the continuum of stroke care

The Continuum of Stroke Care

Justin A. Sattin, M.D.Assistant Professor

UW Department of NeurologyMedical Director

UW Health Comprehensive Stroke Program

The Chain of Survival

• Healthful Choices• Public Recognition• EMS Access• ED Recognition• Radiology / Lab• Neurologist• Pharmacy

• ICU Nursing Care• General RN Care• More Radiology / Lab• Inter-D Care• Rehabilitation• Re-Integration

Stroke Symptoms

Cincinnati Prehospital Stroke Scale

Facial Droop

Instruction: Ask patient to smile

Normal: Both sides of face move equally

Abnormal: One side of face does not move as well

Arm Drift

Instruction: Ask patient to close eyes and extend both arms straight out for 10 seconds

Normal: Both arms move the same or not at all

Abnormal: One arm does not move or drifts down

Speech

Instruction: Ask patient to say “You can’t teach an old dog new tricks.”

Normal: Patient says correct words without slurring

Abnormal: Patient slurs words, says wrong words, or is unable to speak

Kothari RU, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33:373-8.

Ischemic or Hemorrhagic?

Ischemic or Hemorrhagic?

NINDS tPA Trial

0

5

10

15

20

25

30

35

t-PA Placebo

DeathHemorrhage

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Eng J Med. 1995;333:1588–1593.

39 – 26 = 13

13---- = 50% relative benefit26

39 – 26 = 13% absolute difference

100----- = 8 needed to treat 13

Hacke W, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74.

Time is of the Essence

Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: A randomized controlled trial. JAMA. 1999;282:2003-2011.

Mechanical Embolectomy

Leary MC, et al. Beyond tissue plasminogen activator: mechanical intervention in acute stroke. Ann Emerg Med. 2003;41:838-46.

Courtesy of Concentric Medical, Inc.

Mechanical Embolectomy

Annual Stroke Mortality 2001-2004

<10 (64)

10-50 (1,033)

50-100 (1,067)

>100 (1,186)

Avg# of deaths per county per year (total for all counties in group)

Yuan, H. and Brue, C. Wisconsin Heart Disease and Stroke Surveillance Summary Update – 2007 – PPH 43040 (01/07). Wisconsin Department of Health and Family Services, Division of Public Health.

The Joint Commission. Available at: http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCOrgs/ Accessed 10/14/07

General Management Principles

• Hypoxic pts. should receive O2

– SpO2 > 92%

• Cardiac monitoring for at least 24 hrs.

• Treat HTN conservatively for 24 hrs.– Ischemic: SBP < 220 mmHg– Hemorrhagic: SBP < 160 mmHg

General Management Principles

• Minimize urinary catheterization

• Fevers should be evaluated and treated

• Hyperglycemia should be treated– Optimal threshold is not established– < 140 mg/dL? < 185 mg/dL?

General Management Principles

• Dysphagia screening

• Early mobilization

• DVT prophylaxis– LMWH

Stroke

Hemorrhagic

ICH SAH

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknown

Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41.

Stroke

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknown

http://www.florida-oxygen.com/treatment.htm

Stroke

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknown

http://www.cardioliving.com/consumer/Stroke/AF_Causes.shtm

Cardioembolic Stroke

Stroke

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknown

http://biocomp.stanford.edu/3dreconstruction/movies/haveri/stenosis_ica_angio%26ssd.jpg

Stroke

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknown

Stroke

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknownhttp://bbh.hhdev.psu.edu/courses/368/slide.21.(164).htm

Stroke

IschemicCardioembolic

Large artery athero.

Small vessel dz.

Other

Unknown

Risk Factor Modification

• Hypertension• Diabetes• Dyslipidemia• Metabolic Syndrome• Tobacco Dependence

Antithrombotic Therapies

• Aspirin• Aspirin/Dipyridamole (Aggrenox)• Clopidogrel (Plavix)• Warfarin (Coumadin)

Important Collaborators

• PT• OT• Speech• Swallow• Rehab• Neuro Ψ

• Health Ψ• Case Managers!• Social Work• Pastoral Care• Palliative Care• ACE Team

Discharge Dispositions

• Home– often with outpt. or home health therapies)

• Acute Rehab• Subacute Rehab• Skilled Nursing Facility• Hospice• (Celestial Discharge)

Vascular Cognitive

Impairment

How to Reach Us

Emergent ReferralsUW Access Center

Phone: 800-472-0111

Office ReferralsUW Stroke Clinic

Phone: 608-265-8899Fax: 608-265-1753