/S+ A/AS ret + ret ia iv-ia iv
25% 24% 28% 23% 29%23% 21% 30% 39% 38% 30%
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Did you know?Stroke ranks 4th in cause of death in the U.S.
Leading cause of serious, long-term disability
$72 billion spent on stroke care per year
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Review of Cerebral Anatomy
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Cerebrum – Frontal • Motor movement• Judgment• Emotion• Speech
– Expressive– Parietal
• Sensory• Speech
– Receptive – Temporal - hearing– Occipital – vision
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Speech Centers-Left Hemishpere
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Broca’s Area
• Expressive Aphasia
Wernicke’s Area
• Receptive Aphasia
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Review of Cerebral Anatomy Cerebellum - maintain balance and
further control of movement and coordination.
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Review of Cerebral Anatomy• Brain Stem - automatic
functions, such as control of respiration, heart rate, and blood pressure, wake-fullness, arousal and attention.
LOC – most sensitive indicator of cortical function
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Homunculus
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Homunculus
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Anterior Cerebral Artery Large Vessel
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Middle Cerebral Artery – Large Vessel
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Vertebral Arteries• originate from subclavian• ascend up spinal process
and form the Basilar artery
• Supplies spinal cord, brainstem, posterior lobes
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Posterior Cerebral Artery
• Supplies the temporal and occipital lobes, cerebellum
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Posterior Circulation
Bilateral cerebellar hemisphere infarcts.
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Circle of Willis
• Sits at the base of the brain
• Joins the anterior and posterior circulation.
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What is a Stroke?
…a plumbing problem
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Three Stroke Types
IschemicStroke
Clot occludingartery
Intracerebral Hemorrhage
Bleedinginto brain
Subarachnoid Hemorrhage
Bleeding around brain
Focal Brain Dysfunction
Diffuse Brain Dysfunction
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Right (Nondominant) Hemisphere Typical Signs: Left Side Weakness
Right Gaze Preference
Left Hemiparesis
Left Hemisensory
Loss
Left Hemi-inattention
(Neglect)Left Visual
Field Deficit
Due to pathology – if right hemisphere stroke (left muscles become paralyzed)– so only muscles working are the right.
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Left (Dominant) Hemisphere Typical Signs: Right Side Weakness and Aphasia
Aphasia
Left Gaze Preference
Right Hemiparesis
Right Hemisensory Loss
Right Visual Field Deficit
Hemiparesis: weakness or partial
paralysis
Hemiplegia: paralysis
Due to pathology – if left hemisphere stroke (right muscles become paralyzed)– so only muscles working are the left.
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• News reporter with aphasia
http://www.youtube.com/watch?v=xC2nC6NPYp4
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Cerebellum Typical Signs: Lack of Coordination
Ipsilateral (same side) Limb Ataxia (dyscoordination)
Truncal or GaitAtaxia (imbalance)Tremors, or Limb
Ataxia, result from lack of coordination of opposing muscle groups (flexors vs. extensors), causing the muscle groups to fight each other
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Brainstem Typical Signs: Cranial Nerve and Other Deficits
Oropharyngeal Weakness:
Dysarthria (speaking), Dysphagia (swallowing)
Eye Movement Abnormalities:
Diplopia
Dysconjugate Gaze
Gaze Palsy (horizontal gaze
deficit or gaze preference)
Decreased LOC
Nausea, Vomiting
Hiccups, Abnormal Respirations
Vertigo, Tinnitus
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Face
Arm S T
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F
A Speech T
You can’t teach an old dog new tricks
AphasiaDysarthria
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F
A S Time
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Last time known wellRouting planLocal-ready?
Bypass or not?This is CRUCIAL because time is the major determinant in what interventions may be effective—Time matters!“Time of onset” is often difficult to determine, so we default to the level of “time last known well”…Most of the TIME.
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Last time known wellRouting planLocal-ready?
Bypass or not?TCD—Local or state?
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Last time known wellRouting planLocal-ready?
Bypass or not?
Is your local facility stroke ready?
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Last time known wellRouting planLocal-ready?
Bypass or not?
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Door to Neurological Assessment….10 min
Door to CT….25 min
Door to CT/Lab interpretation….45 min
Door to Drug….60 min
The Golden Hour of Stroke Treatment
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Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
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Case Study #1
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82 femaleLeft-sided weaknessSlurred speechVision lossGaze deviationNeglect
PMH: atrial fibrillation, hyperlipidemia and hypertension
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NIHSS 9
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Perfusion Cerebral Blood Volume Mean Transit Time
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Penumbra versus No Penumbra
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CT Perfusion 2/6, 2/7
MTTCBF
CBV
Perfusion Map And CTA
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• Int rounds/embolectomyhttp://www.youtube.com/watch?
v=1cVwqNePlew
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Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
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MRI Perfusion
NIHSS 3 at 24 hours post-interventionDischarged with home health
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“ We wanted my mom to go to her community hospital…….the EMS crew said we needed to go to Saint Luke’s for stroke care and we are so thankful we listened”
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Case Study #2
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86 femaleSudden worst headache of her lifeDecreased LOC Visual disturbanceRight-sided weaknessAphasia
PMH: heart and lung disease and recently quit smoking
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Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
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Repeat CT—5 days later
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DispositionIn-patient Rehab
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Case Study #3
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74 y/o male EMS called at 0630 when wife found him Right hemiplegiaAphasiaLast known w/o stroke symptoms: 8pm the night before
PMH: renal disease, diabetes, htn, pacemaker & PVD
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NIHSS 23
Cerebral Angiogram: small clot in left MCA
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Cerebral Arteriogram
Small clot in the left MCA
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Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
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Cerebral Arteriogram
Successful intra-arterial thrombolysis of left MCA thrombus with restoration of
flow
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Pt. experienced vtach during procedure and converted without meds
NIHSS 9 at 24 hours post-procedure
He remained in the ICU longer than normal due to complicated medical history, but recovered well from his
stroke
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Case Study #479 y/o right-handed female
Sudden onset of right-sided weakness at 1030
EMS transported to local ED
Hx: Diabetes, CAD, Dyslipidemia, Stroke
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No acute CT findings
No exclusion criteria identified
Phone consult with Neurology at SLH
Collaborative decision made to start IV tPA and immediately transfer for possible further intervention
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Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
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NIHSS 3Improved following tPA CT Perfusion
No large vessel perfusion deficit
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CT HeadNo acute findings
Complete Resolution of Neurological Deficits
Discharged Home
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The Challenge Increase Access to IVtPA Safely
•Stroke treatment with IVtPA is time dependent•Patients will most likely present to the closest hospital•Earlier treatment is associated with better outcomes
•The presenting hospital may be able to administer IVtPA but cannot provide intensive monitoring during first 24 hours•The patient is transferred to a more comprehensive center
•Transfer protocols with IVtPA running are not standardized•Is it safe to “ship” the patient immediately after starting tPA?
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Is Immediate Transport Safe?• Retrospective review of consecutive “drip and
ship” cases 2008-2010.• Analysis– SICH or BP>180/105 on arrival– Inaccurate stroke diagnosis– Need for intra-arterial (IA) treatment– Mortality rate– Clinical outcome (mRS at 90 days)
• Location and Size of referring hospital
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Results
1626 ischemic strokes 717 (44%) were transferred
145 (20%) of transferred cases
were “drip and ship”
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63 Referring Hospitals
90% >10 miles63% >50 miles25% > 100 miles
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29 Critical Access Hospitals of <25 beds
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Results
Mean Age - 67.5 years
Mean admission NIHSS score - 10.4
Mean discharge NIHSS score - 3
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Blood Pressure on Arrival
1 SICH
•BP=183/77•MortalityNo
hemorrhage
•BP=232/84•Mortality10
/14
•mRS 0-2 at 90 days
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9.6% had BP >180/105
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Hemorrhage on Arrival
4 •4 (2.7%) cases had SICH on arrival•3 of these had BP <180/105
2 •2 mortalities related to SICH•1 mortality had BP>180/105
2 •Admit NIHSS 25; discharge NIHSS 4•Admit NIHSS 18; discharge NIHSS 10
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Outcomes
mRS 0-2 at 90 days = 72/114 (63%)Note: mRS scores not available for 2008
Mortality = 20/145 (13.7%) IA therapy = 35/145 (24%)Inaccurate diagnosis at sending facility = 6/145 (4.1%) ; all had excellent clinical outcomes.
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Gtt & Ship Data
• Immediate transport of patients with IV tPA infusing is safe with a low incidence of SICH en route
• >90% had BP <180/105 on arrival• The 63% good outcomes may, in part, relate to early
treatment with IV tPA in referring hospitals• Hospitals of every size and location can safely treat
stroke victims with IV tPA if they have access to consultation and transfer agreements with experienced stroke centers
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Case Study #552-year-old female
Sudden onset of difficulty speaking
Resolved upon EMS arrival
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10 hours later...Incomprehensible speech
Right sided paralysis
Left gaze deviation
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What does a mulligan have in common with a TIA?
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TIA Statistics…
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10% of all strokes are preceded by TIAs
1/3 of all persons who experience TIAs…will go on to have an actual stroke• 5% of those strokes will occur within ONE month• 50% within 48hours
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Tia—martinhttp://www.youtube.com/watch?v=1wx9fj-R-0s
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Mild StrokeNIH Stroke Scale: stroke severity scale (0-42)
<5 Mild impairment 10-20 Moderate impairment >20 Severe impairment
Predicted need for long-term nursing care <6 Most will return home 6-13 Most will need short-term hospital care >13 Most will need long-term nursing care
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Stroke Mimics
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Stroke Management Transport Protocols
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• Post IV tPA Treatment & Management• Document neuro assessment & blood pressure Q15min
• If change in neuro: STOP tPA, assess ABC’s & vitals & glucose
• Maintain BP<180/105 after administration and during transport
• Hypertension: Labetalol 10mg IV over 2min. Recheck in 5min; may repeat x1 (do not use if heart rate <60)
• Stop BP infusion if SBP<140 or DBP<80
• Hypotension: STOP tPA, HOB flat, turn off drips, 500ml fluid bolus(NS), reassess
• Start NS at 80ml/hr after infusion complete to clear line and continue if no hx of CHF
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Non-tPA treated patientsTarget BP—220/120
Follow blood pressure management protocol
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Hemorrhagic StrokeTarget BP < =160/90
Follow BP management protocol
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Follow-up
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MERCI Retriever “The Corkscrew”
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Outcomes for patients who received treatment with the Solitaire system during clinical trial:
• Brain artery opened 83% of the time in comparison to 48% with the Merci retriever catheter• Good clinical outcomes 58% of the time vs. 33% with Merci• 55% reduction in patient mortality at 3 months using Solitaire vs. Merci
Solitaire Device
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Types of Clots Retrieved
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Basilar Clot Basilar artery blocked
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Clots
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Discussion
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